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My Intentions for Medical Care Form

Example

Limitations on Preservation of Life Questions Answers Notes
Artificial Breathing If you are not progressing toward an acceptable quality of life as you have defined it, are there a number of weeks at which you would like life-prolonging treatments like artificial ventilation withdrawn? Two weeks. If, I’m not getting better, or it is unlikely I will ever breathe on my own I want to be taken off the ventilator. If all of my children want to be present as the machine is disconnected, up to five days may be added to the two weeks.
Artificial Nutrition and Hydration (ANH) If you are not progressing toward an acceptable quality of life as you have defined it, for how long do you with ANH to be administered? One month or sooner if it is determined I will never again be able to eat and drink by mouth and/or be able make my own medical decisions.  


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