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    Pennsylvania Medical Directive

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    Pennsylvania Medical Directive

    DECLARATION

    I, _________, being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below.

    I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness.

    I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment.

    In addition, if I am in the condition described above, I feel especially strong about the following forms of treatment:

    I ( ) do ( ) do not want cardiac resuscitation.

    I ( ) do ( ) do not want mechanical respiration.

    I ( ) do ( ) do not want tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water).

    I ( ) do ( ) do not want blood or blood products.

    I ( ) do ( ) do not want any form of surgery or invasive diagnostic tests.

    I ( ) do ( ) do not want kidney dialysis.

    I ( ) do ( ) do not want antibiotics.

    I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment.

    Other instructions:

    I ( ) do ( ) do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness. Name and address of surrogate (if applicable):

    Name and address of substitute surrogate (if surrogate designated above is unable to serve):

    I made this declaration on the _________ day of _________(month, year).

    Declarant's signature:

    Declarant's address:

    The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence.

    Witness's signature:

    Witness's address:

    Witness's signature:

    Witness's address:


    Other Forms You May Need

    • Pennsylvania General Durable Power of Attorney for Property, Finances, & Medical Procedures (Immediate)
    • Pennsylvania General Durable Power of Attorney for Property & Finances (Upon Disability)
    • Pennsylvania Durable Health Care Power of Attorney and Health Care Treatment Instructions (Living Will)

    Instant Download - Only $9.99

    • Professional MS Word & PDF formatting Microsoft Word Adobe PDF
    • Fully editable & reusable
    • Lifetime updates
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