Medical Directive

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ALL THE INFORMATION YOU PROVIDE IN THIS QUESTIONNAIRE IS STRICTLY CONFIDENTIAL

Pennsylvania law gives you the right to direct and control the health care treatment you receive. While you are physically and mentally well enough to personally direct your own care, you will be in complete charge of the treatments provided to you. Once you become unable to understand the medical information provided to you, reach a decision, or communicate the decision to others, an Advanced Healthcare Directive will allow you to continue to have control over your care and treatment.

Please keep in mind that no document, no matter how well drafted, is a substitute for thoughtful, informed medical decision making grounded upon conversations between you and your doctor, your doctor, and your healthcare agent, and MOST IMPORTANTLY, between you and your healthcare agent, BEFORE the loss of capacity.

Should you have any questions or need clarification do not hesitate to contact our office to discuss your questions, comments, or concerns.

PART I – HEALTH CARE POWER OF ATTORNEY AGENTS

The agent under a health care power of attorney has the power to make decisions on your behalf on a variety of health-related issues when you are incapacitated. A good agent is honest and loyal, understands your goals and beliefs regarding end-of-life care, does not live far away, and is mentally and physically capable of acting on your behalf when you are unwilling or unable. A secondary agent should be named as a back-up in case the primary agent is unwilling or unable to serve.

Designate your primary agent, and at least one alternative agent, Include contact information for each.

PRIMARY AGENT:
Name
Address
FIRST ALTERNATE AGENT:
Name
Address
SECOND ALTERNATE AGENT:
Name
Address
THIRD ALTERNATE AGENT:
Name
Address

PART II – HEALTH CARE TREATMENT INSTRUCTIONS

SITUATION ONE

Then I direct the following:

1. Cardiopulmonary Resuscitation (CPR)
2. Mechanical Breathing: If, after diagnosis, I require medical assistance with breathing:
3. Tube Feeding
4. Kidney Dialysis
5. Diagnostic Tests
6. Minor Surgery
7. Major Surgery
8. Chemotherapy
9. Blood Transfusion
10. Antibiotics
11. Pain Medication and Comfort Care

ADDITIONAL COMMENTS:

If you want to add any further instructions or clarifications regarding Situation One, please use the space provided here.

SITUATION TWO

If I have sustained a head injury and/or am in a coma with physicians in agreement that the extent of the damage is unknown and the long-range outcome is unpredictable, then I direct the following:

1. Cardiopulmonary Resuscitation (CPR)
2. Mechanical Breathing: If, after diagnosis, I require medical assistance with breathing:
3. Tube Feeding
4. Kidney Dialysis
5. Diagnostic Tests
6. Minor Surgery
7. Major Surgery
8. Chemotherapy
9. Blood Transfusion
10. Antibiotics
11. Pain Medication and Comfort Care

ADDITIONAL COMMENTS:

If you want to add any further instructions or clarifications regarding Situation One, please use the space provided here.

SITUATION THREE

If I am suffering from degenerative brain disease, such as Alzheimer’s, and I have deteriorated to the point where I am no longer able to understand things or make decisions, AND I ALSO DEVELOP A TERMINAL ILLNESS, then I direct the following:

1. Cardiopulmonary Resuscitation (CPR)
2. Mechanical Breathing: If, after diagnosis, I require medical assistance with breathing:
3. Tube Feeding
4. Kidney Dialysis
5. Diagnostic Tests
6. Minor Surgery
7. Major Surgery
8. Chemotherapy
9. Blood Transfusion
10. Antibiotics
11. Pain Medication and Comfort Care

ADDITIONAL COMMENTS:

If you want to add any further instructions or clarifications regarding Situation One, please use the space provided here.

SITUATION FOUR

If I am suffering from a degenerative brain disease, such as Alzheimer’s, and I have deteriorated to the point where I am no longer able to understand things or make decisions, BUT I DO NOT HAVE A TERMINAL ILLNESS, then I direct the following:

1. Cardiopulmonary Resuscitation (CPR)
2. Mechanical Breathing: If, after diagnosis, I require medical assistance with breathing:
3. Tube Feeding
4. Kidney Dialysis
5. Diagnostic Tests
6. Minor Surgery
7. Major Surgery
8. Chemotherapy
9. Blood Transfusion
10. Antibiotics
11. Pain Medication and Comfort Care

ADDITIONAL COMMENTS:

If you want to add any further instructions or clarifications regarding Situation One, please use the space provided here.

AUTHORITY OF INSTRUCTIONS OVER AGENT

You have the choice of either:
(1) require your agent to be bound to the instructions contained withing your Advanced healthcare Directive; or
(2) allow your agent to use the instructions as guidance and potentially override your instructions, subject to any specific limitations.  Please indicate your preference:

After you have carefully considered what medical treatments, you would want to accept or reject if you were in any of the situations described above, it is important that you and your selected health care agent discuss these options and the reasons behind your decision (personal, religious, ethical, moral, etc.)

PART III - ANATOMICAL GIFTS

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