Policy Manual sample

MDT Home Health Care Agency, Inc. DECLARATION TO WITHDRAW/WITHHOLD TREATMENT If I should have an incurable and irreversible condition, that has been diagnosed by two physicians and that will result in my death within a relatively short time without the administration of life-sustaining treatment or has produced an irreversible coma or persistent vegetative state, and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the (state directive) __________________, to withhold or withdraw treatment, including artificially administered nutrition and hydration, that only prolongs the process of dying or the irreversible coma or persistent vegetative state and is not necessary for my comfort or to alleviate pain. If I have been diagnosed as pregnant, and that diagnosis is known to my physician, this declaration shall have no force or effect during my pregnancy. Signed this day of , . Signature: _____________________________________________ Address: _______________________________________________________________ The declarant voluntarily signed this writing in my presence. I am not a healthcare provider, an employee of a healthcare provider, the operator of a community care facility, the operator of a residential care facility for the elderly or an employee of an operator of a residential care facility for the elderly. Witness: ______________________________________ Address: _______________________________________________________________ The declarant voluntarily signed this writing in my presence. I am not entitled to any portion of the estate of the declarant upon his or her death, under any will or codicil thereto of the declarant now existing or by operation of the law. I am not a healthcare provider, an employee of a healthcare provider, the operator of a community care facility, the operator of a residential care facility for the elderly or an employee of an operator of a residential care facility for the elderly. Witness: ______________________________________________________________ Address:_______________________________________________________________ Home Health Agency Miscellaneous M-11