|
Living
Will a Medical Directive
|
|
Full Name:______________________________________________ Address:________________________________________________ City:_________________________________ Province:_________________________ Postal Code: _________________ Phone: ________________________ Doctor's Name:__________________________________________ Doctor's Address:_______________________________________________ Phone: ________________________ At this time I, ____________________________________ am of sound mind and capable of making these decisions. I have carefully considered the ramifications if I refuse certain medical treatment should I become seriously incapacitated. It is my wish to die with dignity without the use of extraordinary measures. If, in the opinions of two or more doctors, I am terminally ill and there is no immediate hope of recovery, I expect that no artificial means be used to keep me alive, such as antibiotics, resuscitation, tube feeding, hydration or other life-support systems. I expect to receive basic palliative care, however, and I request that drugs be used to keep me pain-free even if my life is further shortened. I have the following wishes regarding autopsy: ____________________________________________________________________________________________ I have the following wishes regarding organ/tissue donation: _____________________________________________________________________________________________ The following person is hereby appointed by me to act as my medical power of attorney in the event he/she is consulted about my wishes. Full Name:______________________________________________ Address:________________________________________________ City:_________________________________ Province:_________________________ Postal Code: _________________ Phone: ________________________ My Signature:____________________________________________________ Date:________________________ Witness Name:___________________________ Signature of Witness:__________________________________ Address of Witness:___________________________________________________________________________ Witness Name:___________________________ Signature of Witness:__________________________________ Address of Witness:___________________________________________________________________________ Notary Public:________________________________________________________________________________ |
||
|
[Home] All rights reserved. Copyright 2000. |