An Advanced Directive, or a Living Will, allows you to direct important healthcare decisions when you are not able to do so. The document lets you communicate those very important end of life decisions that are difficult for loved ones to make during an emotional and often high stress time. This form takes you three different scenarios where you choose if you want to receive life saving measures or a feeding tube. You can choose to receive or not to receive these medical treatments. Note: this is not a Do Not Resuscitate form; however, it does allow you to choose organ donation and appoint a Healthcare Proxy. A Healthcare Proxy is someone that you allow to make medical decisions when you are not able to do so for yourself.

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Instructions:

1. After “I,” insert your name.

2. In Part I there are four sections. The first three sections describe different scenarios. Each of these three scenarios has the same three directives. Also note, that at the conclusion of each section, you can also add your initials and direct the reader to refer to the fourth section if you would like to add more specific instructions. You may do this to one or all three of the scenarios.

   1. Section (1) Read the scenario and initial by one directive that matches your wishes. You may also initial the “Specific Instructions” and add more details in section four. If you do this, make certain you are clear which scenario you are referring to.

   2. Section (2) & (3): repeat the same steps as in Section (1)

3. In Part II you are selecting your Healthcare Proxy. The first blank is your first choice of Healthcare Proxy and you write in his or her name. The second blank is for an alternate Healthcare Proxy in the event your first choice is not available. Write your alternate choice in the second blank space.

4. In Part III you may make anatomical gifts. This section allows you to be as general or as specific as you choose. First, initial the purposes of your anatomical donation. Then, initial by each individual body part or chose your entire body. You do not have to complete this section if you choose not to donate any part of your body and may leave it blank and move to Part IV.

5. In Part IV it lists several provisions that you are agreeing to by signing the document. Please note: you must sign this in the presence of two witnesses who are over the age of 18, competent, are not related to you by blood, adoption, or marriage, AND not inheriting from you either by your Last Will and Testament or by law, if you do not have a Will. A notary is not required. If you need assistance with witnesses, please contact B.I.C. Legal to discuss how the firm can assist you.