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 patient’s 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.]