ADVANCED DIRECTIVES

To My Family, Doctors and All Concerned with My Care:
These instructions express my wishes about my health care. I want my family, doctors, and everyone else concerned with my care to act in accord with them.

Appointment of Patient Advocate
I appoint the following person to my Patient Advocate:

 

Patient Advocate Name

 

Address

Appointment of Successor Patient Advocate(s)
I appoint the following person(s), in the order listed, my successor Patient Advocate if my Patient Advocate does not accept my appointment, is incapacitated, resigns or is removed. My successor Patient Advocate is to have the same powers and rights as my Patient Advocate.

 
Name


Address

 
Name

 
Address

My patient Advocate or successor Patient Advocate may delegate his/her powers to the next successor Patient Advocate is he or she is unable to act.

My Patient Advocate or successor Patient Advocate may only act if I am unable to participate in making decisions regarding my medical treatment.

Choice 1: I do not want my life to be prolonged by providing or continuing life-sustaining treatment if any of the following medical condition exist:

I am in an irreversible coma or persistent vegetative state.

I am terminally ill and life-sustaining procedures would serve only to artificially delay my death.

Under any circumstances where my medical condition is such that the burdens of the treatment outweigh the expected benefits of treatment, I want my Patient Advocate to consider the relief of suffering and the quality of my life as well as the extent of possibly prolonging my life.

I understand that this decision could or would allow me to die.

If this statement reflects your desires, sign here:

Choice 2: I want my life to be prolonged by life-sustaining treatment unless I am in a coma or vegetative state which my doctor reasonably believes to be irreversible. Once my doctor has reasonably concluded that I will remain unconscious for the rest of my life, I do not life-sustaining treatment to be provided or continued. I understand that this decision could or would allow me to die.

If this statement reflects your desires, sign here:

Choice 3: I want my life to be prolonged to the greatest extent possible consistent with sound medical practice without regard to my condition, the chances I have for recovery, or the cost of my care, and I direct life-sustaining treatment be provided in order to prolong my life.

If this statement reflects your desires, sign here:

d. Specific Instruction Regarding Medical Examinations
My religious beliefs prohibit a medical examination to determine whether I am unable to participate in making medical treatment decisions. I desire this determination to be made in the following manner.

This document is to be treated as a Durable Power of Attorney for Health Care and shall survive my disability or incapacity.

If I am unable to participate in making decisions for my care and there is no Patient Advocate or successor Patient Advocate able to act for me, I request that the instructions I have given in this document be followed and that this document be treated as conclusive evidence of my wishes.

It is also my intent that anyone participating in my medical treatment shall not be liable for following the directions of my Patient Advocate that are consistent with my instructions

1. General Instructions
My Patient Advocate shall have authority to make all decisions and to take all actions regarding my care, custody and medical treatment including, but not limited to the following:

a. Have access to, obtain copies of and authorize release of my medical and other personal information.

b. Employ and discharge physicians, nurses, therapists, and any other health care providers, and arrange to pay them reasonable compensation.

c. Consent to, refuse or withdraw for me any medical care; diagnostic, surgical, or therapeutic procedure; or other treatment of any type or nature, including life-sustaining treatments. I understand that life-sustaining treatment includes, but is not limited to breathing with the use of a machine and receiving food, water and other liquids through tubes. I also understand that these decisions could or would allow me to die. I have listed below any specific instructions I have related to life-sustaining treatments.

2. Specific Instructions
My Patient Advocate is to be guided in making medical decisions for me by what I have told him/her about my personal preferences regarding my care. Some of my preferences are recorded below and on the following pages:

a. Specific Instructions Regarding Care I Do Want
b. Specific Instructions Regarding Care I Do Not Want
c. Specific Instructions Regarding Life-Sustaining Treatment
I understand that I do not have to choose one of the following instructions regarding life-sustaining treatment listed. If I choose one, I will sign below my choice.

If I sign one of the choices listed, I direct that reasonable measures be taken to keep me comfortable and relieve pain.

This document is signed in the State of Michigan. It is my intent that the laws of the State of Michigan govern all questions concerning its validity, the interpretation of its provisions and its enforceability. I also intend that it be applied to the fullest extent possible wherever I may be.

Photocopies of this document can be relied upon as though they were originals.

I am providing these instructions of my free will. I have not been required to give them in order to receive or have care withheld or withdrawn. I am at least eighteen years old and of sound mind.

Signature


Signed Name
Date

Name
Address

Date of Birth
Social Security Number

Witness Statement and Signature
I declare that the person who signed this designation of Patient Advocate signed it in my presence and is known to me. I also declare that the person who signed appears to be of sound mind and under no duress, fraud, or undue influence and is not my husband or wife, parent, child, grandchild, brother or sister. I declare that I am not the Presumptive heir of the person who signed the previous page, the known beneficiary of his/her will at the time of witnessing, his/her physician or a person named as Patient Advocate. I also declare that I am not an employee of a life or health insurance provider for the person who signed, an employee of a health facility that is treating him/her, or an employee of a home for the aged where he/she resides and that I am at least eighteen years old.

Witnesses (Two witnesses are required)


Signed Name
Date

Name
Address

Signed Name
Date

Name
Address

Reaffirmed


Date
Signature

Date
Signature

Date
Signature

If I am unavailable to act after reasonable effort to contact me, I delegate my authority to the persons the Patient has designated as successor Patient Advocate in the order designated. The successor Patient Advocate is authorized to act until I become available to act.

Patient Advocate


Signed Name
Date

Name
Address

Home Phone
Work Phone

Successor Patient Advocate


Signed Name
Date

Name
Address

Home Phone
Work Phone

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