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ADVANCE HEALTH CARE DIRECTIVE FORM
PART 1: INDIVIDUAL INSTRUCTIONS FOR HEALTH CARE
The following statements only apply
•if I am close to death and life support would only postpone the moment of my death OR
•if I am in an unconscious state such as an irreversible coma or a persistent vegetative state and it is
unlikely that I will ever
become conscious OR
•if I have brain damage or a brain disease that makes me permanently unable to make and communi-
cate health care decisions about myself.
D. ETHICAL, RELIGIOUS, OR SPIRITUAL INSTRUCTIONS (OPTIONAL)
Is there a church, temple, spiritual group or a special person from whom you wish to receive spiritual care
Street Address City State Zip
G. OTHER WISHES:
If you do not agree with any of the choices above or wish to add other instructions, including body and or-
gan donation, you may add pages. If you are or could become pregnant, consult your doctor, and consider
adding special instructions suspending or adding provisions. Remember to sign, date, witness or notarize
File a copy of your Advance Health Care Directive with: Doctor Family Agent
INITIAL ONLY ONE (1) CHOICE IN EACH SECTION and CROSS OUT ALL THAT DO NOT APPLY.
A. CHOICE TO PROLONG OR NOT TO PROLONG LIFE
YES, I do want to have my life prolonged as long as possible within the limits of generally accepted
health care standards that apply to my condition.
NO, I do not want my life prolonged.
B. ARTIFICIAL NUTRITION AND HYDRATION (FOOD AND FLUIDS) BY TUBE INTO STOMACH OR VEIN
YES, I do want artiﬁcial nutrition and hydration.
NO, I do not want artiﬁcial nutrition and hydration.
C. RELIEF FROM PAIN
YES, I do want treatment to relieve my pain or discomfort.
NO, I do not want treatment to relieve my pain or discomfort.
E. DO YOU WANT HOSPICE CARE, IF APPROPRIATE ____ YES ____ NO
(Hospice provides physical, psychosocial, emotional, and spiritual support and counseling for the patient
and his/her family. Hospice is available in home, hospital, hospice-unit, and nursing home settings.)
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