Georgia Advanced Directives For Health Care Form Page 6
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9My condition will be determined in writing
after personar examination by my attending
physician and a second physician in accordaice
with currently accepted medical standards.
(7) TREATMENT PREFERENCES
fstate your treatment preference by initiaring (A), (B), o,
,(q). If you choose (c), state your
additional treatment Preferences by initialing-or"L,
more of the stit"mentsfollows (c). you may
provide additional instructions about your
treatment preferences in the next section. you
will be
provided with comfort care, includins
tratn ,eir.j ii, you rnay arso want to state your specific
preferences regardingpain relief in tiinext
sec;;" i
If I am in any condition that I initialed in section (6)
above and I can no longer communicate
my
treatrnentprefere'nces afterreasonable and appropriate
efforts have been made to communicate with
me about my treahent preferences, then:
(A)
-(kritials)
Try to extend my life for as long as possible, using
all medications,
machines, or ofher medical procedures tnut i" ,r*ooubL
mlaicat;udgment could keep me
alive' If I am unable to take nutrition or fluids
by mouth, then I want t receive nutrition or
fluids by tube or other medicai means.
OR
(B)
finitials)- Allow my natural death to occur. I do not want any
medications,
machines' or other medical procedures that in reasonable
medical judgment could keep me
*:::::H"":"::f:,.11"-^1Try1j
to rery.ive nutrition or nuids by tube or other medical
_--__r,_ s
uvwswu ru pruvlutr
pam mgolcatlon.
OR
5l].- .*,
-',Jfi:t:)-
l*,i"t
want anv medicarions, machines, or orher medicai proee-
uuisD iriai iil ieasonabie medicai judgment
could keep me alive but cannot cure mg, except
as follows:
[Initial each statement that you want to apply to option (C).J
o,
"*o",ff}r|jifi:ffi""*le
to take nutrition bymouth, I wanto receive nufiition by tube
(Initials) If I am unable to take fluids by
mouth, I want to receive fluids by tube or
cither medical means.
(Initials) If I need assistaace to breath,
I want to have a ventilator used.
Page 6 of 9 pages. ..
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