FlowersConsent to Withhold Life Sustaining Treatment


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***Special Note***

The following is a copy of the actual document I am given each year to sign on my mother's behalf.

I, ____________________________choose to exercise my right to self-determination by informed decision regarding life-sustaining, resuscitative treatment In the event a situation arises when I am not breathing independently or I suffer cardiac arrest, I understand the choices I have. My signature below is acknowledgment of my understanding.

(Check one)

1. Resuscitation. I choose to have cardio-pulmonary resuscitation (CPR) performed. I understand this procedure and the effects that it may have on me My physician has explained this to me. _____________

2 Not be resuscitated. I choose to not have CPR performed. I understand that no life sustaining or "Heroic measures' will be taken to prolong my life. I understand that I will be kept comfortable and my dignity preserved and protected. ______________

Please indicate choice: (check one)

______________It is my wish, after being given written and verbal information from both my physician and this facility to be resuscitated and have my life preserved and sustained by any and all means available.

______________It is my wish, after being given written and verbal information from both my physician and this facility to not be resuscitated. I understand that my physician will order D.N.R. in my medical record, and that I will be allowed to continue my life comfortably and with dignity.



In the event that I am choking, I understand that the Heimlich Maneuver will be performed as it is non invasive and is intended only to clear obstructive material from mv airway.



Signature of Patient ______________________________Date _________________

Signature of patient Representative____________________________ Date__________________

Signature of Facility Representative_____________________________Date__________________

Witness_________________________Date___________________

(check one)

__________Durable Power Of Attorney for Health Care

__________Guardian

__________Responsible party without legal power



Living Will, Power of Attorney, Letter of Guardianship or other Advanced Medical Directives on file with: ______________________________________(name of facility)

Yes____________

No ____________

Signed Acknowledgment of Advanced Directives:

Yes__________

No___________

............................................................................................................................................................................................

It is my understanding that my patient_____________________________, and the patient's family are informed and understand self-determination, their choice to receive or refuse life-sustaining treatment.

Signature of Physician_________________________________

Date ___________________

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