Consent to Withhold Life Sustaining Treatment
***Special Note***
The following is a copy of the actual document I am given each year to sign on my mother's behalf.
(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.
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
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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