WDo you intend for this Directive to be effective if you become permanently unconscious?
This Directive states the Grantor's wishes regarding life-prolonging treatment and artificially provided nutrition and hydration if he or she no longer has decisional capacity or has a terminal condition. Enter an X if the Grantor also wishes that this Directive be effective if he or she is permanently unconscious. Press [Ctrl+F1] for more information.
Enter the Surrogate's name(s) or use the P.I. Manager to select and paste a record. Two Surrogates may be designated and together they must agree on the health care decisions being made on behalf of the Grantor. NOTE THAT CERTAIN INDIVIDUALS SHOULD NOT BE DESIGNATED AS A SURROGATE. Press [Ctrl+F1] for more information.
AKY02010
Yes, appoint an Alternate Surrogate.
ADDIKY02
ZWill an Alternate Surrogate be appointed if the Surrogate is unwilling or unable to serve?
9Who will be appointed as Alternate Health Care Surrogate?
Enter the Alternate Surrogate's name(s) or use the P.I. Manager to select and paste a record. Two Alternate Surrogates may be designated and together they must agree on the health care decisions being made on behalf of the Grantor. NOTE THAT CERTAIN INDIVIDUALS SHOULD NOT BE DESIGNATED AS A SURROGATE.
AKY02021
Yes, Surrogate will consult the Grantor's physician and consider his/her recommendation.
ADDIKY02
aWill the Surrogate be required to consult your physician before making any health care decisions?
AKY02035
Yes, include annulment/divorce statement.
ADDIKY02
Do you wish to revoke the Surrogate's authority if the Surrogate is or ever becomes your spouse, and the marriage is annulled or you are divorced?
AKY02036
{NEXT_?}
No, Spouse would no longer serve as Surrogate.
ADDIKY02
EWill your spouse continue to serve as Surrogate if you are separated?
{NEXT_?}
Yes, a Surrogate will be designated.
ADDIKY02
+Will a Health Care Surrogate be designated?
Enter an X to designate a "Surrogate". A surrogate is a person who is authorized by the Grantor to make medical and health care decisions for the Grantor if the Grantor is unable to do so. This provision must be initialed by the Grantor on the printed document. Press [Ctrl+F1] for more information.
AKY02002
{NEXT_?}
If I have a terminal condition:#| or am permanently unconscious:I direct that treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication deemed necessary to alleviate pain.I DO NOT authorize that life-prolonging treatment be withdrawn or withheld.
ADDIKY03
yDo you wish to receive life-prolonging treatment if you have a terminal condition and/or you are permanently unconscious?
Life sustaining procedures are withheld or withdrawn if the Grantor is in a terminal condition with no hope of recovery. Enter an X if the Grantor wants procedures withheld or withdrawn if "permanently unconscious" (an absence of cerebral cortical functions indicative of consciousness or behavioral interaction).
{NEXT_?}
No, nutrition is to be withheld or withdrawnYes, nutrition is desiredSurrogate to make the decision
ADDIKY04
vDo you wish to receive artificial nutrition and or fluids under any of the conditions listed in the previous question?
{NEXT_?}
Yes, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-prolonging treatment, it is my preference that this document be given effect at that point.
ADDIKY05
tIf you have been diagnosed as pregnant, do you desire that this Directive be enforced if the fetus will not survive?
AKY05003
Yes, if life-prolonging treatment will be physically harmful or unreasonably painful to me, I request that such harm or pain be considered in determining whether this document shall be effective if I am pregnant.
ADDIKY05
|Should pain or physical harm be considered in determining whether life-prolonging treatment should be withheld or withdrawn?
{NEXT_?}
Yes, include a Pregnancy provision.
ADDIKY05
_Do you wish to change the enforcement of this Directive if you have been diagnosed as pregnant?
AKY05002
{NEXT_?}
Artificial/mechanical respirationYesNo
ADDIKY06
<Do you wish to receive artificial or mechanical respiration?
AKY06003
Cardiopulmonary resuscitationYesNo
ADDIKY06
5Do you wish to receive cardiopulmonary resuscitation?
AKY06004
Blood or blood productsYesNo
ADDIKY06
/Do you wish to receive blood or blood products?
AKY06005
Surgery or invasive diagnostic proceduresYesNo
ADDIKY06
MDo you wish to receive any form of surgery or invasive diagnostic procedures?
AKY06006
Kidney dialysisYesNo
ADDIKY06
'Do you wish to receive kidney dialysis?
AKY06007
AntibioticsYesNo
ADDIKY06
#Do you wish to receive antibiotics?
AKY06008
ChemotherapyYesNo
ADDIKY06
$Do you wish to receive chemotherapy?
AKY06009
RadiationYesNo
ADDIKY06
!Do you wish to receive radiation?
AKY06010
#' $(!%)Yes"&*No
ADDIKY06
4What other medical procedure do you wish to receive?
AKY06018
AKY06010
Yes, consider current circumstances.
ADDIKY06
+mWill the current circumstances be considered when determining if procedures or treatments should be provided?
Enter an X to include a paragraph containing additional options which consider the circumstances at the time any of the previously listed procedures or treatments are prescribed.
AKY06046
AKY06050
If I have a terminal conditionIf I am in a permanent comaIf I have a terminal condition or am in a permanent coma
ADDIKY06
./0xUnder what circumstances do you NOT want to receive the procedures or treatments marked "YES" in the previous questions?
Enter an X if the Grantor does not wish to receive any procedure marked "YES" if the Grantor has a "terminal condition" (except to the extent necessary to provide comfort and freedom from pain).
Enter an X if the Grantor does not wish to receive any procedure marked "YES" if the Grantor is in a "permanent coma" (except to the extent necessary to provide comfort and freedom from pain).
Enter an X if the Grantor does not wish to receive any procedure marked "YES" if the Grantor has a "terminal condition" or is in a "permanent coma" (except to the extent necessary to provide comfort and freedom from pain).
AKY06050
Surrogate to determine whether the procedures or treatment should be provided.#| Procedures or treatment should not be provided if Grantor is in a coma or has a terminal condition.
ADDIKY06
What circumstances should be considered when determining whether the previously listed procedures or treatments should be provided?
Enter an X if the Grantor desires that his/her Surrogate consider the circumstances at the time any of the previously described procedures are prescribed, and that the Surrogate determine whether the procedure or treatment should be provided.
Enter an X if the Grantor does not wish to receive the previously described procedures if the Grantor has a terminal condition or is in a permanent coma.
AKY06019
AKY06050
Other requests or instructions:#|
ADDIKY06
12RWhat other specific requests or instructions should be included in this Directive?
If desired, enter any other specific requests or instructions of the Grantor. For example, any other wishes, values, religious beliefs, philosophy or other personal preferences that are relevant, such as location of care, or limits on the Surrogate's authority. Press [Ctrl+F1] for more information.
{NEXT_?}
AKY06050
Yes, specify medical procedures.
ADDIKY06
XDo you wish to specify certain medical procedures that you do or do not want to receive?
AKY06002
{NEXT_?}
ADDIKY07
{NEXT_?}
City: |State: |[Include Country]Country: |[Include SSN]SSN: |[Include Date of Birth]Birthdate: |
ADDIKY08
+What is the Grantor's personal information?
{NEXT_?}
WitnessesNotary
ADDIKY09
)Who will witness the Grantor's signature?
AKY09003
{NEXT_?}
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
ADDIKY09
2What are the names and addresses of the witnesses?
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