Planning Ahead - Florida Developmental Disabilities Council

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Suggested form of a Living Will, Florida Statutes Section 765.303.A living will may, BUT NEED NOT, be in the following form:LIVING WILLDeclaration made this __________ day of __________ 2_____, I _____________________Willfully and voluntarily make known my desire that my dying not be artificially prolongedunder the circumstances set forth below, and I do hereby declare that, if at any time I amincapacitated and_____ (initial) I have a terminal condition.or_____ (initial) I have an end stage condition.or_____ (initial) I am in a persistent vegetative state.and if my attending or treating physician and another consulting physician have determinedthat there is no reasonable medical probability of my recovery from such condition, I directthat life-prolonging procedures be withheld for withdrawn when the application of such procedureswould serve only to prolong artificially the process of dying, and that I be permitted todie naturally with only the administration of medication or the performances of any medicalprocedure deemed necessary to provide me with comfort care or to alleviate pain.It is my intention that this declaration be honored by my family and physician as the finalexpression of my legal right to refuse medical or surgical treatment and to accept the consequencesfor such refusal.In the event that I have been determined to be unable to provide express and informed consentregarding the withholding, withdrawal, or continuation of life-prolonging procedures, Iwish to designate, as my surrogate to carry out the provisions of this declaration:Name ________________________________________________________Address ________________________________________________________City____________________ State _______ Zip_____________________Phone ________________________________________________________I understand the full import of this declaration, and I am emotionally and mentally competentto make this declaration.84Section 3, Helpful Attachments
Additional Instructions (optional):(Signed): ________________________________Witness ________________________________ Witness___________________________Street Address ___________________________ Street Address _____________________City, State, Zip ___________________________ City, State, Zip _____________________Phone __________________________________ Phone ____________________________The principal’s failure to designate a surrogate shall not invalidate the living will~ This form offered as a courtesy of The Florida bar and the Florida Medical Association ~Section 3, Helpful Attachments85
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AcknowledgementsWe would like to th
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SECTION 1THE HANDBOOKDevelopmental
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in realizing goals and outcomes he
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• Identify agencies and organizat
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TO BE SURE YOU HAVE ACCESSED ALL AV
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CHAPTER THREEUsing Government Benef
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Property or assets mean real estate
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There is a special program for peop
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Department of Elder Affairs: The De
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Be sure to complete the application
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Most services provided to persons w
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CHAPTER FIVEAdvocating and Coordina
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family member receives services. De
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• Use the chain of command. If yo
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28ChooseYour family member may make
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7. Skilled Nursing HomeSkilled nurs
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There are now more opportunities fo
Page 40 and 41: If your family member really thinks
Page 42 and 43: pre-need directive. As the term ind
Page 44 and 45: Can the Living Will and the Health
Page 46 and 47: Although it is not required by stat
Page 48 and 49: The potential ward, if capable of u
Page 50 and 51: LETTERS OF INTENTIn addition to hav
Page 52 and 53: TAX ISSUESIn your planning, do not
Page 54 and 55: CHAPTER TENDealing WithHealth Care
Page 56 and 57: CHAPTER ELEVENCoping with Changes a
Page 58 and 59: • Arrange visits to an area funer
Page 61 and 62: SECTION 2THE PERSONALINFORMATION SU
Page 63 and 64: Senior CenterHomemakerPersonal Care
Page 65 and 66: List relatives who are emotionally
Page 67 and 68: Recognizes danger of: (Circle those
Page 69 and 70: Do violent or sexually suggestive T
Page 71 and 72: The type of neighborhood preferred
Page 73 and 74: During the day goes to:EMPLOYMENT/R
Page 75 and 76: Provide a brief summary of Medical
Page 77 and 78: Section 2, The Personal Information
Page 79 and 80: The following activity (e.g., being
Page 81 and 82: PROTECTING LEGAL RIGHTS AND FINANCI
Page 83 and 84: Has a standby guardian been appoint
Page 85 and 86: Memorial Service: Yes No Location:S
Page 89: SECTION 3HELPFUL ATTACHMENTSDevelop
Page 93 and 94: My Personal OutcomesWHO AM I?What g
Page 95 and 96: Bill Of RightsIn June of 1975 the G
Page 97 and 98: Stakeholders requested a change in
Page 99 and 100: Adjudicatory hearing to determinein
Page 101 and 102: Guardianship To-Do List(Step-by-Ste
Page 103: New York State Developmental Disabi
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Planning Ahead - Florida Developmental Disabilities Council

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