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.

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