Advance Medical Directive: Sample Form
The current case of Terri Schiavo has focussed the spotlight on the issue of advance medical directives. An advance directive, through a living will or the designation of a health care proxy, prevents the involvement of the courts "in virtually all cases," according to George J. Annas, J.D., M.P.H writing in an article published online by The New England Journal of Medicine on March 22, 2005.
Here is an example of an Advance Medical Directive. It is a real one. It happens to have been prepared (and signed) by a 36-year-old woman who lives in the State of Texas. Points 1-6 (below) are, as required, in accord with the Texas Health Code. Point 7 was added to specify further her wishes.
Remember that this is just an example. Your Advance Medical Directive should reflect your own personal wishes.
Directive to Physicians
Directive made this __th day of ____ in the year ____.
I,_____, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth in this directive.
Signed ______________ in the City of ____________etc.
I am not a person designated by the declarant to make a treatment decision. I am not related to the declarant by blood or marriage. I would not be entitled to any portion of the declarant's estate on the declarant's death. I am not the attending physician of the declarant or an employee of the attending physician. I have no claim in against any portion of the declarant's estate on the declarant's death. Furthermore, if I am an employee of the health care facility in which the declarant is a patient, I am not involved in providing direct patient care to the declarant and am not an officer, director, partner, or business office employee of the heath care facility or of any parent organization of the health care facility.
Reference: Texas Health and Safety Code, Chapter 166
Last Editorial Review: 3/23/2005