SYS_Advance Directive Booklet

Your Name:

Pennsylvania Advance

Health Care Directive

This form lets you have a say about how

you want to be treated if you get very sick.

Choose a medical decision-maker

A medical decision-maker is a person who can make health

care decisions for you if you are too sick to make them yourself.

Make your own health care choices

This form lets you choose the kind of health care you want.

This way, those who care for you will not have to guess what

you want if you are too sick to tell them yourself.

Sign the form

It must be signed before it can be used.

You can fill out Part 1, Part 2, or both.

Fill out only the parts you want. Always sign the form in

Part 3. 2 witnesses need to sign on page 11.

This form has 3 parts. It lets you:

Pennsylvania Advance Health Care Directive

If you only want to name a medical decision-maker:

go to Part 1 on page 3.

If you only want to make your own health care choices:

go to Part 2 on page 6.

If you want both:

fill out Part 1 and Part 2.

Always sign the form in Part 3 on page 9.

2 witnesses need to sign on page 11.

Fill out a new form.

Tell those who care for you about your changes.

Give the new form to your medical decision-maker and doctor.

What if I change my mind?

What if I have questions about the form?

Ask your doctors, nurses, social workers, friends, or family to

answer your questions. Lawyers can help too.

What if I want to make health care choices that are not on

this form?

Write your choices on page 9.

Share this form and your choices with your family, friends,

and medical providers.

Pennsylvania Advance Health Care Directive

PART 1

The person who can make health care decisions

for you if you are too sick to make them yourself.

Is at least 18 years old

Knows you well

Can be there for you when you need them

You trust to do what is best for you

Can tell your doctors about the decisions you made on this

form

Whom should I choose to be my medical decision-maker?

A family member or friend who:

Your decision-maker cannot be your doctor or someone who

works at your hospital or clinic, unless he/she is a family member.

What will happen if I do not choose a medical decision-maker?

If you are too sick to make your own decisions, a person will be

chosen for you according to Pennsylvania law. This person may

not know what you want.

What kinds of decisions can my medical decision-maker make?

Doctors, nurses, social workers

Hospitals, clinics, or where you live

Medications, tests, or treatments

What happens to your body and organs after you die

Agree to, say no to, change, stop or choose:

Your decision-maker will need to follow the health

care choices you make in Part 2.

Choose your medical decision-maker

Pennsylvania Advance Health Care Directive

PART 1

Other decisions your medical decision-maker can make:

Life Support Treatments

Medical care to try to help you live longer

CPR or cardiopulmonary resuscitation

(cardio = heart) (pulmonary = lungs) (resuscitation = to bring back)

This may involve:

Pressing hard on your chest to keep your blood pumping

Electrical shocks to jump-start your heart

Medicines in your veins

Choose your medical decision-maker

Breathing machine or ventilator

The machine pumps air into your lungs and breathes for you.

You are not able to talk when you are on the machine.

Dialysis

A machine that cleans your blood if your kidneys stop working.

Feeding Tube

A tube used to feed you if you cannot swallow. The tube is

placed down your throat into your stomach. It can also be

placed by surgery.

Blood transfusions

To put blood in your veins.

Surgery

Medicines

Call in a spiritual leader

Decide if you die at home or in the hospital

Decide where you should be buried

End of Life Care

If you might die soon your medical decision-maker can:

Show your medical decision-maker this form.

Tell your decision maker what kind of medical care you want.

Pennsylvania Advance Health Care Directive

PART 1

I want this person to make my medical decisions if I cannot make my own.

Your Medical Decision Maker

First Name

Last Name

Home Number Work Number Relationship

Street Address City Zip CodeState

If the first person cannot do it, then I want this person to make my medical decisions.

Also, if the first person is a spouse and you divorce, the doctors will turn to this person.

First Name Last Name

Home Number Work Number Relationship

Street Address City Zip CodeState

Put an X next to the sentence you agree with:

My medical decision-maker can make decisions for me right after I sign this form.

My medical decision-maker will make decisions for me only after I cannot make my own decisions.

How do you want your medical decision maker to follow your healthcare wishes?

Put an X next to the one sentence you most agree with:

Total Flexibility: It is OK for my decision-maker to change any of my medical decisions if

my doctors think it is best for me at that time.

Some Flexibility: It is OK for my decision-maker to change some of my decisions if the

doctors think it is best. But, these are some wishes I never want changed:

No Flexibility: I want my decision maker to follow my medical wishes exactly, no matter what.

It is not OK to change my decisions, even if the doctors recommend it.

To make your own health care choices, go to Part 2 on the next page.

If you are done, you must sign this form on page 9.

Pennsylvania Advance Health Care Directive

PART 2

Write down your choices so those who care for you will not have to guess.

Make your own health care choices

Think about what makes your life worth living.

Put an X next to all the sentences you most agree with:

My life is only worth living if I can:

Talk to family or friends

Wake up from a coma

Feed, bathe, or take care of myself

Be free from pain

Live without being hooked up to machines

My life is always worth living no matter how sick I am

I am not sure

If I am dying, it is important for me to be:

At home In the hospital I am not sure

Is religion or spirituality important to you?

No Yes If you have one, what is your religion?

What should your doctors know about your religious or spiritual beliefs?

If you are sick, your doctors and nurses will always

try to keep you comfortable and free from pain.

Your Name:

Pennsylvania Advance Health Care Directive

PART 2

Life support treatments are used to try to keep you alive. These can be CPR, a

breathing machine, feeding tubes, dialysis, blood transfusions, or medicine.

Make your own health care choices

Please read this whole page before you make your choice.

Put an X next to the one choice you most agree with.

If I am so sick that I may die soon:

Try all life support treatments that my doctors think might help. If

the treatments do not work and there is little hope of getting better,

I want to stay on life support machines even if I am suffering.

Try all life support treatments that my doctors think might help. If

the treatments do not work and there is little hope of getting better,

I do NOT want to stay on life support machines. If I am suffering, I

want to stop.

I do not want life support treatments, and I want to focus on being

comfortable. I prefer to have a natural death.

I want my medical decision-maker to decide for me.

I am not sure.

*If you are pregnant and become unable to make decisions:

Pennsylvania law may require your doctor to give you life support

treatments even if you have an advance directive.

Your Name:

If you want to write down medical wishes

that are not on this form, go to page 9.

Pennsylvania Advance Health Care Directive

PART 2

Your doctors may ask about organ donation and autopsy after you die.

Please tell us your wishes.

Make your own health care choices

Put an X next to the one choice you most agree with.

Donating (giving) your organs can help save lives.

I want to donate my organs.

Which organs do you want to donate?

Any organ

Only:

I do not want to donate my organs.

I want my decision-maker to decide.

I am not sure.

An autopsy can be done after death to find out why someone died. It

is done by surgery. It can take a few days.

I want an autopsy.

I do not want an autopsy.

I only want an autopsy if there are questions about my death.

I want my decision-maker to decide.

I am not sure.

What should your doctors know about how you want your body to be

treated after you die? Do you have funeral or burial wishes?

8 Your Name:

Pennsylvania Advance Health Care Directive

PART 2

What other wishes are important to you?

Make your own health care choices

PART 3

Before this form can be used, you must:

Sign the form

Sign this form if you are at least 18 years of age

Have 2 witnesses sign the form

Sign your name and write the date.

Sign your name Date

Print your first name Print your last name

Address City State Zip Code

/ /

Pennsylvania Advance Health Care Directive

PART 3

Before this form can be used you must

have 2 witnesses sign the form

Witnesses

Be over 18 years of age

Know you

See you sign this form

Your witnesses must:

Be your medical decision-maker

Be your health care provider

Work for your health care provider

Work at the place that you live

Your witnesses cannot:

Be related to you in any way

Benefit financially (get any money or property) after you die

Also, one witness cannot:

Witnesses need to sign their

names on the next page.

Pennsylvania Advance Health Care Directive

PART 3

Have your witnesses sign their

names and write the date

Witnesses Signing

By signing, I promise that

signed this form while I watched.

(name)

He/she was thinking clearly and was not forced to sign it. I also promise that:

I know this person and he/she could prove who he/she was

I am 18 years or older

I am not his/her medical decision-maker

I am not his/her health care provider

I do not work for his/her health care provider

I do not work where he/she lives

One witness must also promise that:

I am not related to him/her by blood, marriage, or adoption

I will not benefit financially (get any money or property) after he/she dies

Witness #1

Sign your name Date

Print your first name Print your last name

Address City State Zip Code

/ /

Sign your name Date

Print your first name Print your last name

Address City State Zip Code

/ /

Witness #2

Pennsylvania Advance Health Care Directive

You are now done with this form.

Share this form with your family,

friends, and medical providers.

Talk with them about your medical

wishes.

This advance directive is in compliance with the Pennsylvania Probate Code 20 PA. C.S.A. §§ 5421-5431.

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