1) HIPAA designation.

    Do you want your designee to have access to all medical records & information effective immediately?

2) Philosophy regarding end-of-life care decisions.

A) How do you feel about these statements?

- An act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person

- Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected

- The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable

- Medical treatment may be withheld or withdrawn if it is deemed to be futile or excessively burdensome to the patient

- The sick person in a "vegetative state", awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed. He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery

- The administration of water and food, even when provided by artificial means, represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering

- If I am determined to be in a terminal condition, I do not want the following:

• food/water provided via tubes
• mechanical respiration
• cardiac resuscitation
• kidney dialysis
• chemotherapy
• antibiotics
• other:

B) Do you want your Patient Advocate to consult with anyone or anything regarding your end-of-life care decisions?

3) Spiritual Arrangements.


What, if anything, do you want done if it is determined that your death is imminent?

4) Organ donation.


Do you want to give your Patient Advocate the authority to make anatomical   gifts / agree to organ donation for you?