Addendum to Durable Power of Attorney for Health Care

LIFE SUPPORT................................................................................... Yes No Maybe

Pacemaker- any device that substitutes for the normal heart beat

Peritoneal Dialysis

Kidney Dialysis- alternative means of filtering poisons from the body when the kidneys fail

Respirator- breathing machine attached to a tube inserted into the lungs through nose or mouth.

Cardiopulmonary resuscitation (CPR)- intervention given by man, machine or drugs when the heart and/or lungs stop working.

LIFE PROLONGING OR LIFE SUSTAINING PROCEDURES

Feeding tube for food or fluid- a tube placed into the stomach or bowel to give fluid and/or nutrition

Hypodermoclysis for nutrition or fluid- placing fluid under the skin outside a vein with a needle. The body will absorb the fluid.

Intravenous (IV)- tubes for feeding and hydration

Antibiotics- to treat pneumonia or any other infections

Cancer Therapy/Radiation- X-ray treatments given for tumors or cancers. Chemotherapy- cancer medicine given by mouth or intravenously.

Transfusion- blood or blood products given into the vein Medical Treatment/diagnostic procedures and tests- further tests and procedures to monitor my failing condition

Surgery- an operation only if it provides for my comfort and dignity

Paramedic- for transport to an acute hospital with CPR in progress

Uniform Gift Act/Organ Transplant- donating body part, specify parts, if usable.

Autopsy, complete or selective, to confirm my diagnosis

OTHER CONCERNS OR CORRECTIONS

I wish:

1. Caring and supportive nursing and medical care to relieve pain and suffering including narcotics to relieve pain even if respiration is depressed.

2. Food and fluids to be offered as long as I am conscious to take them by mouth and then moist sponges to moisten my lips to relieve the sensation of dehydration.

This form is to be included in my Durable Power of Attorney for Health Care.

__________________________________

Signature

_________________

Date

From Veterans Hospital, S.F. 1991

Since many states require a notary or witnesses, I suggest you follow the same rules for this in order for it to be properly included.

Have Fun (?) with this. Revise anyway you like. Add your own diseases. Suggest your own problems.