Advance Directive Form for Persons Choosing Not to Follow Quarantine, Isolation, or Social Distancing Guidelines
I, _____________________________________________________________, write this document as a directive regarding my medical care.
In the following sections, put the initials of your name in the blank spaces by the choices you want.
PART 1. My Durable Power of Attorney for Health Care
_____ I have not appointed anyone to make health care decisions for me in this or any other document.
PART 2. My Living Will
These are my wishes for my future medical care if there ever comes a time when I can't make these decisions for myself.
A. These are my wishes if I have a terminal condition
Life-sustaining treatments _____ I do not want life-sustaining treatment (including CPR) started. If life-sustaining treatments are started, I want them stopped.
Artificial nutrition and hydration _____ I do not want artificial nutrition and hydration started if they would be the main treatments keeping me alive. If artificial nutrition and hydration are started, I want them stopped.
Comfort care _____ I want to be kept as comfortable and free of pain as possible, unless such care prolongs my dying.
B. These are my wishes if I am ever in a persistent vegetative state
_____ I do not want life-sustaining treatments (including CPR) started. If life-sustaining treatments are started, I want them stopped.
Artificial nutrition and hydration _____ I do not want artificial nutrition and hydration started if they would be the main treatments keeping me alive. If artificial nutrition and hydration are started, I want them stopped.
Comfort care _____ I want to be kept as comfortable and free of pain as possible, unless such care prolongs my dying.
C. Other directions
You have the right to be involved in all decisions about your medical care, even those not dealing with terminal conditions or persistent vegetative states. If you have wishes not covered in other parts of this document, please indicate them below.
I have chosen to risk my life and health, and those of others to whom I may be exposed. I choose to take personal responsibility for the risks I have chosen to take. If it should be determined that another person became ill from the Sars-CoV-2 (COVID-19) virus, or died from the Sars-CoV-2 (COVID-19) virus as a result of my actions, I hereby direct the executor/executrix of my estate to ensure my estate recompense to the fullest extent possible those who were so harmed.
PART 3. Other Wishes
A. Organ donation _____ I want to donate all of my organs and tissues.
B. Autopsy _____ I agree to an autopsy if my doctors wish it.
C. Other statements about your medical care If you wish to say more about any of the choices you have made or if you have any other statements to make about your medical care, you may do so on a separate piece of paper. If you do so, put here the number of pages you are adding:
___None__________
PART 4. Signatures
You and two witnesses must sign this document before it will be legal.
A. Your signature By my signature below, I show that I understand the purpose and the effect of this document. Signature _____________________________________________________ Date ______ Address ___________________________________________________________________
B. Your witnesses' signatures I believe the person who has signed this advance directive to be of sound mind, that he/she signed or acknowledged this advance directive in my presence and that he/she appears not to be acting under pressure, duress, fraud or undue influence. I am not related to the person making this advance directive by blood, marriage or adoption nor, to the best of my knowledge, am I named in his/her will. I am not the person appointed in this advance directive. I am not a health care provider or an employee of a health care provider who is now, or has been in the past, responsible for the care of the person making this advance directive.
Witness #1 Signature _____________________________________________________ Date ______ Address ___________________________________________________________________
Witness #2 Signature _____________________________________________________ Date ______ Address ___________________________________________________________________