Fillable ADVANCE HEALTHCARE DIRECTIVE FORM

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ADVANCE HEALTHCARE DIRECTIVE FORM

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ADVANCE HEALTHCARE DIRECTIVE FORM
This Advance Healthcare Directive form, created as a courtesy by Lancaster General
Health, consists of both a Healthcare Power of Attorney and a Living Will. This
document expresses my wishes and instructions for medical care when I am unable to
make medical decisions for myself.
My Personal Information
Name:
Street Address:
City, State, Zip Code:
Telephone: ( )
Date of Birth:
PART I: HEALTHCARE POWER OF ATTORNEY
Part I allows you to appoint a person to make healthcare decisions for you when you
are unable to make healthcare decisions for yourself. If you do not appoint a person in
this Part I, the person(s) identified in 20 Pa.C.S.A. §5461(d) are authorized to make
healthcare decisions for you.
A. No Healthcare Agent
Initial the box below if you choose not to appoint a person to make healthcare decisions
for you when you are unable to make healthcare decisions for yourself. You are not
required to appoint a person. If you initial the box below, DO NOT complete Sections B,
C, D, and E, below.
I choose not to appoint a healthcare agent.
B. My Healthcare Agent
I designate the person below to be my healthcare agent:
Name:
Street Address:
City, State, Zip Code:
Telephone: ( ) Cell Phone: ( )
C. My First Alternate Healthcare Agent
If the person in Section B is unable or unwilling to serve as my healthcare agent, I
appoint the following individual as my alternate healthcare agent:
Name:
Street Address:
City, State, Zip Code:
Telephone: ( ) Cell Phone: ( )
My Second Alternate Healthcare Agent
If my first alternate healthcare agent is unable or unwilling to serve as my healthcare
agent, I appoint the following individual as my second alternate healthcare agent:
Name:
Street Address:
City, State, Zip Code:
Telephone: ( ) Cell Phone: ( )
D. Authority of My Healthcare Agent
My healthcare agent has the authority to make the following healthcare decisions for me
in the event I am unable to make these healthcare decisions for myself. (You may
cross out any healthcare decisions below that you do not want your healthcare agent to
make.)
1. To authorize, withhold, or withdraw medical care and surgical procedures.
2. To authorize, withhold, or withdraw nutrition (food) or hydration (water) medically
supplied by tube through my nose, stomach, intestines, arteries, or veins.
3. To authorize my admission to, or discharge from, a medical, nursing, residential,
or similar facility and to make agreements for my care and health insurance for
my care, including hospice and/or palliative care.
4. To hire and fire medical, social service, and other support personnel responsible
for my care.
5. To take any legal action necessary to do what I have directed.
6. To request that a physician responsible for my care issue a do-not-resuscitate
(DNR) order, including an out-of-hospital DNR order, and sign any required
documents and consents.
E. Additional Authority of My Healthcare Agent
1. If I suffer from severe and irreversible brain damage or brain disease with no
realistic hope of significant recovery, I would consider such condition intolerable and the
application of aggressive medical care to be burdensome. I therefore request that my
healthcare agent respond to any intervening life-threatening conditions in the same
manner as directed for an end-stage medical condition or state of permanent
unconsciousness as I have indicated in Part II. (Initial your choice below)
I Agree I Disagree
2. Below, I list some things which are important to me and provide additional
instructions or directions to my healthcare agent:
PART II: LIVING WILL
The following healthcare treatment instructions exercise my right to make my own
healthcare decisions. These instructions are intended to provide clear and convincing
evidence of my wishes to be followed when I lack the capacity to understand, make, or
communicate my treatment instructions and I am permanently unconscious or in an
end-stage medical condition.
A. If I have an end-stage medical condition (which will result in my death, despite
the introduction or continuation of medical treatment) or am permanently
unconscious such as in an irreversible coma or an irreversible vegetative state,
and there is no realistic hope of significant recovery, then I choose the following
(initial your choice below):
I DO NOT want aggressive medical care and give the following
instructions:
1. I direct that I be given healthcare treatment to relieve pain or provide
comfort even if such treatment may shorten my life, suppress my appetite
or breathing, or be habit forming.
2. I direct that all life prolonging procedures be withheld or withdrawn.
3. I do not want any of the following life prolonging procedures: CPR;
mechanical ventilation; dialysis; surgery; chemotherapy; radiation
treatment; or antibiotics.
I DO want aggressive medical treatment and want my healthcare
team to attempt to prolong my life as long as possible within the limits of
generally accepted medical standards.
B. Additional Information
1. I indicate below whether I want nutrition (food) or hydration (water) medically
supplied by a tube through my nose, stomach, intestine, arteries, or veins if I
have an end-stage medical condition or I am permanently unconscious and there
is no realistic hope of significant recovery (initial your choice below):
I do want tube feedings to be given.
I do not want tube feedings to be given.
2. If I designated a healthcare agent in Part I, I indicate below whether my
healthcare agent must follow the instructions in this Part II if I am in an end-stage
medical condition or am permanently unconscious (initial your choice below):
My healthcare agent must follow the instructions in this Part II.
_____ My healthcare agent may use these instructions as guidance and
override any instructions I have given in this Part II.
3. I indicate below whether I want to donate my organs and tissues at the time of
my death for the purpose of transplant, medical study, or education (initial your
choice below):
I consent to donate my organs or tissues.
I do not consent to donate my organs or tissues.
PART III: SIGNATURE
Pennsylvania law protects my healthcare agent and healthcare providers from any legal liability for their good faith
actions in following my wishes as expressed in this document or in complying with my healthcare agent’s direction.
On behalf of myself, my executors, and heirs, I further hold my healthcare agent and my healthcare providers
harmless and indemnify them against any claim for their good faith actions in recognizing my healthcare agent’s
authority or in following my treatment instructions.
Having carefully read this document, I have signed it this _____ day of ___________, 20___, revoking all previous
healthcare powers of attorney and living wills.
(Signature)
Two witnesses at least 18 years of age are required by Pennsylvania law and should witness your signature in each
other’s presence. A person who signs this document on behalf of and at the direction of the principal may not be a
witness. It is preferable if the witnesses are not your heirs, nor your creditors, nor employed by any of your
healthcare providers).
(Witness Signature) (Witness Printed Name)
(Witness Signature) (Witness Printed Name)
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SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
To follow these orders, an EMS provider must have an order from his/her medical command physician
Pennsylvania
Orders for Life-Sustaining
Treatment (POLST)
Last Name
First/Middle Initial
Date of Birth
FIRST follow these orders, THEN contact physician, certified registered nurse practitioner or physician assistant. This is an Order Sheet based on the
person’s medical condition and wishes at the time the orders were issued. Everyone shall be treated with dignity and respect.
A
Check
One
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
CPR/Attempt Resuscitation DNR/Do Not Attempt Resuscitation (Allow Natural Death)
When not in cardiopulmonary arrest, follow orders in B, C and D.
B
Check
One
MEDICAL INTERVENTIONS: Person has pulse and/or is breathing.
COMFORT MEASURES ONLY Use medication by any route, positioning, wound care and other measures to
relieve pain and suffering. Use oxygen, oral suction and manual treatment of airway obstruction as needed for
comfort. Do not transfer to hospital for life-sustaining treatment. Transfer if comfort needs cannot be met in current
location.
LIMITED ADDITIONAL INTERVENTIONS Includes care described above. Use medical treatment, IV fluids and
cardiac monitor as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation.
Transfer to hospital if indicated. Avoid intensive care if possible.
FULL TREATMENT Includes care described above. Use intubation, advanced airway interventions, mechanical
ventilation, and cardioversion as indicated.
Transfer to hospital if indicated. Includes intensive care.
Additional Orders _______________________________________________________________
C
Check
One
ANTIBIOTICS:
ARTIFICIALLY ADMINISTERED HYDRATION / NUTRITION:
Always offer food and liquids by mouth if feasible
No antibiotics. Use other measures to relieve
symptoms.
No hydration and artificial nutrition by tube.
Determine use or limitation of antibiotics when
infection occurs, with comfort as goal
Trial period of artificial hydration and nutrition by tube.
Use antibiotics if life can be prolonged
Long-term artificial hydration and nutrition by tube.
Additional Orders
Additional Orders
E
Check
One
SUMMARY OF GOALS, MEDICAL CONDITION AND SIGNATURES:
Discussed with
Patient
Parent of Minor
Health Care Agent
Health Care Representative
Court-Appointed Guardian
Other:
Patient Goals/Medical Condition:
By signing this form, I acknowledge that this request regarding resuscitative measures is consistent with the known
desires of, and in the best interest of, the individual who is the subject of the form.
Physician /PA/CRNP Printed Name:
Physician /PA/CRNP Phone Number
Physician/PA/CRNP Signature (Required):
DATE
Signature of Patient or Surrogate
Signature (required)
Name (print)
Relationship (write “self” if patient)
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SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
Other Contact Information
Surrogate
Relationship
Phone Number
Health Care Professional Preparing Form
Preparer Title
Phone Number
Date Prepared
Directions for Healthcare Professionals
Any individual for whom a Pennsylvania Order for Life-Sustaining Treatment form is completed should ideally have an advance health care
directive that provides instructions for the individual’s health care and appoints an agent to make medical decisions whenever the patient is
unable to make or communicate a healthcare decision. If the patient wants a DNR Order issued in section “A”, the physician/PA/CRNP
should discuss the issuance of an Out-of-Hospital DNR order, if the individual is eligible, to assure that an EMS provider can honor his/her
wishes. Contact the Pennsylvania Department of Aging for information about sample forms for advance health care directives. Contact the
Pennsylvania Department of Health, Bureau of EMS, for information about Out-of Hospital Do-Not-Resuscitate orders, bracelets and
necklaces. POLST forms may be obtained online from the Pennsylvania Department of Health. www.health.state.pa.us
Completing POLST
Must be completed by a health care professional based on patient preferences and medical indications or decisions
by the patient or a surrogate. This document refers to the person for whom the orders are issued as the “individual”
or “patient” and refers to any other person authorized to make healthcare decisions for the patient covered by this
document as the “surrogate.”
At the time a POLST is completed, any current advance directive, if available, must be reviewed.
Must be signed by a physician/PA/CRNP and patient/surrogate to be valid. Verbal orders are acceptable with follow-
up signature by physician/PA/CRNP in accordance with facility/community policy. A person designated by the patient
or surrogate may document the patient’s or surrogate’s agreement. Use of original form is strongly encouraged.
Photocopies and Faxes of signed POLST forms should be respected where necessary
Using POLST
If a person’s condition changes and time permits, the patient or surrogate must be contacted to assure that the
POLST is updated as appropriate.
If any section is not completed, then the healthcare provider should follow other appropriate methods to determine
treatment.
An automated external defibrillator (AED) should not be used on a person who has chosen “Do Not Attempt
Resuscitation”
Oral fluids and nutrition must always be offered if medically feasible.
When comfort cannot be achieved in the current setting, the person, including someone with “comfort measures
only,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).
A person who chooses either “comfort measures only” or “limited additional interventions” may not require transfer or
referral to a facility with a higher level of care.
An IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”
Treatment of dehydration is a measure which may prolong life. A person who desires IV fluids should indicate
“Limited Additional Interventions” or “Full Treatment.
A patient with or without capacity or the surrogate who gave consent to this order or who is otherwise specifically
authorized to do so, can revoke consent to any part of this order providing for the withholding or withdrawal of life-
sustaining treatment, at any time, and request alternative treatment.
Review
This form should be reviewed periodically (consider at least annually) and a new form completed if necessary when:
(1) The person is transferred from one care setting or care level to another, or
(2) There is a substantial change in the person’s health status, or
(3) The person’s treatment preferences change.
Revoking POLST
If the POLST becomes invalid or is replaced by an updated version, draw a line through sections A through E of the
invalid POLST, write “VOID” in large letters across the form, and sign and date the form.
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Completed 10 June 2021

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