Shore Health Systems
Shore Health System

Advance Directives


ADVANCE DIRECTIVE PART B

HEALTH CARE INSTRUCTIONS

(Optional Form)

(Cross through this whole part of the form if you do not want to use it to give health care instructions. If you do want to complete this portion of the form, initial those statements you want to be included in the document and cross through those statements that do not apply.)

If I am incapable of making an informed decision regarding my health care, I direct my health care providers to follow my instructions as set forth below. (initial all those that apply.)

  1. If my death from a terminal condition is imminent and even if life-sustaining procedures are used there is no reasonable expectation of my recovery:
    _______I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
    _______I direct that my life not be extended by life-sustaining procedures, except that, if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially.

  2. If I am in a persistent vegetative state, that is, if I am not conscious and am not aware of my environment nor able to interact with others, and there is no reasonable expectation of my recovery:
    _______I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
    _______I direct that my life not be extended by life-sustaining procedures, except that, if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially.

  3. If I have an end-stage condition, that is, a condition caused by injury, disease, or illness, as a result of which I have suffered severe and permanent deterioration indicated by incompetency and complete physical dependency and for which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective:
    _______I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
    _______I direct that my life not be extended by life-sustaining procedures, except that, if I am unable to take food and water by mouth, I wish to receive nutrition and hydration artificially.

  4. _______I direct that, no matter what my condition, medication to relieve pain and suffering not be given to me if the medication would shorten my remaining life.

  5. _______I direct that, no matter what my condition, I be given all available medical treatment in accordance with accepted health care standards.

  6. If I am pregnant, my decision concerning life-sustaining procedures shall be modified as follows:
    __________________________________________________________________________
    __________________________________________________________________________
    __________________________________________________________________________

  7. I direct (in the following space, indicate any other instructions regarding receipt or nonreceipt of any health care): __________________________________________________________________________
    __________________________________________________________________________
    __________________________________________________________________________

By signing below, I indicate that I am emotionally and mentally competent to make this appointment of a health care agent and that I understand its purpose and effect. (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)
_________________________________
_________________________________
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