Advance Directive For Health Care (Page 4 of 7) in pdf

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS AND REHABILITATION

ADVANCE DIRECTIVE FOR HEALTH CARE

CDCR 7421 (REV. 09/09)

PART 2: Instructions for Health Care (Optional – but strongly recommended)

If you fill out this part of the form, you may cross out any wording you do not want.

End-of-Life Decisions: If I am suffering from a terminal condition from which death is expected in a

matter of months, or if I am suffering from an irreversible condition that leaves me unable to make

decisions and life-support treatments are needed to keep me alive, then I choose the following statement

as closest to my wishes (initial A or B if you agree):

_________

If I am at the end of my life as described above then I request that all treatments

other than those needed to keep me comfortable be discontinued or not started

and that my doctor allows me to die as peacefully as possible.

_________

If I am at the end of my life as described above, then I request that my life be

prolonged as long as possible within the limits of generally accepted health care

standards.

_________

Other wishes: (If you do not agree with any of the optional choices above and

wish to write your own, or if you wish to add to the instructions you have given

above, you may do so here.) I direct that:

_______________________________________________________________

(Add additional sheets if needed)

Relief from Pain: In all cases except as I state in the following space, I direct that treatment for

alleviation of pain or discomfort be provided at all times, even if it hastens my death:

_______________________________________________________________________________

(Add additional sheets if needed)

Specific Health Care Instructions: (Examples: will you accept blood transfusions, feeding by a

tube in your stomach, kidney dialysis, mechanical ventilation):

_______________________________________________________________________________

(Add additional sheets if needed)

Distribution: Original-UHR, Copy to Inmate

Page 4 of 7

Advance Directive For Health Care Page 4