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Medical Directive Consultation Form

Medical Directives express your preferences for medical care in the event that you cannot communicate your wishes, and it legally binds your healthcare providers to follow your orders. You can specify what care you want provided or withheld if you are diagnosed to have a terminal illness or to be in a permanent coma, and you can name an agent to ensure that your wishes are followed.

The following terms have special meaning when used in your healthcare Directive.

  • Terminal condition means a condition that will cause imminent death, or to a reasonable degree of medical certainty, is hopeless unless artificially supported through the use of life-sustaining procedures. The condition must be confirmed by a physician who is qualified and experienced in making such a diagnosis.
  • Permanent coma means a condition that, to a reasonable degree of medical certainty:
    •will last permanently, without improvement, and
    •in which there is no cognitive thought, sensation, purposeful action, social interaction and awareness of self and environment.
    In addition, the condition must have existed for a period of time sufficient to make such a diagnosis, and must be confirmed by a physician who is qualified and experienced in making such a diagnosis.
  • Life-prolonging treatment means any medical treatment, procedure or intervention that, in the judgment of the attending physicians, would only serve to prolong the dying process where the patient has a terminal illness or injury, or would serve only to maintain the patient in a condition of permanent unconsciousness. These procedures include assisted ventilation, cardiopulmonary resuscitation, renal dialysis, surgical procedures, blood transfusions and the administration of drugs and antibiotics.
  • Artificially administered food and water -- also called nutrition and hydration -- means administering food and water through a tube or intravenous line, where the recipient is not required to chew or swallow voluntarily.
  • Comfort care means any care that doctors think is necessary to make a patient comfortable or alleviate pain. It does not include artificially-administered food and water.

We need the following information to prepare your Medical Directive:

Your Full Name: First, Middle, Last

E-mail address

Date of birth

Social Security Number

Address (physical, not P.O. Box)

Telephone Number

Who would you like to name as your “Agent-in-Fact” (i.e., the person to whom will make medical decisions on your behalf)?

Full Name: First, Middle, Last

Address

Telephone Number

Would you like to name a back-up Agent-in-Fact, in case your primary choice is unable/unwilling to act in this capacity?
No
Yes (please give full name of back-up, including phone/address)

Treatment Options
If you are diagnosed with a TERMINAL CONDITION, what treatment would you like?
No treatment
All available treatment
Artificially administered food/water ONLY
Comfort Care ONLY
Life-Prolonging Treatment ONLY

If you are diagnosed with a PERMANENT COMA, what treatment would you like?
No treatment
All available treatment
Artificially administered food/water ONLY
Comfort Care ONLY
Life-Prolonging Treatment ONLY

COMMENTS
If you have any further instructions, requests or have need of clarification, please enter that information here before submitting your completed form. Once you have submitted your completed Consulation form, our offices will be in contact with you.

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