MEDICAL DIRECTIVE OF 
_______________________________

(client name)

This Medical Directive expresses, and shall stand for, my wishes regarding medical treatments in the event that illness should make me unable to communicate them directly. I, _________________, of ___________________, Alaska, make this Directive, being 18 years or more of age, of sound mind, and appreciating the consequences of my decisions. 
 


SITUATION A

If I am in a coma or a persistent vegetative state and, in the opinion of my physician and two consultants, have no known hope of regaining awareness and higher mental functions no matter what is done, then my wishes -- if medically reasonable -- for this and any additional illness would be: 
 
 

I want


I want treatment tried. 
If no clear 
improvement stop.

I am undecided

I do not want

1. Cardiopulmonary resuscitation (chest compressions, drugs, electric shocks, and artificial breathing aimed at reviving a person who is on the point of dying) or major surgery (for example, removing the gall bladder or part of the colon)   N/A    
2. Mechanical breathing (respiration by machine, through a tube in the throat), or dialysis (cleaning the blood by machine or by fluid passed through the belly).        
3. Blood transfusions or blood products.   N/A    
4. Artificial nutrition and hydration (given through a tube in a vein or in the stomach)        
5. Simple diagnostic tests (for example, blood tests or x-rays), or antibiotics (drugs to fight infection)   N/A    
6. Pain medications, even if they dull consciousness and indirectly shorten my life.   N/A    
THE GOAL OF MEDICAL CARE SHOULD BE: ____prolong life, treat everything 

____choose quality of life over longevity 

____provide comfort care only 

____other (please specify) 

________________________________ 

________________________________


 

SITUATION B

If I am in a coma or a persistent vegetative state and, in the opinion of my physician and two consultants, have a small but uncertain chance of regaining higher mental functions, a somewhat greater chance of surviving with permanent brain damage, and a much greater chance of not recovering at all, then my wishes -- if medically reasonable -- for this and any additional illness would be: 
 

I want


I want treatment tried. 
If no clear 
improvement stop.

I am undecided

I do not want

1. Cardiopulmonary resuscitation (chest compressions, drugs, electric shocks, and artificial breathing aimed at reviving a person who is on the point of dying) or major surgery (for example, removing the gall bladder or part of the colon)   N/A    
2. Mechanical breathing (respiration by machine, through a tube in the throat), or dialysis (cleaning the blood by machine or by fluid passed through the belly).        
3. Blood transfusions or blood products.   N/A    
4. Artificial nutrition and hydration (given through a tube in a vein or in the stomach)        
5. Simple diagnostic tests (for example, blood tests or x-rays), or antibiotics (drugs to fight infection)   N/A    
6. Pain medications, even if they dull consciousness and indirectly shorten my life.   N/A    
THE GOAL OF MEDICAL CARE SHOULD BE: ____prolong life, treat everything 

____choose quality of life over longevity 

____provide comfort care only 

____other (please specify) 

________________________________ 

________________________________

SITUATION C

If I have brain damage or some brain disease that in the opinion of my physician and two consultants cannot be reversed and that makes me unable to recognize people, to speak meaningfully to them, or to live independently, and I also have a terminal illness, then my wishes -- if medically reasonable -- for this and any additional illness would be: 
 

I want


I want treatment tried. 
If no clear 
improvement stop.

I am undecided

I do not want

1. Cardiopulmonary resuscitation (chest compressions, drugs, electric shocks, and artificial breathing aimed at reviving a person who is on the point of dying) or major surgery (for example, removing the gall bladder or part of the colon)   N/A    
2. Mechanical breathing (respiration by machine, through a tube in the throat), or dialysis (cleaning the blood by machine or by fluid passed through the belly).        
3. Blood transfusions or blood products.   N/A    
4. Artificial nutrition and hydration (given through a tube in a vein or in the stomach)        
5. Simple diagnostic tests (for example, blood tests or x-rays), or antibiotics (drugs to fight infection)   N/A    
6. Pain medications, even if they dull consciousness and indirectly shorten my life.   N/A    
THE GOAL OF MEDICAL CARE SHOULD BE: ____prolong life, treat everything 

____choose quality of life over longevity 

____provide comfort care only 

____other (please specify) 

________________________________ 

________________________________

SITUATION D

If I have brain damage or some brain disease that in the opinion of my physician and two consultants cannot be reversed and that makes me unable to recognize people, to speak meaningfully to them, or to live independently, but I have no terminal illness, then my wishes -- if medically reasonable -- for this and any additional illness would be: 
 

I want

I want treatment tried. 

If no clear improvement stop.

I am undecided

I do not want

1. Cardiopulmonary resuscitation (chest compressions, drugs, electric shocks, and artificial breathing aimed at reviving a person who is on the point of dying) or major surgery (for example, removing the gall bladder or part of the colon)   N/A    
2. Mechanical breathing (respiration by machine, through a tube in the throat), or dialysis (cleaning the blood by machine or by fluid passed through the belly).        
3. Blood transfusions or blood products.   N/A    
4. Artificial nutrition and hydration (given through a tube in a vein or in the stomach)        
5. Simple diagnostic tests (for example, blood tests or x-rays), or antibiotics (drugs to fight infection)   N/A    
6. Pain medications, even if they dull consciousness and indirectly shorten my life.   N/A    
THE GOAL OF MEDICAL CARE SHOULD BE: ____prolong life, treat everything 

____choose quality of life over longevity 

____provide comfort care only 

____other (please specify) 

________________________________ 

________________________________

SITUATION E



If in the opinion of my physician and two consultants, I have an incurable chronic illness that involves mental disability or physical suffering and ultimately causes death, and in addition I have an illness that is immediately life threatening but reversible, and I am temporarily unable to make decisions, then my wishes -- if medically reasonable -- for this and any additional illness would be: 
 

I want


I want treatment tried. 
If no clear 
improvement stop.

I am undecided

I do not want

1. Cardiopulmonary resuscitation (chest compressions, drugs, electric shocks, and artificial breathing aimed at reviving a person who is on the point of dying) or major surgery (for example, removing the gall bladder or part of the colon)   N/A    
2. Mechanical breathing (respiration by machine, through a tube in the throat), or dialysis (cleaning the blood by machine or by fluid passed through the belly).        
3. Blood transfusions or blood products.   N/A    
4. Artificial nutrition and hydration (given through a tube in a vein or in the stomach)        
5. Simple diagnostic tests (for example, blood tests or x-rays), or antibiotics (drugs to fight infection)   N/A    
6. Pain medications, even if they dull consciousness and indirectly shorten my life.   N/A    
THE GOAL OF MEDICAL CARE SHOULD BE: ____prolong life, treat everything 

____choose quality of life over longevity 

____provide comfort care only 

____other (please specify) 

________________________________ 

________________________________

SITUATION F



If I am in my current state of health (describe briefly and then have an illness that, in the opinion of my physician and two consultants, is life threatening but reversible, and I am temporarily unable to make decisions, then my wishes -- if medically reasonable -- for this and any additional illness would be: 
 

I want


I want treatment tried. 
If no clear 
improvement stop.

I am undecided

I do not want

1. Cardiopulmonary resuscitation (chest compressions, drugs, electric shocks, and artificial breathing aimed at reviving a person who is on the point of dying) or major surgery (for example, removing the gall bladder or part of the colon)   N/A    
2. Mechanical breathing (respiration by machine, through a tube in the throat), or dialysis (cleaning the blood by machine or by fluid passed through the belly).        
3. Blood transfusions or blood products.   N/A    
4. Artificial nutrition and hydration (given through a tube in a vein or in the stomach)        
5. Simple diagnostic tests (for example, blood tests or x-rays), or antibiotics (drugs to fight infection)   N/A    
6. Pain medications, even if they dull consciousness and indirectly shorten my life.   N/A    
THE GOAL OF MEDICAL CARE SHOULD BE: ____prolong life, treat everything 

____choose quality of life over longevity 

____provide comfort care only 

____other (please specify) 

________________________________ 

________________________________

MY PERSONAL STATEMENT



Please mention anything that would be important for your physician and your proxy to know. In particular, try to answer the following questions: 
 

1. What medical conditions, if any, would make living so unpleasant that you would want life-sustaining treatment withheld? (Intractable pain? Irreversible mental damage? Inability to share love? Dependence on others? Another condition you would regard as intolerable? 
 
 
 
 
 

2. Under what medical circumstances would you want to stop interventions that might already have been started? 
 
 
 
 
 
 
 

Should there be any difference between my preferences detailed in the illness situations and those understood from my goals or from my personal statement, I wish my treatment selections/my goals/my personal statement (please delete as appropriate) to be given greater weight. 
 

When I am dying, I would like -- if my proxy and my health care team think it is reasonable -- to be cared for 
 

____ at home or in a hospice 

____ in a nursing home 

____ in a hospital 

____ other (please specify) __________________________________ 
 


ORGAN DONATION



____ I hereby make this anatomical gift, to take effect after my death: 
 

I give ____ my body 

____ any needed organs, tissue, or parts 

____ the following parts:____________________________ 
 

to: ____ the following person or institution: ___________ 

____ the physician in attendance at my death 

____ the hospital in which I die 

____ the following physician, hospital storage bank, or 

other medical institution: 
 
 
 

for: ____ any purpose authorized by law 

____ therapy of another person 

____ medical education 

____ transplantation 

____ research 
 

____ I do not wish to make any anatomical gift from my body. 
 
 
 
 
 
 
 
 
 
 

DURABLE POWER OF ATTORNEY FOR HEALTH CARE
 

I appoint as my proxy decision-maker(s): 
 

(Name and address) 

First Alternate: 

Second Alternate: 
 
 
 

I direct my proxy to make health-care decisions based on his/her assessment of my personal wishes. If my personal desires are unknown, my proxy is to make health-care decisions based on his/her best guess as to my wishes. My proxy shall have the authority to make all health-care decisions for me, including decisions about life-sustaining treatment, if I am unable to make them myself. My proxy's authority becomes effective if my attending physician determines in writing that I lack the capacity to make or to communicate health-care decisions. My proxy is then to have the same authority to make health-care decisions as I would, if I had the capacity to make them, EXCEPT (list the limitations, if any, you wish to place on your proxy's authority): 
 
 
 

Should there be any disagreement between the wishes I have indicated in this document and the decisions favored by my above-named proxy, I wish my proxy to have authority over my written statements/I wish my written statements to bind my proxy. (Please delete as necessary) If I have appointed more than one proxy and there is disagreement between their wishes, ____________________________ shall have final authority. 
 
 
 

Signed: 

Signature Printed Name 
 

Address 
 

Witness:

Signature Printed Name 
 

Address 
 

Witness: 

Signature Printed Name 
 

Address 
 

Physician: (optional): 
 

I am ______________________'s physician. I have seen this advance care document and have had an opportunity to discuss his/her preferences regarding medical interventions at the end of life. If becomes incompetent, I understand that it is my duty to interpret, and implement the preferences contained in this document in order to fulfill his/her wishes. 
 

Signature Printed Name 
 

Address





Copyright © Valerie M. Therrien
Attorney-at-Law, P.C.