An advance directive is any instruction you give relating to the provision of health care in the event you become unable to make your own decisions. Examples of advance directive include: Living Wills, Durable Power of Attorney, and Appointment of a Health Care Surrogate.

Below are the three situations when life-prolonging measures may be withheld or withdrawn. It is important for you to document your wishes and discuss your wishes with your family and/or surrogate. For each of the three conditions, circle what your choices would be for the treatments listed. Note: In many cases in the situations described below, it may take days or even weeks for the prognosis to be established. Only after the prognosis is known with reasonable medical certainty is it appropriate to be withdraw or withhold such treatment.

Possible Treatment:	Terminal Condition:	Persistent Vegetative State:	End-Stage Condition:
Assume none of the following will improve or cure the condition described in the situation:	A condition caused by injury, disease, or illness which from which there is no reasonable medical probability of recovery and which, without treatment, can be expected to cause death.	A permanent and irreversible condition of unconsciousness in which there is the absence of voluntary action or cognitive behavior of any kind, or an inability to communicate or interact purposefully with the environment.	A condition caused by injury, disease, or illness which has resulted in severe and permanent deterioration, indicated by incapacity and physical dependency, and for which, to a reasonable degree of medical certainty,treatment of the irreversible condition would be medically ineffective.
1. Do you want efforts to be made to resuscitate (chest massage, artificial breathing) you if your heart or breathing stops?	Yes No Undecided	Yes No Undecided	Yes No Undecided
2. If you are unable to breathe on your own, do you want a machine to breathe for you?	Yes No Undecided	Yes No Undecided	Yes No Undecided
3. If your kidney fails, do you want kidney dialysis (cleaning the blood through a machine) even if it cannot improve or cure the condition?	Yes No Undecided	Yes No Undecided	Yes No Undecided
4. Do you want any surgery,even if it cannot improve or cure your condition?	Yes No Undecided	Yes No Undecided	Yes No Undecided
5. Do you want pain medications to keep you comfortable?	Yes No Undecided	Yes No Undecided	Yes No Undecided
6. Do you want other medications, such as antibiotic which may prolong your life?	Yes No Undecided	Yes No Undecided	Yes No Undecided
7. Do you want food and water given to you through tubes in your veins, nose, or stomach	Yes No Undecided	Yes No Undecided	Yes No Undecided

INTRODUCTION TO THE ADVANCE DIRECTIVE

Every competent adult has, in most cases, the freedom to accept or refuse medical treatment. When you are well, you can talk with your physician and family and make your wishes known. However, severe illness or an accident could cause you to be unable to communicate or to make choices. During that time, important decisions about your medical care may have to be made. Without any written instructions from you, your family and physicians would have to guess what treatment you would want. In some cases, they may be forced to proceed with treatments they know you would not desire simply because your preference was not expressed in writing. You can help your family and physicians by telling them. In advance, what you would want done in certain situations. This planning ahead for future health care decisions is known as “ADVANCE DIRECTIVE”. Your DIRECTIVE goes into effect ONLY if you become unable to make choices or express your wishes. You can change it at any time up until that point.

You may also choose a person to act as you HEALTHCARE SURROGATE to make decisions for you if you are unable to make them yourself. Your HEALTHCARE SURROGATE is obligated to make the choices he or she believes you would make if you were able. You are encouraged to complete both the DIRECTIVE and the appointment of a surrogate since not every possible situation is addressed in the DIRECTIVE. Your DIRECTIVE can assist your surrogate in determining what your wishes would be.

Before you fill out the ADVANCE DIRECTIVE - LIVING WILL form, you may want you talk to your family, friends, physician, lawyer, or spiritual advisor. If you choose to designate a HEALTHCARE SURROGATE, since that person may someday be called upon to make decisions on your behalf, you may want to discuss your thoughts to your surrogate.

When you make your personal choices in the DIRECTIVE, you may want to consider one question. Is there a condition or set of circumstances which could exist in which you would refuse efforts to prolong your life? The DIRECTIVE describes three situations and allows you to indicate which treatments you would want or would not want if your physician recommend them. If a situation you are particularly concerned about is not included, you can make additional comments in the section provided

After you have completed your directive, give a copy to your regular physician, your health care surrogate and to a trusted family member or friend.

THE ADVANCE DIRECTIVE - LIVING WILL FORM IS A COMMUNITY SERVICE PROJECT. IF YOU HAVE ANY QUESTIONS ABOUT THE DIRECTIVE, CONTACT YOUR ATTORNEY,PHYSICIAN OR CLERGYMAN.

Commonly Asked Questions - About Advance Directives

1. What is an Advance Directive?

It is any instruction you give relating to the provision of health care in the event you become unable to make your own decisions. Examples of advance directives include: Living Wills; Durable Power of Attorney; and Appointment of a HealthCare Surrogate. Using a directive allows you to give specific instructions about your health care in certain situations, or designate a person to act on behalf indecision making, or a combination of both

2. Is a Living Will the Same Thing as an Advance Directive?

A Living Will is one kind of advance directive; however, at the present time in Florida the standard Living Will only pertains to situations involving a terminal illness. Many conditions and situations may arise which do not involve a terminal illness. The Advance Directive - Living Will is an expanded from addressing terminal illness and other conditions.

3. What is a Persistent Vegetative State?

The term refers to a condition caused by a brain injury. The victim is unable to respond to his or her surroundings and is not aware of anything, even though the eyes may be open periodically. It is similar to a coma in that the person is unresponsive, but is a permanent condition. A head injury, stroke or other event may result in this condition and a person may be kept alive indefinitely in this condition by artificial means.

4. Are Advance Directives just for “Senior Citizens”?

No. A severe illness or serious accident can happen to a person at any age. If you have strong feeling about what choices you would want in such a situation, regardless of your age, you are encouraged to consider an advance directive.

5. May I Change My Advance Directive?

Yes, you may do so at any time. If you do make changes to any Advance Directive, be sure to destroy all of the outdated copied and provide copies of the updated version to the appropriate people.

6. Will My Advance Directive Be Honored in an Emergency?

Usually, it is not possible to determine the chances of survival in an emergency situation or to determine the outlook for recovery. After the initial emergency have passed and the prognosis for recover is known, your Advance Directive will come into play if you are not able to express your wishes.

7. Is it Difficult to Stop a Treatment Once it Has Been Started?

No, not if you have an Advance Directive and your instructions are clear. Particularly in conditions with a sudden onset, it may take days or even weeks before the prognosis is known to a reasonable degree of certainty. During the time before the outlook is known, it is appropriate to use any treatments which might be beneficial. When the prognosis is established, if your instructions indicate you would not want continued treatment under circumstances, treatment can be stopped.

8. May I Request That I not Be Given Food & Water Artificially?

Yes, it is believed your right to make choices includes the ability to choose not to be given food and water artificially, even if withholding this treatment shortens your life.

9. Are There Any Limitations On Carrying Out Instruction In My Directive If I Am Pregnant?

Yes. Most likely any instructions which would result in withholding or withdrawing life-prolonging treatments would not be honored during the time you are pregnant.

10.​ What About My Religious Belief?

Some choices you may make in filling out an advance directive may be influenced by teachings of your religion. If so, discuss the matter with your minister, priest, rabbi or other spiritual mentor.

11. Do I Need a Lawyer or a Notary to Complete an Advance Directive?

In most cases, no; the document need only be signed in the presence of two witnesses. One of the witnesses must be someone who is not your spouse, blood relative, heir, or person responsible for paying your medical bills. However, if you have any questions concerning the legal effect of these documents or any other aspect of this matter, you should contact your attorney.

12. After I Complete an Advance Directive, What Do I Do With It?

Give copies to someone who would know if you became seriously ill. You may also want to consider giving a copy to your physician, minster, family members or close friends. Discuss with them the details of your directive and ask that they keep a copy to make available if it is ever needed. Of course you should give a copy to your health care surrogate, if you appoint one.

13. What is a HealthCare Surrogate?

A health care surrogate is a person you choose to make health decisions for you if you are not able to do so for yourself. Your surrogate should be someone who knows your wishes and who will make decisions based on what he/she believes you would want, not based on his or her own preferences. You are encourages to appoint a health care surrogate even if you have made other written expressions of your wishes, since it is difficult to address every situation in a directive.

14. How Do I Designate a Healthcare Surrogate?

Under Florida law, designation of a Health Care Surrogate should be made through a written document,and should be signed in the presence of two witnesses, at least one of whom is neither the spouse nor a blood relative of the maker. The person designated as Surrogate cannot act as a witness to the signing of the document.

15. Can I Have More than One Health Care Surrogate?

The maker can also explicitly designate the Alternate Surrogate. The Alternate Surrogate may assume the duties as Surrogate is unwilling or unable to perform his or her duties. If the maker is physically unabe to sign the designation, he or she may, in the presence of witnesses, direct that another person sign the document. An exact copy of the designation may be provided to the HealthCare Surrogate. Unless the designation states a time of termination, the designation will remain in effect until revoked by its maker.

16. Can the Living Will and the Health Care Surrogate designation by revoked?

Both the Living Will and the Designation of Health Care Surrogate may be revoked by the maker at any time by a signed and dated letter of revocation; by physically canceling or destroying the original document: by an oral expression of one’s intent to revoke; or by means of a later executed document which is materially different from the former document. It is very important to tell the attending physician that the Living Will and Designation of Health Care Surrogate has been revoked?

17. Where Can I Go to Obtain Legal Advice on this Issue?

If you believe you need legal advice, call your attorney. If you do not have an attorney, call the Florida Bar Lawyer Referral Service at 1-800-342-8011, or the local lawyer referral service or legal aid office listed in the yellow pages of your telephone book

Advance Directive or Living Will

Many health care organizations now require us to offer you the opportunity to file an Advance Directive or Living Will. Please check the appropriate line below, sign and date for our records

The right to make fundamentals decisions regarding your medical care is yours. If you are not able to make these decisions for yourself due to incapacity, you can make an “Advance Directive” stating your wishes regarding your care. You are not required to do this, but it is an option available to you. We can provide the necessary forms along with further information.

1. Designation of a HealthCare Surrogate. ​You may choose someone (spouse, relative) to act as your healthcare surrogate to make decisions regarding your medical care if you are not about to do so. Your surrogate is obligated to make the choices he/she believes you would make if you were able.

2. Living Will. ​This can help your Health Care Surrogate determine what your wishes would be

LIVING WILL

And if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct the life prolong artificially the process, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care to alleviate pain.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event that I have been determined to be unable to provide expressed and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:

I understand the full import of this declaration, and I am emotionally and mentally competent to make this decision.