Advance Directive: My Patient Advocate

If I am no longer able to make my own health care decisions, this document names the person I choose to make these choices for me. This person will be my Patient Advocate. This person will make my health care decisions when I am determined, by either two physicians or a physician and licensed psychologist, to be incapable of making health care decisions. I understand that it is important to have ongoing discussions with my Patient Advocateabout my health and health care choices. I hereby give my Patient Advocate permission to send a copy of the document to other doctors, hospitals and health care providers that provide my medical care. (NOTE: If your wishes change, you may revoke your patient Advocate Designation at any time and in any manner sufficient to communicate an intent to revoke. It is recommended that you complete a new Advance Directive and give it to everyone who has a previous copy.)

Advance Directive:

My Patient Advocate
The person I choose as my Patient Advocate is

Name: [NAME]
Relationship (if any):
Telephone (Day): [PHONE NUMBER]
(Evening): [PHONE NUMBER]
(Cell): [PHONE NUMBER]
Address: [STREET ADDRESS]
City/State/Zip Code: [CITY, STATE, ZIP CODE]

First Alternate (Successor) Patient Advocate (strongly advised)
If Patient Advocate above is not capable or willing to make these choices for me, then I designate the following person to serve as my Patient Advocate.

Name: [NAME]
Relationship (if any):
Telephone (Day): [PHONE NUMBER]
(Evening): [PHONE NUMBER]
(Cell): [PHONE NUMBER]
Address: [STREET ADDRESS]
City/State/Zip Code: [CITY, STATE, ZIP CODE]

I have instructed my Patient Advocate(s) concerning my wishes and goals in the use of lifesustaining treatment – such as, but not limited to: ventilator (breathing machine), cardiopulmonary resuscitation (CPR), nutritional tube feedings, intravenous hydration, kidney dialysis, blood pressure or antibiotic medications—and hereby give my Patient Advocate(s) express permission to help me achieve my goals of care. This may include beginning, not starting, or stopping treatment(s). I understand that such decisions could or would allow my death. Medications and treatment intended to provide comfort or pain relief shall not be withheld or withdrawn.

I expressly authorize my Patient Advocate to make decisions to withhold or withdraw treatment which would allow me to die, and I acknowledge such decisions could or would allow my death.

Signature of the Individual in the Presence of the Following Witnesses

I am providing these instructions of my own free will. I have not been required to give them in order to receive care or have care withheld or withdrawn. I am at least eighteen (18) years old and of sound mind.

Signature: _______________________________________________
Date: [DAY] day of [MONTH], 20[XX]
Address: [STREET ADDRESS]
City/State/Zip Code: [CITY, STATE, ZIP CODE]

Signatures of Witnesses

I know this person to be the individual identified as the “Individual” signing this form. I believe him or her to be of sound mind and at least eighteen (18) years of age. I personally saw him or her sign this form, and I believe that he or she did so voluntarily and without duress, fraud, or undue influence. By signing this document as a witness, I certify that I am:

• At least 18 years of age.
• Not the Patient Advocate or alternate Patient Advocate appointed by the person signing this document.
• Not the patient’s spouse, parent, child, grandchild, sibling or presumptive heir.
• Not listed to be a beneficiary of, or entitled to, any gift from the patient’s estate.
• Not directly financially responsible for the patient’s health care.
• Not a health care provider directly serving the patient at this time.
• Not an employee of a health care or insurance provider directly serving the patient at this time.

Witness Number 1:
Signature: _______________________________________________
Date: [DAY] day of [MONTH], 20[XX]
Print Name: [NAME]
Address: [STREET ADDRESS]
City/State/Zip Code: [CITY, STATE, ZIP CODE]

Witness Number 2:
Signature: _______________________________________________
Date: [DAY] day of [MONTH], 20[XX]
Print Name: [NAME]
Address: [STREET ADDRESS]
City/State/Zip Code: [CITY, STATE, ZIP CODE]