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Kentucky Advance Health Care Directive Form 2

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Kentucky Advance Health Care Directive Form 2 Page 2
Hosparus Inc.
Making Choices for End-of-Life Care
in Kentucky
Effective Date: 11/93 Attachment Page 2 of 3
Rev. Date: 01/08 JG, 04/10 EG
Once you have signed a Living Will, make sure that your loved ones, your health care surrogate,
physician, attorney and any other health care providers know that you have an advance
directive. Be sure to tell them where it is located. Ask your physician and other health care
providers to make your advance directives part of your permanent medical record.
DO NOT RESUSCITATE (DNR)
Hosparus patients are asked to consider their wishes regarding a Do Not Resuscitate status,
which means that no cardiopulmonary resuscitation (CPR) is to be initiated at the time of death.
We hope that the following information, which has been gathered from current research, will
help you with this.
CPR is sometimes helpful when the heart and lungs stop suddenly due to a problem that can
be fixed, such as an abnormal heart rhythm during a heart attack.
CPR involves pressing on the chest and giving electrical shocks to the chest. Medications
may be given and a tube may be placed in the throat to help breathing.
CPR can cause injuries such as broken ribs or a collapsed lung.
When CPR is started within 5 minutes of the heart stopping in patients who do not have
severe chronic diseases, it may be successful in prolonging life.
For patients dying of cancer or other severe chronic illnesses, CPR will not prevent death.
While you are in an acute care hospital or in a nursing facility the doctor will write an order for
your wishes to be honored. If you are home when an emergency occurs, there is no medical
chart or physician’s order. Therefore for situations outside of the hospital or health facility, you
may execute an Emergency Medical Services (EMS) DNR. You must provide a copy of the DNR
form to emergency personnel in order for your wishes to be followed. Your EMS DNR may be
canceled by you at any time. Having a DNR is not required for participation in a hospice
program. Patients/families not wishing DNR status may secure emergency assistance by
calling 911. EMS personnel will attempt to resuscitate patients who do not have a DNR Order
form or bracelet to present to them. However, EMS is not a covered hospice service.
AUTHORIZATION TO MAKE HEALTHCARE DECISIONS
If you have not executed a Living Will and have not designated a healthcare surrogate and you
are no longer able to make your own decisions, Kentucky has defined the people who can make
decisions in your behalf.
1. The judicially appointed guardian of the patient, if the guardian has been appointed and if
medical decisions are within the scope of the guardianship
2. The attorney-in-fact named in a durable power of attorney (DPOA), if the DPOA
includes authority for health care decisions
3. The spouse of the patient
4. An adult child of the patient, or if the patient has more than one (1) child, the majority of the
adult children who are reasonably available for consultation
5. The parents of the patient
6. The nearest living relative of the patient, of if more than one (1) relative of the same relation
is reasonably available for consultation, a majority of the nearest living relatives.
Kentucky Advance Health Care Directive Form 2
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