Pennsylvania Advance Health Care Directive This frm lets yu have a say abut hw yu want t be treated if yu get very sick. This frm has 3 parts. It lets yu: Part 1: Chse a medical decisin maker. A medical decisin maker is a persn wh can make health care decisins fr yu if yu are t sick t make them yurself. Part 2: Make yur wn health care chices. This frm lets yu chse the kind f health care yu want. This way, thse wh care fr yu will nt have t guess what yu want if yu are t sick t tell them yurself. Part 3: Sign the frm. It must be signed befre it can be used. Yu can fill ut Part 1, Part 2, r bth. Fill ut nly the parts yu want. Always sign the frm in Part 3. 2 witnesses need t sign n page 11. Yur Name: 1
Pennsylvania Advance Health Care Directive If yu nly want t name a medical decisin maker g t Part 1 n page 3. If yu nly want t make yur wn health care chices g t Part 2 n page 6. If yu want bth then fill ut Part 1 and Part 2. Always sign the frm in Part 3 n page 9. 2 witnesses need t sign n page 11. What if I change my mind? Fill ut a new frm. Tell thse wh care fr yu abut yur changes. Give the new frm t yur medical decisin maker and dctr. What if I have questins abut the frm? Ask yur dctrs, nurses, scial wrkers, friends r family t answer yur questins. Lawyers can help t. What if I want t make health care chices that are nt n this frm? Write yur chices n page 9. 2 Share this frm and yur chices with yur family, friends, and medical prviders.
Pennsylvania Advance Health Care Directive Part 1 Chse yur medical decisin maker The persn wh can make health care decisins fr yu if yu are t sick t make them yurself Whm shuld I chse t be my medical decisin maker? A family member r friend wh: is at least 18 years ld knws yu well can be there fr yu when yu need them yu trust t d what is best fr yu can tell yur dctrs abut the decisins yu made n this frm Yur decisin maker cannt be yur dctr r smene wh wrks at yur hspital r clinic, unless he/she is a family member. What will happen if I d nt chse a medical decisin maker? If yu are t sick t make yur wn decisins, a persn will be chsen fr yu accrding t Pennsylvania law. This persn may nt knw what yu want. The kinds f decisins yur medical decisin maker can make She r he will be able t chse: dctrs, nurses, scial wrkers, caregivers hspitals, clinics, nursing hmes medicatins, tests, r treatments what kind f persnal care yu get, such as where yu live wh can lk at yur medical infrmatin what happens t yur bdy and rgans after yu die 3
Part 1: Chse yur health care agent Pennsylvania Advance Health Care Directive Mre decisins yur medical decisin maker can make: Life supprt treatments medical care t try t help yu live lnger CPR r cardipulmnary resuscitatin cardi = heart pulmnary = lungs resuscitatin = t bring back This may invlve: pressing hard n yur chest t keep yur bld pumping electrical shcks t jump start yur heart medicines in yur veins Breathing machine r ventilatr The machine pumps air int yur lungs and breathes fr yu. Yu are nt able t talk when yu are n the machine. Dialysis A machine that cleans yur bld if yur kidneys stp wrking. Feeding Tube A tube used t feed yu if yu cannt swallw. The tube is placed dwn yur thrat int yur stmach. It can als be placed by surgery. Bld transfusins T put bld in yur veins. Surgery Medicines End f life care if yu might die sn yur medical decisin maker can: call in a spiritual leader decide if yu die at hme r in the hspital decide where yu shuld be buried r cremated Write dwn any decisins yu d nt want yur medical decisin maker t make: Talk t yur medical decisin maker abut this frm and yur chices. 4 Yur Name:
Part 1: Chse yur medical decisin maker Pennsylvania Advance Health Care Directive Yur Medical Decisin Maker I want this persn t make my medical decisins if I cannt make my wn first name last name ( ) ( ) hme number wrk number relatinship street address city state zip cde If the first persn cannt d it, then I want this persn t make my medical decisins. Als, if the first persn is a spuse and yu divrce, the dctrs will turn t this persn. first name last name ( ) ( ) hme number wrk number relatinship street address city state zip cde Put an X next t the sentence yu agree with. My medical decisin maker can make decisins fr me right after I sign this frm. My medical decisin maker will make decisins fr me nly after I cannt make my wn decisins. Hw d yu want yur medical decisin maker t fllw yur healthcare wishes? Put an X next t the ne sentence yu mst agree with. Ttal Flexibility: It is OK fr my decisin maker t change any f my medical decisins if my dctrs think it is best fr me at that time. Sme Flexibility: It is OK fr my decisin maker t change sme f my decisins if the dctrs think it is best. But, these are sme wishes I never want changed: N flexibility: I want my decisin maker t fllw my medical wishes exactly, n matter what. It is nt OK t change my decisins, even if the dctrs recmmend it. T make yur wn health care chices g t Part 2 n the next page. If yu are dne, yu must sign this frm n page 9. 5
Pennsylvania Advance Health Care Directive Part 2 Make yur wn health care chices Write dwn yur chices s thse wh care fr yu will nt have t guess. Think abut what makes yur life wrth living. Put an X next t all the sentences yu mst agree with. My life is nly wrth living if I can: m talk t family r friends m wake up frm a cma m feed, bathe, r take care f myself m be free frm pain m live withut being hked up t machines m My life is always wrth living n matter hw sick I am m I am nt sure If I am dying, it is imprtant fr me t be: at hme in the hspital I am nt sure Is religin r spirituality imprtant t yu? n yes If yu have ne, what is yur religin? What shuld yur dctrs knw abut yur religius r spiritual beliefs? If yu are sick, yur dctrs and nurses will always try t keep yu cmfrtable and free frm pain. 6 Yur Name:
Part 2: Make yur wn health care chices Pennsylvania Advance Health Care Directive Life supprt treatments are used t try t keep yu alive. These can be CPR, a breathing machine, feeding tubes, dialysis, bld transfusins, r medicine. Please read this whle page befre yu make yur chice. Put an X next t the ne chice yu mst agree with. If I am s sick that I may die sn: Try all life supprt treatments that my dctrs think might help. If the treatments d nt wrk and there is little hpe f getting better, I want t stay n life supprt machines even if I am suffering. Try all life supprt treatments that my dctrs think might help. If the treatments d nt wrk and there is little hpe f getting better, I d NOT want t stay n life supprt machines. If I am suffering, I want t stp. I d nt want life supprt treatments, and I want t fcus n being cmfrtable. I prefer t have a natural death. I want my medical decisin maker t decide fr me. I am nt sure. * If yu are pregnant and becme unable t make decisins: Pennsylvania law may require yur dctr t give yu life supprt treatments even if yu have an advance directive. If yu want t write dwn medical wishes that are nt n this frm, g t page 9. Yur Name: 7
Part 2: Make yur wn health care chices Pennsylvania Advance Health Care Directive Yur dctrs may ask abut rgan dnatin and autpsy after yu die. Please tell us yur wishes. Put an X next t the ne chice yu mst agree with. Dnating (giving) yur rgans can help save lives. I want t dnate my rgans. Which rgans d yu want t dnate? m any rgan m nly I d nt want t dnate my rgans. I want my decisin maker t decide. I am nt sure. An autpsy can be dne after death t find ut why smene died. It is dne by surgery. It can take a few days. I want an autpsy. I d nt want an autpsy. I nly want an autpsy if there are questins abut my death. I want my decisin maker t decide. I am nt sure. What shuld yur dctrs knw abut hw yu want yur bdy t be treated after yu die? D yu have funeral r burial wishes? 8 Yur Name:
Part 2: Make yur wn health care chices Pennsylvania Advance Health Care Directive What ther wishes are imprtant t yu? Part 3 Sign the frm Befre this frm can be used, yu must: sign this frm if yu are at least 18 years f age have tw witnesses sign the frm Sign yur name and write the date. sign yur name / / date print yur first name print yur last name address city state zip cde 9
Pennsylvania Advance Health Care Directive Part 3 Witnesses Befre this frm can be used yu must have 2 witnesses sign the frm Yur witnesses must: be ver 18 years f age knw yu see yu sign this frm Yur witnesses cannt: be yur medical decisin maker be yur health care prvider wrk fr yur health care prvider wrk at the place that yu live Als, ne witness cannt: be related t yu in any way benefit financially (get any mney r prperty) after yu die Witnesses need t sign their names n the next page. 10
Part 3: Sign the frm Pennsylvania Advance Health Care Directive Have yur witnesses sign their names and write the date By signing, I prmise that signed this frm while I watched. (name) He/she was thinking clearly and was nt frced t sign it. I als prmise that: I knw this persn and he/she culd prve wh he/she was. I am 18 years r lder I am nt his/her medical decisin maker I am nt his/her health care prvider I d nt wrk fr his/her health care prvider I d nt wrk where he/she lives One witness must als prmise that: I am nt related t him/her by bld, marriage, r adptin I will nt benefit financially (get any mney r prperty) after he/she dies Witness #1 sign yur name / / date print yur first name print yur last name address city state zip cde Witness #2 sign yur name / / date print yur first name print yur last name address city state zip cde 11
Pennsylvania Advance Health Care Directive Yu are nw dne with this frm. Share this frm with yur family, friends, and medical prviders. Talk with them abut yur medical wishes This advance directive is in cmpliance with the Pennsylvania Prbate Cde 20 PA. C.S.A. 5421-5431. This wrk is licensed under the Creative Cmmns Attributin-NnCmmercial-ShareAlike License. http://creativecmmns.rg/licenses/by-nc-sa/2.0/ 2015 Rebecca Sudre, MD 12 Revised10/15/2015