COVID-19 Advanced Directive
Addendum: Documenting Your
Preferences
Please attach this form to your advance directive and date and sign. Then have it signed by witnesses
in accordance with witness signature requirements for your state’s Advanced Directives. Plea
se note,
this Advance Directive is only intended to provide instructions in the event that this person has
COVID-19.
If your oxygen levels are dropping, do you want to go to the hospital or would you prefer to try
to get non-invasive respiratory care at home?
If you are not able to receive non-invasive respiratory care at home, do you want to go to
the hospital?
If the care that is available to you at home can keep you comfortable, but cannot save your life, is
your preference to stay at home? Or do you want to go to the hospital?
When you get to the hospital, do you want healthcare providers to only treat you with non-
invasive options that could still save your life (such as oxygen through a face mask or nasal
mask) and anything necessary to keep you comfortable and control your symptoms? Or do
you want to be put on a ventilator if that becomes necessary to safe your life?
If you would like to be ventilated, are there any guidelines around how long you want to stay on
the ventilator?
Is there a length of time that you want to stay on the ventilator? Days? Weeks? Months?
Do you want your healthcare proxy to have the ability to override any of these orders if he or
she believes you have a reasonable chance of living a life consistent with your values and
priorities based on the information provided by the doctor? Or, do you want these orders
followed no matter what?
________________________________
Sign and Date
_________________________________
_________________________________
Witness and Date
Witness and Date
Attach this form to your advance directive. Sign and date it. Then have it signed by witnesses in accordance
with witness signature requirements for your state’s Advanced Directives.
Do you want to stay on the ventilator if your kidneys also shut down and you need
dialysis?
Do you want to stay on the ventilator if you are also going to need tubes to feed you to
keep you alive?
If your heart stops, do you want to be resuscitated via CPR?
click to sign
signature
click to edit
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