[This document is only a sample of a healthcare treatment directive.
IT MAY NOT CONFORM TO THE LAWS IN YOUR STATE.]
I, _____________________________[your name], make this healthcare
treatment directive to exercise my right to determine the course of
my healthcare and to provide clear and convincing proof of my
treatment decisions when I lack the capacity to make or communicate
my decisions and there is no realistic hope that I will regain such
capacity.
If my physician believes that a certain life-sustaining procedure or
other healthcare treatment may provide me with comfort, relieve
pain, or lead to a significant recovery, I direct my physician to
try the treatment for a reasonable period of time. However, if such
treatment proves to be ineffective, I direct treatment to be
withdrawn even if so doing may shorten my life.
I direct that I be given healthcare treatment to relieve pain or to
provide comfort even if such treatment might shorten my life,
suppress my appetite or my breathing, or be habit forming.
I direct that all life-sustaining procedures be withheld or
withdrawn when there is no hope of significant recovery, and I have:
- a terminal condition, or
- a condition, disease, or injury without reasonable expectation
that I will regain an acceptable quality of life; or
- substantial brain damage or brain disease that cannot be
significantly reversed.
- When any of the above conditions exist, I DO NOT WANT the life
prolonging procedures that I have initialed below. [You should
assume any treatments not initialed may be administered to you.]
- I make other instructions as follows: [You may describe here
what a minimally acceptable quality of life is for you.]
________________________________________________________________________
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- Please see my Durable Power of Attorney for Healthcare for
appointment of my agent for healthcare decisions at times when I
am incapacitated for making my own healthcare decisions.
[Discuss this document and your ideas about quality of life with
your agent, physician(s), family members, friends, and clergy and
provide them with a signed copy (or photocopy thereof). You may
revoke or change this document at any time. Periodic review is
recommended. If there are no changes after each review, initial and
date in the margin.]
This content is reviewed periodically and is subject to
change as new health information becomes available. The
information is intended to inform and educate and is not a
replacement for medical evaluation, advice, diagnosis or
treatment by a healthcare professional.
© 2009 RelayHealth and/or its affiliates. All Rights Reserved.
This
information is approved and/or reviewed by U-M Health System providers
but it is not a tool for self-diagnosis or a substitute for medical
treatment. You should speak to your physician or make
an appointment to be seen if you have questions or concerns about
this information or your medical condition.