Estate Planning Questionnaire - End of Life Planning & Burial

Today's Date*

Your Full Name*

Prefix First Middle Last Suffix

1. Agents Under Health Care Power of Attorney

The power of attorney for medical care gives the person you name as your agent the authority to make a wide range of medical decisions on your behalf. It also gives your agent access to your medical information and authority to fully participate with your treating physicians in deciding the care to be provided to you. Obviously, the person you designate to be your agent should be someone you trust with life and death decisions. Please be sure to discuss these decisions with your agent and with your doctor in detail.

Names of addresses of at least (2) people to act as your agent from the Advanced Health Care Directive.

Person #1*

First Last

Relationship*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Person #2*

First Last

Relationship*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Person #3 (Optional)

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

2. Advanced Directives for Health and Personal Care

Advance Health Care Directive and Power of Attorney for Health Care are important health care decision making documents. It appoints someone you name to make medical care decisions for you if you cannot make your own medical decisions. It applies to more situations than the living will, which addresses only continued life support if you have a terminal condition.

Option #1

I recognize that modern medical technology has made possible the artificial prolongation of my life beyond natural limits. I do not wish to artificially prolong the process of my dying if continued health care will not improve my prognosis for recovery and my death is likely to occur within several months, or if I require life support as the result of an irreversible condition, even if that life support might prolong my life for a sustained period. Therefore, I do not want efforts made to prolong my life and I do not want life-sustaining treatment to be provided or continued: (1) if I am in an irreversible coma or persistent vegetative state; or (2) if I am terminally ill and the use of life-sustaining procedures would serve only to artificially delay the moment of my death; or (3) under any other circumstances in which the burdens of treatment outweigh the expected benefits. BY an "irreversible coma," I mean a coma from which the treating physicians have reasonably concluded I will never regain consciousness. In making decisions about life-sustaining treatment under provision (3) above, I want my agent to consider the relief of suffering and quality of remaining life as well as the extent of the possible prolongation of my life. At the same time that I am signing this advance health care directive, I am entering entering my initials in the space immediately below this provision to show that I have read this provision and that it reflects my desires.e

Enter initials here for Option #1

Option #2

I want to receive medical treatment that prolongs and sustains my life unless I am in an irreversible coma. By an "irreversible coma," I mean a coma from which the treating physician or physicians have reasonably concluded I will never regain consciousness. If I am in such an irreversible coma, I do not want to receive medical treatment that prolongs and sustains my life. At the same time that I am signing this advance health care directive, I am entering my initials below this provision to show that I have read this provision and that it reflects my desires.

Enter initials here for Option #2

Option #3

I want to live as long as possible; therefore, I want to receive all medical treatment that will prolong and sustain my life within the limits of generally accepted health care standards. I want such treatment provided to me regardless of my chances of recovery, my condition, or the cost of such treatment. At the same time that I am signing this advanced health care directive, I am entering my initials in the space immediately below this provision to show that I have read this provision and that it reflects my desires.

Enter initials here for Option #3

Relief from Pain and Palliative Care

I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death. I wish to receive any other forms of palliative care that may ease my suffering. (Initial below)

Please state other wishes you may have about likes/dislikes or preferences toward the end of life. For instance: use of antibiotics, intravenous fluids which sustain the body, etc.

I. Organ Donation and Burial

Body organs donation (Do you wish to specify that you desire to donate your body organs for transplant upon death?):*

Yes
No

If yes, are you also willing to donate organs and tissue for Medical, Educational, or Scientific purposes? (Check all that apply)

Medical
Educational
Scientific

Funeral Arrangements - You may have a strong desire regarding funeral arrangements (for example, burial or cremation.)*

To be cremated.
To have my whole body or specific part given for medical or scientific purposes. ***
To be buried at a specified grave site or location ***
I do not wish to express my desires concerning my remains at this moment and I leave this decision to those who survive me.
I do not wish to express my desires concerning my remains in my will and leave this decision to those who survive me.

*** Please specify purposes/location:

Life is short, plan well.℠

EP Planning: Section(s) H & I - Health Care POA, End of Life Planning, Organ Donation & Burial

1. Agents Under Health Care Power of Attorney

2. Advanced Directives for Health and Personal Care

Relief from Pain and Palliative Care

I. Organ Donation and Burial

Estate Planning Questionnaire – End of Life Planning & Burial

EP Planning: Section(s) H & I - Health Care POA, End of Life Planning, Organ Donation & Burial

1. Agents Under Health Care Power of Attorney

2. Advanced Directives for Health and Personal Care

Relief from Pain and Palliative Care

I. Organ Donation and Burial