If you have already completed the Medical Power of Attorney form, the next step is to complete the Directive to Physicians and Family or Surrogates form. This form allows you to write down the kind of care you would like in the future. Please take some time to reflect as you think through these options.

These simple steps below will help guide you as you complete the form. To download the form, click here.

STEP 1

Determine your choices if you have six months to live.

If your doctor determines because of your condition that you are likely to pass away in the next six months – regardless of treatment – choose one of the following:

___Request all treatments be discontinued or withheld except those to keep
me comfortable and allow me to die as gently as possible

OR

___Request that I be kept alive in this terminal condition using available
life-sustaining treatment.

STEP 2

Determine your choices if you have an irreversible condition.

If your doctor determines that you have an irreversible condition so that you cannot care for or make decisions for yourself – choose one of the following:

____Request all treatments other than those needed to keep me comfortable be discontinued or withheld and allow me to pass away as gently as possible

OR

____Request that I be kept alive in this irreversible condition using available life-sustaining treatment

STEP 3

Consider writing down other treatments you do or do not want.

Think about whether you want treatments such as CPR, breathing machines, or artificial nutrition. Talk with your nurses, social workers or doctors about what the likely success, failure or complications of these treatments might be. Think about whether it is important for you to die in the hospital or at home.

STEP 4

Sign and date the form.

STEP 5

Have two witnesses sign and date the form.

Please note that at least one of the two witnesses may not:

  • be your health care agent
  • be related to you by blood or marriage
  • be entitled to get any part of your estate following your death
  • be your attending physician or an employee of that physician
  • be involved in providing direct patient care
  • be an officer, director, partner or business office employee of the health care facility

OR if you do not have two witnesses, a notary public may sign on page 13

STEP 6

Make copies of this form and give them to your healthcare agent, your doctor, and other individuals involved in your care.

STEP 7

Discuss your choices with your health care agent, your doctor, and your loved ones.