MEDICAL GUIDELINES

I, _________________________________________, being of sound mind, make this statement to guide my Health Care Agent if and when I am unable to participate in decisions regarding my medical care. These guidelines are suggestions only and in no way limit or restrict my Health Care Agent's power and authority granted in my Health Care Power of Attorney, signed and dated by me on ___________________________________.

Medical Procedure	Yes	No	Unsure
1. CPR: Use drugs, electric shock and artificial breathing to bring me back to life when my heart stops.
2. Mechanical breathing: Use a machine to do my breathing for me when I cannot breathe unaided.
3. Artificial nutrition: Give me food through a tube in my vein or my stomach.
4. Artificial hydration: Give me liquid through a tube in my vein.
5. Hospitalization: Move me from a home or hospice or nursing home to a hospital.
6. Major surgery: Operate on something like a blockage in my stomach or remove my gall bladder.
7. Kidney dialysis: Have a machine do the work of my kidneys, cleansing my blood, when they stop working on their own.
8. Chemotherapy: Give me drugs to fight cancer.
9. Minor surgery: Operate on something minor like an infected toe.
10. Major tests: Do tests like heart catheterization or colonoscopy to see what's wrong inside me.
11. Blood: Transfuse blood or blood products into me if I am in need of them.
12. Antibiotics: Give me drugs to fight diseases like pneumonia or a kidney infection.
13. Minor tests: Do an x-ray or a blood test to see what's wrong with me.
14. Pain medication: Give me enough medication so that I am not in pain.
15. Home: Move me from the hospital so that I can die at home.
16. Other:

This the ___________________ day of ________________________

Signature: _______________________________________________

I hereby state that the declarant, ____________________________________, being of sound mind signed the above statement in my presence and that I am not related to the declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the declarant under any existing will or codicil of the declarant or as an heir under the Intestate Succession Act if the declarant died on this date without a will. I also state that I am not the declarant's attending physician or an employee of the declarant's attending physician, or an employee of a health facility in which the declarant is a patient or an employee of a nursing home or any group-care home where the declarant resides. I further state that I do not now have any claim against the declarant.

Witness: ____________________________________________

CERTIFICATE

I, _________________________________, Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for _________________ County hereby certify that ______________________, the declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his/her Medical Directive, and that he/she had willingly and voluntarily made and executed it as his/her free act and deed for the purposes expressed in it.

I further certify that _________________________ and _______________________, witnesses, appeared before me and swore that they witnessed ____________________________________, declarant, sign the attached statement, believing him/her to be of sound mind; and also swore that at the time they witnessed the statement (i) they were not related within the third degree to the declarant or to the declarant's spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the declarant upon the declarant's death under any will of the declarant or codicil thereto then existing or under the Intestate Succession Act as it provides at that time, and (iii) they were not a physician attending the declarant or an employee of an attending physician or an employee of a health facility in which the declarant was a patient or an employee of a nursing home or any group-care home in which the declarant resided, and (iv) they did not have a claim against the declarant. I further certify that I am satisfied as to the genuineness and due execution of the statement.

This the ______________ day of __________________, 20____.

_______________________________________________________
Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for the County of

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