Choosing My Patient Advocate - Saint Joseph Mercy Health System

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SECTION 2:INSTRUCTING MY PATIENT ADVOCATEA. General InstructionsI want my Patient Advocate to be able to:• Make choices for me about my medical careor services, such as testing, medications,surgery, and hospitalization. If treatment hasbeen started, he or she can keep it going orhave it stopped depending upon my specificinstructions (see below) or, if I have includedno specific instructions, my best interest.This authority includes the authority to makedecisions about life-sustaining treatments. Lifesustainingtreatment may include, but is notlimited to, breathing machines and the givingof fluids and nutrition by use of tubes;• Interpret any instructions I have given inthis form (or in other discussions) accordingto his or her understanding of my wishes andvalues;• Review and release my medical records, mentalhealth records, and personal files as needed formy medical care;• Arrange for my medical care, treatment andhospitalization in Michigan or any other state,as he/she thinks appropriate;• Determine which health professionalsand organizations may provide my medicaltreatment; and• Make choices about my mental healthtreatment, including the ability to consentto forced administration of medicines andinpatient hospitalization.B. Specific Instructions (Optional)I give my Patient Advocate permission to makethe following decisions.Life–Sustaining Treatment(You may, if you wish, give your Patient Advocatespecific permission to refuse life-sustaining treatmentby initialing below the following statement.)If I reach a point where it is reasonably certain that Iwill not recover my ability to interact meaningfullywith my family, friends, and environment, I wantto stop or withhold all treatments that might beused to prolong my existence. Treatments I wouldnot want if I were to reach this point include butare not limited to tube feedings, IV hydration,ventilators, CPR, and antibiotics.My initials: ______________– 6 –Other Specific InstructionsI want my Patient Advocate to follow thespecific instructions below, which may limitthe authority described above in the GeneralInstructions (section 2, part A)._____________________________________________________________________________________________________________________SECTION 3:ORGAN DONATION AND AUTOPSYBelow are the instructions I want followed by myPatient Advocate after my death. If my PatientAdvocate is unable or unavailable to make thesedecisions, I ask that my next of kin and physicianfollow these requests if possible.Donation of My Organs or Tissue:(Initial one choice only and draw a line through thestatements that you do not want.)_________I wish to donate any organs or tissue if I ama candidateI wish to donate only the following organsor parts if possible (name the specificorgans or tissue):__________________________________I do not want to donate any organ or tissueAutopsy:(Initial both the first and second choice, or just onechoice, and draw a line through the statements thatyou do not want.)_________I would accept an autopsy if it can helpmy blood relatives understand the cause ofmy death or assist them with their futurehealth care decisions.I would accept an autopsy if it can helpthe advancement of medicine or medicaleducation.I do not want an autopsy performed on me,unless it is required by law.
SECTION 4:SIGNING THE PATIENT ADVOCATE FORM AND HAVING IT WITNESSEDSignature of the PatientI am providing these instructions of my own free will. I have not been required to give them in order toreceive care or have care withheld or withdrawn. I am at least eighteen years old and of sound mind.Signature: ________________________________________________________ Date: _________________Address:________________________________________________________________________________Signature of the WitnessesI know this person to be the individual identified in the Patient Advocate form. I believe him or her tobe of sound mind and at least 18 years of age. I personally saw him or her sign this form, and I believe thathe or she did so voluntarily and without duress, fraud, or undue influence. By signing this document as awitness, I certify that I am:• At least 18 years of age.• Not the Patient Advocate appointed by the person signing this document.• Not related to the person signing this document by blood, marriage or adoption.• Not directly financially responsible for the person’s health care.• Not a health care provider directly serving the person at this time.• Not an employee of a health care or insurance provider directly serving the person at this time.• Not aware that I am entitled to or have a claim against the person’s estate.Witness number 1:Signature: ________________________________________________________ Date: ________________Print name _____________________________________________________________________________Address _______________________________________________________________________________Witness number 2:Signature: ________________________________________________________ Date: ________________Print name _____________________________________________________________________________Address _______________________________________________________________________________Advance Care Planning Programc/o Medical RecordsSaint Joseph Mercy Health System5301 East Huron River DriveP.O. Box 995Ann Arbor, Michigan 48106-0995Medical Records Fax 734-712-7387– 7 –
Page 2 and 3: Unpublished Work (c) 2008 Trinity H
Page 4 and 5: INSTRUCTIONS FOR “CHOOSING MY PAT
Page 6: - 4 -
Page 12: h. The patient may waive the right

Choosing My Patient Advocate - Saint Joseph Mercy Health System

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