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Parsons Technology resource data  |  1995-05-23  |  5.9 KB  |  119 lines
  1. PARSONS TECHNOLOGY RESOURCE FILE
  2. AOK01001;
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  20. AOK10000
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  23. Name: |
  24. ADDIOK01
  25. 1Who is this Advance Directive being prepared for?
  26. {NEXT_?}
  27. This section states that if you are in a terminal condition, and cannot communicate, life-sustaining treatment should be withheld or withdrawn if such treatment would only prolong the dying process. Two physicians must certify that you have an incurable and irreversible condition, and you would die within six months, even with the application of life-sustaining treatment.  Treatment for pain would continue to be provided.  This section needs to be signed by the Declarant on the printed document. 
  28. ADDIOK02
  29. {NEXT_?}
  30. Yes, life-sustaining treatment shall be withheld or withdrawn if I am persistently unconscious.
  31. ADDIOK03
  32. kDo you request that life-sustaining treatment be withheld or withdrawn if you are persistently unconscious?
  33. Enter an X if to withhold or withdraw such treatment if it will only maintain you in a "persistently unconscious" state, as determined by your attending physician and another physician.  The Declarant must sign this instruction to authorize the withholding of life-support.  Press [Ctrl+F1] for more information.
  34. {NEXT_?}
  35. I understand that the subject of the artificial administration of nutrition and hydration (food and water) is of particular importance if I have a condition described above.  I understand that if I do not sign this paragraph, artificially administered nutrition (food) and hydration (water) will be administered to me.  I further understand that if I sign this paragraph, I am authorizing the withholding and withdrawal of artificially administered nutrition and hydration. 
  36. __________________________ - Declarant Signature 
  37. ADDIOK04
  38. {NEXT_?}
  39. Entire bodySpecific organs, tissues, or parts
  40. ADDIOK05
  41. :Which organs or tissues does the Declarant wish to donate?
  42. Enter an X if the Declarant authorizes the donation of only certain organs, tissues, or parts.  You will be asked to specify the items which may be donated in the following questions.
  43. AOK05003
  44. {NEXT_?}
  45. CHECK ALL THAT APPLY#| lungsliverpancreas
  46. ADDIOK05
  47. Which organs are to be donated?
  48. AOK05006
  49. CHECK ALL THAT APPLY#| heartkidneysbrain
  50. ADDIOK05
  51. Which organs are to be donated?
  52. AOK05009
  53. CHECK ALL THAT APPLY#| skinbones/marrowbloods/fluids
  54. ADDIOK05
  55. Which organs are to be donated?
  56. AOK05012
  57. CHECK ALL THAT APPLY#| tissuearterieseyes/cornea/lensglands
  58. ADDIOK05
  59. Which organs are to be donated?
  60. AOK05016
  61. Yes, the following organs.
  62. ADDIOK05
  63. 3Does the Declarant wish to donate any other organs?
  64. {NEXT_?}
  65. Name: |Street 1: |Street 2: |City: |State: |Zip Code: |[Include Country]Country: |
  66. ADDIOK06
  67. +Who will be appointed as Health Care Proxy?
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  69. Name: |Street 1: |Street 2: |City: |State: |Zip Code: |[Include Country]Country: |
  70. ADDIOK06
  71. \Who will be appointed as Alternate Health Care Proxy if the first choice is unable to serve?
  72. {NEXT_?}
  73. Yes, include Proxy section.
  74. ADDIOK06
  75. -Do you wish to designate a Health Care Proxy?
  76. AOK06002
  77. {NEXT_?}
  78. 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-sustaining treatment, it is my preference that this document be given effect at that point.
  79. ADDIOK07
  80. |If you have been diagnosed as pregnant, do you desire that this Advance Directive be enforced if the fetus will not survive?
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  82. Yes, if life-sustaining 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.
  83. ADDIOK07
  84. Should pain or physical harm to you be considered in determining whether life-sustaining treatment should be withheld or withdrawn?
  85. {NEXT_?}
  86. Yes, include pregnancy provision.
  87. ADDIOK07
  88. ^Do you wish to change the enforcement of this document if you have been diagnosed as pregnant?
  89. AOK07002
  90. {NEXT_?}
  91.  Other requests:#|
  92. ADDIOK08
  93. ^What other specific requests or instructions, if any, do you wish to include in this document?
  94. If desired, use this space to state any other specific requests or instructions.
  95. {NEXT_?}
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  97. SEVERABILITY.  If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
  98. ADDIOK09
  99. 3Do you wish to include this severability provision?
  100. {NEXT_?}
  101. ADDIOK10
  102. {NEXT_?}
  103. City: |County: |State: |[Include country]Country: |[Include SSN]SSN: |[Include birthdate]Birthdate: |
  104. ADDIOK11
  105. %What is the address of the Declarant?
  106. {NEXT_?}
  107. Name: |
  108. Address 1: |
  109. Address 2: |
  110. City: |
  111. State: |
  112. Zip: |
  113. [Include country]
  114. Country: |
  115. ADDIOK12
  116. ,What is the name and address of the Witness?
  117. {NEXT_?}
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  119.