Advance Healthcare Directive (AHD)

End of Life Management Toolkit #5 | by Team Passare and Y Colaborative

Advanced Healthcare Directive

Decide on what kind of life-support treatment you will want in case you are incapacitated.

Option 1
I would like all life support treatments that might prolong my life.
Option 2
I would like no life support treatments, even if they might prolong my life.
Option 3
I would like some life support treatments, including:
Medical devices to aid breathing (ventilator)
Medical devices to aid nutrition and hydration (tube feeding)
Blood transfusions
Dialysis
Antibiotics
Surgery
Option 4
I want a Do Not Resuscitate (DNR)
If incapacitated, decide on who is going to make the decisions for you ( AKA Power of Attorney or Health Care Proxy)
I have asked my first choice, and they have agreed
I have asked my second choice, and they have agreed
If I am unconscious, in a coma, or in a vegetative state and there is little or no chance of recovery
Yes, I would want life-sustaining treatments
I’m not sure. It depends on the circumstance
No. I would not want life-sustaining treatments.
If I have permanent, severe brain damage that makes me unable to recognize my family or friends
Yes, I would want life-sustaining treatments
I’m not sure. It depends on the circumstance
No. I would not want life-sustaining treatments.
I have a permanent condition where other people must help me with my daily needs (for example eating and bathing)
Yes, I would want life-sustaining treatments
I’m not sure. It depends on the circumstance
No. I would not want life-sustaining treatments.
If I have a condition that will make me die very soon, even with life-sustaining treatments.
Yes, I would want life-sustaining treatments
I’m not sure. It depends on the circumstance
No. I would not want life-sustaining treatments.
Have signed (or notarized, if state requirements) by at least two witnesses:
Witness 1:
Witness 2:
I have stored in obvious and accessible location and copies have been made

 

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