A SAMPLE OF AN ADVANCE DIRECTIVE

DECLARATION of LIVING WILL

I, (Name), (age), and currently residing at (address), make known my healthcare directives in an event that I become unconscious or incapacitated and unable to decide for myself.  I attest that I am of sound mind in initiating this directive.

I attest that Catholic faith is an important part of my life and that interventions be in line with the teachings of the Church.

I ask that I will be given treatments and interventions appropriate to my illness. There should be no excessive or burdensome medical interventions to prolong my life or that would be too costly on my family or the community. Life-sustaining measures that will only prolong my illness shall not be initiated. Nothing should also be done with the intention of causing my death.

I intend to allow death takes its natural course. I request only the administration of medication or the performance of medical procedures that are necessary to provide me with comfort care or to alleviate pain even if their use may have the unintended result of shortening my life.  

I believe nutrition and hydration, whether administered orally or artificially through tube feeding should be provided to me unless it is clear and convincing ­­that they cause physical discomfort and harmful side effects, are excessively burdensome, and can no longer sustain my life.

I would like to ask that efforts be made to call a Catholic priest to administer the Sacraments of Penance, Anointing as well as Viaticum and to offer spiritual support to my family.  I would like reasonable steps to be taken to allow my family and other significant persons to be present at my bedside.  I ask that we will be given time and opportunity to be reconciled with each other if needed.

Those making decisions on my behalf should be guided by the moral teachings of the Church.  I request that a priest or someone knowledgeable on the teachings of the Church to provide guidance if my healthcare providers are unfamiliar with such teachings.

If possible, I would like to die at home, or in a home setting that would only provide me with comfort measures, when death is deemed imminent.

 APPOINTMENT OF HEALTH CARE SURROGATE

I designate (name) to be my primary health care surrogate. If the above named primary surrogate is unable to act, I hereby appoint (name) as the alternative healthcare surrogate.

 III. OTHER DECLARATIONS LIKE ORGAN DONATION, DNR (THERE IS A SEPARATE FORM TO BE FILLED OUT FOR OUT-OF-HOSPITAL DNR IN MANY STATES, INCLUDING FLORIDA)

 ATTESTATION: Signed this _____________day of our Lord, 20____

 VWITNESSES

This declarant is personally known to me.  I attest that the declarant is at least eighteen years old, of sound mind and initiate this declaration willfully.

(Two witnesses will sign this document. Only one witness can be a close family relative)

Name___________Address______Phone no._____

Name __________Address______Phone no.____

__________________________________________

It is important to seek counsel from your physician and/or from a lawyer to fulfill the legal requirements of this declaration.

 References:

 The National Catholic Bioethics Center, A Guide to End-of-Life Decisions, Philadelphia Pennsylvania, rev 2011.  Can be purchased through https://www.ncbcenter.org/publications/end-life-guide/

Virginia Catholic Conference -Diocese of Arlington and Diocese of Arlington, Catholic Advance Medical Directives: Making Life Decisions, (Richmond, VA, June, 2014), available at http://www.cdrcmfl.org/wp-content/uploads/2014/01/Advance-Medical-Directive.pdf,

Florida Agency for Healthcare Administration. Healthcare Advance Directive. http://www.floridahealthfinder.gov/reports-guides/advance-directives.aspx.

3 comments

  1. I have a question regarding hydration that I don’t see covered in the form. I agree with all it covers, but I would like to make sure that if the time comes to disconnect me from all artificial life support, including a feeding tube I will at least receive fluids through intravenous method. I witnessed, and made me sad and angry an old uncle that it was decided to unplug him, but his body kept working, breathing on his own. That was unexpected. I understood there was nothing else to do, and using a feeding tube was out of the question. Now he died, since for 4 or 5 days he never received water. Even if he couldn’t drink, I asked for fluids intravenous, but they had decided not to all, and I was not “direct” family. I prayed for him, I cry, and I was really upset.
    I would like to hear from you, how is that approached? Am I wrong in thinking that he died (was killed) by not giving him fluids?

    Thank you for your time and consideration.

    Juan J. Guevara

    Like

    • Thank you for your note, Juan. I posted a reply to your questions. I am sorry for the pain you experienced. Your feeling was valid. Your relative might have been actively dying that time. His body could no longer absorb or assimilate feedings, including fluids. It might even be more painful for him had fluids been administered. I pray that your relative is now experiencing the eternal peace in God’s Kingdom. Please see the article below:

      Like

  2. Juan, thank you for your note. The article below may help clarify some of your questions. This is one of the articles posted on this site. Blessings!:

    SHALL WE CONTINUE GIVING TUBE FEEDING TO A DYING PATIENT?

    Studies show that dying patients may spontaneously reduce their intake without experiencing hunger or thirst. This stage, called natural dehydration, offers benefits by producing a sedative effect on the brain and reducing secretions and excretions, making the dying process more tolerable.[1] In this instance, providing tube feedings can interfere with the natural course of dehydration that causes severe discomfort to patients facing imminent death. Artificial hydration tends to increase respiratory secretions that may cause aspiration. It can also cause an accumulation of fluids in the abdomen. It makes it more difficult for patients to breathe. Moreso, artificial feeding may expand the edema layer around tumors of cancer patients which contributes to worsening of pain and discomfort.[2]

    All of the above factors may be helpful in assessing the administration or placement of tube feeding to other individuals with advanced pathological conditions. The use of tube feeding must always have to be evaluated in terms of the totality of a patient’s condition considering any undesirable effects and the likelihood of benefit. We cannot just demand or refuse artificial nourishment or tube feeding without proper discernment and without asking relevant questions.

    PLEASE NOTE: The use of artificial feedings and intravenous fluids should always be assessed, taking into account their risks and benefits on patient’s overall health and condition.

    In case that cessation of tube feeding is conscientiously decided, it is important that healthcare professionals inform surrogates and family members that the patient may cease eating and drinking near the end of life. It is helpful that conversations will include instructions on keeping the patient as comfortable as possible. Some of these interventions include giving medications to avoid irritability, applying ice chips or mouth swabs to relieve dryness, and providing a comfortable environment. These interventions give assurance and relief to family members that despite stopping tube feedings and other treatments, the care rendered to their loved ones continues.

    Like

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