These forms vary with each state! Check with a specialized Elder Care Attorney in your state.
There is more to "advance care planning" than completing legally valid documents.  Completing the documents is perhaps the easiest part of an effective care planning process. The goal of this web site is to help you complete this process.  If you already have completed a directive,
chances are your treatment instructions are too vague to be of much help should anyone ever need to rely on them. Use this site to ONLY to review your current advance care plans and documents.

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Prehospital Medical Care Directive

In the event of cardiac or respiratory arrest, I refuse any resuscitation measures including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration
of advanced cardiac life support drugs and related emergency medical procedures.

 

Patient: _______________________________________ Date: ______________

(Signature or mark)

Attach recent photograph here
or provide all of the following
information below:

 

 

 

 Date of birth_____________________________ Sex ________

 Eye Color ______________ Hair Color _______________ Race ____________

 Hospice program (if any) _____________________________________________

Name and telephone number of patientís physician: ____________________________________________________
{Note: A licensed health care provider and witness must sign on reverse.}

I have explained this form and its consequences to the signer and obtained assurance
that the signer understands that death may result from any refused care listed above.

______________________________________________ Date ________________
(Licensed health care provider)

I was present when this was signed (or marked). The patient then appeared to be of
sound mind and free from duress.

_____________________________________________ Date _________________
(Witness)

[Note: This form is to be printed on two sides on orange paper.]