Section IV. Surrogate Consent
I, _______________________, the Surrogate certified to make decisions in consultation
with the attending physician, regarding the providing, withholding, withdrawal of life-
sustaining treatment for the Patient. After consultation with the attending physician, I
hereby direct that resuscitative measures be withheld from the Patient in the event of
cardiopulmonary cessation. I believe that this decision conforms as closely as possible
to what the Patient would have wanted. I make this decision in good faith and without
consideration of the financial benefit or burden which may accrue to me or to the health
care provider as a result of this decision. A copy of the Health Care Surrogate
Designation has been attached and made part of the Patient’s Medical Record.
Signature of Surrogate _______________________ Date ____________
V. *Physician Authorization
Based on the aforementioned information, I hereby direct any and all medical
personnel, emergency responders, and paramedical personnel to withhold resuscitative
measures i.e. cardiopulmonary resuscitation, chest compression, endotracheal
intubation and other advanced airway management, artificial ventilation, cardiac
resuscitative mediations, and cardiac defibrillation, in the event of cardiopulmonary
cessation in the Patient.
I further direct the implementation of all reasonable comfort care such as oxygen,
suction, control of bleeding, administration of pain medication by personnel so
authorized, and other therapies to provide comfort and alleviate suffering by the Patient;
and to provide support to the Patient, family members, friends, and others present.
Signature of Physician _______________________ Date ____________
Print Name _______________________
*Physician’s authorization is required in all 50 States except Kentucky.
VI. *Witness(es) and/or Notary Public
I/We, the undersigned Witness(es), declare that all signing parties to this document
were of sound mind, and under no duress, fraud, or undue influence. In addition, I
hereby attest to have witnessed their signatures and have no monetary gain from the
authorization of this form, including but not limited to, being made part of the Patient’s
estate or of a relative that is part of the Patient’s estate.
Signature of Witness #1 _______________________ Date ____________
Print Name _______________________
