Advance Directives

• Instructions
• Download Five Wishes
  For viewing only. Hard copies are available at the hospital information desk, or through Aging with Dignity.
• Part A - Appointment of a Health Care Agent
• Part B - Health Care Instructions
• Organ Donation Addendum
• Living Will
• Frequently Asked Questions (FAQ)

1. I, __________________________________________________________
   residing at:___________________________________________________
   ____________________________________________________________
   appoint the following individual as my agent to make health care decisions for me:
   ____________________________________________________________
   ____________________________________________________________
   (Full Name, Address and Telephone Number of Agent)

   Optional: If this agent is unavailable or is unable or unwilling to act as my agent, then I appoint the following person to act in this capacity:
   ____________________________________________________________
   ____________________________________________________________
   (Full Name, Address and Telephone Number of Agent)

2. My agent has full power and authority to make health care decisions for me, including the power to:
   1. Request, receive, and review any information, oral or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, and consent to disclosure of this information;

   2. Employ and discharge my health care providers;

   3. Authorize my admission to or discharge from (including transfer to another facility) any hospital, hospice, nursing home, adult home, or other medical care facility; and

   4. Consent to the provision, withholding, or withdrawal of health care, including, in appropriate circumstances, life-sustaining procedures

3. The authority of my agent is subject to the following provisions and limitations:
4. If I am pregnant, my agent shall follow these specific instructions:
5. My agent's authority becomes operative (initial only the one option that applies):
   _____When my attending physician and a second physician determine that / am incapable of making an informed decision regarding my health care, or
   _____When this document is signed.
6. My agent is to make health care decisions for me based on the health care instructions I give in this document and on my wishes as otherwise known to my agent. If my wishes are unknown or unclear, my agent is to make health care decisions for me in accordance with my best interest, to be determined by my agent after considering the benefits, burdens, and risks that might result from a given treatment or course of treatment, or from the withholding or withdrawal of a treatment or course of treatment.
7. My agent shall not be liable for the costs of care based solely on this authorization.

(Date)________________________
(Signature of Declarant)___________________________________________

The declarant signed or acknowledged signing this appointment of a health care agent in my presence and, based upon my personal observation appears to be a competent individual.

(Witness Signature) _________________________________ (Address) _________________________________ _________________________________ _________________________________

(Witness Signature) _________________________________ (Address) _________________________________ _________________________________ _________________________________