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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ATTACHMENT
TO THE LIVING WILL &
HEALTH
CARE POWER OF ATTORNEY of
{Print
your name}
REFUSAL
OF ALL LIFE-SUSTAINING TREATMENT BECAUSE OF CURRENT
POOR QUALITY OF LIFE
Because
of health losses I have experienced, I consider my quality of life to be
unacceptable, or only marginally acceptable. For that reason, if I have or
get a life-threatening condition (when I cannot make my own health care
decisions) I want no life-sustaining treatment. Even if such treatment
might completely reverse a life-threatening condition, I do not want it. {Explain
this choice here. If you need more space, use the reverse or attach
additional pages and reference that you have done so here.}
________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
___________________________________
______________
Sign
here in the presence of your witness.
Date
STATEMENT
OF WITNESS: ________________________________________is
personally
known to me, and I believe him/her to be of sound mind and to have
voluntarily completed this directive. I affirm that I am at least 18 years
old, not related to him/her by blood, marriage or adoption, and not an
agent named in this directive. I am not, to my knowledge, a beneficiary of
his/her will or any codicil, and I have no claim against his/her estate. I
am not directly involved in his/her health care.
_________________________________________
_________________
Witness signature
Date
Print witness name
Phone
____________________________________________________________
Address
{If you complete this page, attach it to your Living Will & Health Care Power of Attorney.}