Free CMP PersonalWishes #34827 - Massachusetts

PERSONAL WISHES STATEMENT
This form is an expression of my wishes and not legally binding. I, __________________________________________________________, sign this form for the purpose of offering my Health Care Agent guidance so that he or she may make decisions based on an assessment of my personal wishes as well as medical information provided by my physicians. My Health Care Agent has authority to make such decisions in accordance with Massachusetts law. This form is an expression of my wishes and not legally binding. If there is no reasonable expectation for my recovery and, in the opinion of my physician, I will die without life sustaining treatment that only prolongs the dying process, I ask that my Health Care Agent consider the following (initial lines that express your wishes) ______ Treatment should be given to maintain my dignity, keep me comfortable and relieve pain. ______ If my heart stops, I do not want it to be restarted. ______ If I stop breathing, I do not want to have a breathing tube put into my throat and be hooked up to a breathing machine. ______ My physician may withdraw or withhold treatment that only serves to prolong the dying process. Some examples of types of such treatment include: ______ If I cannot drink, I do not want to receive fluids through a needle placed in my vein unless necessary to keep me comfortable. ______ If I cannot eat, I do not want a tube inserted in my nose, mouth or surgically placed to give me food. ______ If I have an infection, I do not want antibiotics administered to prolong my life without hope of cure unless necessary to keep me comfortable. ______ If possible, I would like to die at home with hospice care, if needed. ______ Unless necessary for my comfort, I would prefer NOT to be hospitalized. ______ My faith tradition is ____________________________________________________. My spiritual contact person is______________________________________________. My faith community is __________________________________________________. ______ I wish to have spiritual support. ______ I do not wish spiritual support. ______ If possible, I wish to be an organ donor. ______ Following is additional guidance for my Health Care Agent's consideration: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Signature: ____________________________________________ Date: ________________

This Personal Wishes Statement was adapted from "My Choices: An Advance Directive for Health Care Choices," Missoula Demonstration Project, Missoula, Montana, and prepared by The Central Massachusetts Partnership to Improve Care at the End of Life. The Partnership grants permission to reproduce this document in its entirety, so long as the source, including this statement, is shown. 12/03