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Pennsylvania Medical Directive Templates Free Download
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Pennsylvania Medical Directive DECLARATION I, _________, being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment. In addition, if I am in the condition described above, I feel especially strong about the following forms of treatment: I ( ) do ( ) do not want cardiac resuscitation. I ( ) do ( ) do not want mechanical respiration. I ( ) do ( ) do not want tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water). I ( ) do ( ) do not want blood or blood products. I ( ) do ( ) do not want any form of surgery or invasive diagnostic tests. I ( ) do ( ) do not want kidney dialysis. I ( ) do ( ) do not want antibiotics. I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment. Other instructions: I ( ) do ( ) do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness. Name and address of surrogate (if applicable): Name and address of substitute surrogate (if surrogate designated above is unable to serve): I made this declaration on the _________ day of _________(month, year). Declarant's signature: Declarant's address: The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence. Witness's signature: Witness's address: Witness's signature: Witness's address: Other Forms You May Need * Pennsylvania General Durable Power of Attorney for Property & Finances (Immediate) * Pennsylvania General Durable Power of Attorney for Property & Finances (Upon Disability) * Pennsylvania Durable Health Care Power of Attorney and Health Care Treatment Instructions (Living Will)click to download Pennsylvania Medical Directive template
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