Medical Record #:
Choosing My Health Care Preferences
This section along with Part 2: My Values & Beliefs describes my preferences to guide my doctors
and health care agent to make medical decisions for me if I am unable to make my own health care
decisions AND life sustaining interventions are needed to keep me alive.
but doing so while
you are healthy
gives you a voice
for a time when
you might not
This document represents my health care preferences:
If I am unable to make my own health care decisions and
interventions are needed to keep me alive, I ask that my health care agent
represent my health care preferences as described below.
I know that decisions will be made in partnership with my doctors and care
team and they will consider my values & beliefs, my health care preferences,
and my medical condition at the time decisions need to be made.
Note: By documenting your health care preferences in this directive, your health
care agent and doctors can make decisions based on what you have written rather
than guessing, assuming, or trying to remember. Discuss your preferences and your
values and beliefs with your agent and doctors.
What are life
Life sustaining interventions include any medical procedures, devices,
or medications that may be used to keep me alive.
These interventions may or may not work, and they do not treat the underlying
condition or cause of illness.
Life sustaining interventions include the following:
• Cardiopulmonary resuscitation (CPR): an attempt to restart the
heart with chest compressions if your heart and breathing were to stop.
• Ventilator: a machine that breathes for you when your lungs are not
working. A tube is inserted either through your mouth or an incision in
your neck into your airway. The tube connects to the machine.
• Tube feeding: also called articial nutrition, is a medical treatment that
provides liquid food (nutrition) to the body. This is done when a person
cannot eat enough by mouth or they have problems swallowing.
• Dialysis: a machine that removes waste from your blood if your
kidneys are not working.
• Blood transfusions or use of blood products for treatments:
the process of transferring blood or blood products into your body
through a narrow tube placed within a vein in your arm.