MY Definitions:
Terminal Condition means a condition caused by injury, disease, or illness from which there is no reasonable medical probability of recovery and which, with or without treatment, can be expected to cause death.
To be considered permanently unconscious, two physicians must determine that you have no reasonable possibility of regaining consciousness or decision-making ability.
A persistent vegetative state (PVS) is a condition of patients with severe brain damage in whom coma has progressed to a state of wakefulness without detectable awareness and no reasonable hope of recovery.
This IS NOT a do-not-resuscitate (DNR) order. If something happens I DO want all available treatments until such time that one of the above conditions is clearly determined by at least two independent physicians.
Two independent physicians means two doctors that have not been involved in my care and have each examined my fully and have formed their own conclusions. That may mean 2 cardiologists and 2 neurologists and 2 internists to get a complete picture. Obviously, I do not want to die before my time but I also do not want to be a burden to anyone and do not want to have a poor quality of life if I am technically alive.
In a nutshell, I do not want my children coping with my long-term hospitalization or of my continued care if there is no hope of a full recovery. I do not want anyone to be burdened with uneccesary medical bills on my behalf.
IMPORTANT NOTICE
TO MY HEALTH CARE PROVIDER
Please carefully read the attached formal health care document. I have health care instructions that may be different and more extensive than provided for in standardized forms. The attached document contains specific instructions about the health care that I want — or do not want — if I am terminally ill or permanently unconscious and unable to communicate my wishes.
My wishes may be summarized as follows:
If I am terminally ill, I direct that:
• the artificial administration of food and water be withheld.
• medicines and treatments be administered if necessary to ease my pain and keep me comfortable.
• all additional life-sustaining procedures be withheld, including: blood and blood products, cardio-pulmonary resuscitation (CPR), diagnostic tests, dialysis, drugs, respirator and surgery.
If I am permanently unconscious, I direct that:
• the artificial administration of food and water be withheld.
• medicines and treatments be administered if necessary to ease my pain and keep me comfortable.
• all additional life-sustaining procedures be withheld, including: blood and blood products, cardio-pulmonary resuscitation (CPR), diagnostic tests, dialysis, drugs, respirator and surgery.
If I am pregnant, I direct that my Declaration to Physicians be given no effect during the course of my pregnancy.
Thank you for taking the time to understand my health care instructions.
DECLARATION TO PHYSICIANS
I, being of sound mind, voluntarily state my desire that my dying may not be prolonged under the circumstances specified in this document. Under those circumstances, I direct that I receive the medical care directed in this document. If I am unable to give directions regarding the use of life-sustaining procedures or feeding tubes, I intend that my family and physician honor this document as the final expression of my legal right to direct my own medical or surgical treatment.
If I have a TERMINAL CONDITION, as determined by two physicians who have personally examined me, the following are my directions regarding the use of feeding tubes:
Yes, I want feeding tubes used if I have a terminal condition.
X No, I do not want feeding tubes used if I have a terminal condition.
IF YOU HAVE NOT CHECKED EITHER STATEMENT, feeding tubes will be used.
In addition, if I am diagnosed to have a terminal condition, I direct that:
• all additional life-sustaining procedures be withheld, including: blood and blood products, cardio-pulmonary resuscitation (CPR), diagnostic tests, dialysis, drugs, respirator and surgery.
• medicines and treatments be administered if necessary to ease my pain and keep me comfortable.
If I am in a PERSISTENT VEGETATIVE STATE, as determined by two physicians who have personally examined me, the following are my directions regarding the use of life-sustaining procedures:
Yes, I want life-sustaining procedures used if I am in a persistent vegetative state.
X No, I do not want life-sustaining procedures used if I am in a persistent vegetative state.
Use only the following life-sustaining procedures, which I want provided: Not applicable.
IF YOU HAVE NOT CHECKED ANY OF THE STATEMENTS ABOVE, life-sustaining procedures will be used.
If I am in a PERSISTENT VEGETATIVE STATE, as determined by two physicians who have personally examined me, the following are my directions regarding the use of feeding tubes:
Yes, I want feeding tubes used if I am in a persistent vegetative state.
X No, I do not want feeding tubes used if I am in a persistent vegetative state.
IF YOU HAVE NOT CHECKED ANY OF THE STATEMENTS ABOVE, feeding tubes will be used.
In addition, if I am in a persistent vegetative state, I specifically direct that:
• medicines and treatments be administered if necessary to ease my pain and keep me comfortable.
If I am pregnant, I direct that my Declaration be given no effect during the course of my pregnancy.
SEVERABILITY
If any of the specific directions in this document are held invalid, that shall not affect other directions that can be given effect without the invalid direction.
If you are interested in more information about the significant terms used in this document, see section 154.01 of the Wisconsin Statutes or the information accompanying this document.
DIRECTIVES TO ATTENDING PHYSICIAN
This document authorizes directing medical care when two physicians, one of whom is the attending physician, have personally examined and certified in writing that the patient has a terminal condition or is in a persistent vegetative state.
The choices in this document were made by a competent adult. Under the law, the patient’s stated desires must be followed. If the patient’s desires are that life-sustaining procedures or feeding tubes be used, this directive must be followed.
If you feel that you cannot comply with this document, you must make a good faith attempt to transfer the patient to another physician who will comply. Refusal or failure to make a good faith attempt to do so constitutes unprofessional conduct.
The person making this document may use the following space to record the names of those individuals and health care providers to whom he or she has given copies of this document:
My Dad, My Aunt (now deceased), My boyfriend, My lawyer
NOTICE TO PERSON MAKING THIS DOCUMENT
YOU HAVE THE RIGHT TO MAKE DECISIONS ABOUT YOUR HEALTH CARE. NO HEALTH CARE MAY BE GIVEN TO YOU OVER YOUR OBJECTION, AND NECESSARY HEALTH CARE MAY NOT BE STOPPED OR WITHHELD IF YOU OBJECT.
BECAUSE YOUR HEALTH CARE PROVIDERS IN SOME CASES MAY NOT HAVE HAD THE OPPORTUNITY TO ESTABLISH A LONG-TERM RELATIONSHIP WITH YOU, THEY ARE OFTEN UNFAMILIAR WITH YOUR BELIEFS AND VALUES AND THE DETAILS OF YOUR FAMILY RELATIONSHIPS. THIS POSES A PROBLEM IF YOU BECOME PHYSICALLY OR MENTALLY UNABLE TO MAKE DECISIONS ABOUT YOUR HEALTH CARE.
IN ORDER TO AVOID THIS PROBLEM, YOU MAY SIGN THIS LEGAL DOCUMENT TO SPECIFY THE PERSON WHOM YOU WANT TO ENFORCE YOUR HEALTH CARE DECISIONS AS EXPRESSED IN YOUR DECLARATION TO PHYSICIANS, IF YOU ARE UNABLE TO MAKE THOSE DECISIONS PERSONALLY. THAT PERSON IS KNOWN AS YOUR HEALTH CARE AGENT. YOU SHOULD TAKE SOME TIME TO DISCUSS YOUR THOUGHTS AND BELIEFS ABOUT MEDICAL TREATMENT WITH THE PERSON OR PEOPLE WHOM YOU HAVE SPECIFIED. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF HEALTH CARE THAT YOU DO OR DO NOT DESIRE, AND YOU MAY LIMIT THE AUTHORITY OF YOUR HEALTH CARE AGENT. IF YOUR HEALTH CARE AGENT IS UNAWARE OF YOUR DESIRES WITH RESPECT TO A PARTICULAR HEALTH CARE DECISION HE OR SHE IS REQUIRED TO DETERMINE WHAT WOULD BE IN YOUR BEST INTERESTS IN MAKING THE DECISION.
THIS IS AN IMPORTANT LEGAL DOCUMENT. IT GIVES YOUR AGENT BROAD POWERS TO ENFORCE HEALTH CARE DECISIONS THAT YOU HAVE MADE IN YOUR DECLARATION TO PHYSICIANS. IT REVOKES ANY PRIOR POWER OF ATTORNEY FOR HEALTH CARE THAT YOU MAY HAVE MADE. IF YOU WISH TO CHANGE YOUR POWER OF ATTORNEY FOR HEALTH CARE, YOU MAY REVOKE THIS DOCUMENT AT ANY TIME BY DESTROYING IT, BY DIRECTING ANOTHER PERSON TO DESTROY IT IN YOUR PRESENCE, BY SIGNING A WRITTEN AND DATED STATEMENT OR BY STATING THAT IT IS REVOKED IN THE PRESENCE OF TWO WITNESSES. IF YOU REVOKE, YOU SHOULD NOTIFY YOUR AGENT, YOUR HEALTH CARE PROVIDERS AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY. IF YOUR AGENT IS YOUR SPOUSE AND YOUR MARRIAGE IS ANNULLED OR YOU ARE DIVORCED AFTER SIGNING THIS DOCUMENT, THE DOCUMENT IS INVALID.
DO NOT SIGN THIS DOCUMENT UNLESS YOU CLEARLY UNDERSTAND IT.
IT IS SUGGESTED THAT YOU KEEP THE ORIGINAL OF THIS DOCUMENT ON FILE WITH YOUR PHYSICIAN.
POWER OF ATTORNEY FOR HEALTH CARE
CREATION OF POWER OF ATTORNEY FOR HEALTH CARE
I, being of sound mind, intend by this document to create a Power of Attorney for Health Care. My executing this Power of Attorney for Health Care is voluntary. Despite the creation of this Power of Attorney for Health Care, I expect to be fully informed about and allowed to participate in any health care decision for me, to the extent that I am able. For the purposes of this document, “health care decision” means an informed decision to accept, maintain, discontinue or refuse any care, treatment, service or procedure to maintain, diagnose or treat my physical or mental condition as directed in the attached Declaration To Physicians.
DESIGNATION OF HEALTH CARE AGENT
If I am no longer able to make health care decisions for myself, due to my incapacity, I hereby designate:
My boyfriend
to be my health care agent for the purpose of enforcing health care decisions I have made in my Declaration to Physicians.
If he or she is ever unable or unwilling to do so, I hereby designate:
My sister
to be my alternate agent for the purpose of enforcing health care decisions I have made in my Declaration to Physicians. Neither my health care agent nor my alternate health care agent whom I have designated is my health care provider, an employee of my health care provider, an employee of a health care facility in which I am a patient or a spouse of any of those people, unless he or she is also my relative. For purposes of this document, “incapacity” exists if two physicians or a physician and a psychologist who have personally examined me sign a statement that specifically expresses their opinion that I have a condition that means that I am unable to receive and evaluate information effectively or to communicate decisions to such an extent that I lack the capacity to manage my health care decisions. A copy of that statement must be attached to this document.
GENERAL STATEMENT OF AUTHORITY GRANTED
If I ever am found to be incapacitated, I instruct my health care provider to obtain the health care decision of my health care agent, if I need treatment, for all of my health care and treatment, subject to the limitations set forth in this document. I have discussed my desires thoroughly with my health care agent and believe that he or she understands my philosophy regarding the health care decisions I would make if I were able. I desire that my wishes be carried out through the authority given to my health care agent under this document.
I grant my agent full authority to enforce the instructions I have set out in the Declaration to Physicians to which this Power of Attorney for Health Care is attached. However, I do not authorize my agent to act on my behalf for any other purpose.
If I am unable, due to my incapacity, to make a health care decision, my health care agent is instructed to make the health care decision for me consistent with the health care wishes expressed in my Declaration to Physicians, to which this document is attached. My health care agent should try to discuss with me any specific proposed health care if I am able to communicate in any manner, including by blinking my eyes. If this communication cannot be made, my health care agent shall base his or her decision on the specific instructions set out in the Declaration to Physicians attached to this Power of Attorney.
HEALTH CARE DECISIONS FOR PREGNANT WOMEN
My health care agent may make health care decisions for me even if my agent knows I am pregnant.
LIMITATIONS ON MENTAL HEALTH TREATMENT
My health care agent may not admit or commit me on an inpatient basis to an institution for mental diseases, an intermediate care facility for the mentally retarded, a state treatment facility or a treatment facility. My health care agent may not consent to experimental mental health research or psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures for me.
INSPECTION AND DISCLOSURE OF INFORMATION
The authority I grant to my agent shall include the authority to:
• hire and fire medical personnel.
• visit me in a hospital or other medical care facility.
• review and receive any information regarding my physical or mental health, including medical and hospital records.
• sign any releases or other documents required to obtain this information.
• sign any documents required to request, withdraw or refuse medical treatment or to be released or transferred from a hospital or other medical facility.
• sign any waiver or release from liability required by a hospital or physician.
