Fill and Sign the Making Decisions for Your Advance Directive American Cancer Society Form

ADVANCE HEALTH CARE DIRECTIVE Explanation You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your supervising health care provider. If you use this form, you may complete or modify all or any part of it. You are free to use a different form. Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator or employee of a residential or community care facility at which you are receiving care. Unless the form you sign limits the authority of your agent, your agent may make all health care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to: (a) Consent or refuse consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition; (b) Select or discharge health care providers and institutions; (c) Approve or disapprove diagnostic tests, surgical procedures, programs of medication and orders not to resuscitate; and (d) Direct the provision, withholding or withdrawal of artificial nutrition and hydration and all other forms of health care. Part 2 of this form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death.
Part 4 of this form lets you give instructions about any other aspect of your health care. You must write out these instructions. Part 5 of this form gives you the right to designate your supervising health care provider to make health care decisions for you and to make decisions for you about your death. If you do not specify this person's name in part 5, you're supervising health care provider has the right to decide how to handle the person's affairs. To request a health care proxy and make choices about your will, complete part 1, part 2 and part 3 of this form. Each part is marked through. Each item in a portion is a choice. You must put all your choices in a written list, then complete a copy of the list in the bottom of part 5, then sign on the top. When you fill out this form, remember to check the box next to a choice and put it in the correct box if you make that choice. If you are not the one who completes part 1, you should complete part 1 instead and then complete part 2. Then, as each choice is made, complete part 3, and sign the top portion of that next section. If you are not the one who completes part 2, take the time to complete part 2 as well and sign the area marked “authorization to be deemed the natural estate holder” under that line. You may sign and date all or any part of this document. If there are questions about any part of this declaration, you can contact your designated health care agent. Your health care agent is your primary care doctor or other health care provider for life and for health care related to the condition of your health. If you have not had any health care in recent months, your health care agent will help you figure out all your health care needs and help you sign and complete all forms and instructions. You may have to answer questions about your medical history, including your medical history before the illness, injury, disorder or surgery. For example, before a condition or surgery such as a hip or knee replacement or gallbladder surgery. After those events, you will give your health care agent the name of a designated health care provider who will be responsible for helping you understand information the health care agent will give you and help you complete all forms and instructions. That designated health care provider is called a surrogate decision maker. In order to help you choose a medical treatment and to assist you in making your own.