1Who is this Advance Directive being prepared for?
{NEXT_?}
Yes, procedures should be withheld or withdrawn if I am permanently unconscious.
ADDIVA02
If you are in a permanently unconscious condition (or COMA), do you want life-prolonging procedures to be withheld or withdrawn?
This Advance Directive authorizes the Declarant's physician to withdraw or withhold life-prolonging procedures if the Declarant is in a terminal condition with no hope of recovery. Enter an X if the Declarant also wants such procedures withdrawn or withheld if he or she is permanently unconscious. Press [Ctrl+F1] for more information.
{NEXT_?}
YesNo
ADDIVA03
{Do you wish to receive artificially administered nutrition or hydration if you have a condition described in this document?
Enter an X if you WISH TO RECEIVE artificially administered nutrition and hydration, even though you have a condition described in this document.
Enter an X if you DO NOT WISH TO RECEIVE artificially administered nutrition and hydration if you have a condition described in this document.
{NEXT_?}
Yes, include nutrition and hydration statement.
ADDIVA03
QDo you wish to specify your desires regarding artificial nutrition and hydration?
AVA03002
{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-sustaining procedures, it is my preference that this document be given effect at that point.
ADDIVA04
sIf you have been diagnosed as pregnant, do you desire that this document be enforced if the fetus will not survive?
AVA04003
Yes, if life-prolonging procedures 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.
ADDIVA04
}Should pain or physical harm be considered in determining whether life-prolonging procedures should be withheld or withdrawn?
{NEXT_?}
Yes, include pregnancy provision.
ADDIVA04
^Do you wish to change the enforcement of this document if you have been diagnosed as pregnant?
AVA04002
{NEXT_?}
Other requests:#|
ADDIVA05
^What other specific requests or instructions, if any, do you wish to include in this document?
If desired, use this space to state any other specific requests or instructions.
Enter the Agent's name or use the P.I. Manager to select and paste a record. An "agent" is someone you designate to make health care decisions for you if you are unable to do so. Press [Ctrl+F1] for more information.
^Who will be appointed as Alternate Agent, if the first choice is unable or unwilling to serve?
{NEXT_?}
Yes, include Agent provision.
ADDIVA06
"Do you wish to designate an Agent?
AVA06001
{NEXT_?}
Make decisions regarding medical careAccess the Declarant's medical recordsEmploy and discharge health care providersAuthorize health care facility admission and dischargeTake lawful action to carry out the Declarant's desires
ADDIVA07
What powers will the Agent have?
Enter an X if the Agent will have the power to make decisions regarding medical care, including artificial feeding and resuscitation. [CHOOSE ONE OR MORE OF THE FOLLOWING.]
{NEXT_?}
Yes, specify Agent's powers.
ADDIVA07
*Do you wish to specify the Agent's powers?
AVA07001
{NEXT_?}
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.
ADDIVA08
3Do you wish to include this severability provision?
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