ÿWPC :5ÏXáŠÐã6…¤tˆuñ¶l(8 @¼0žv:Þ7²«ô`/ûÖ¬%®öOEòò7¨.þŸéGN6±µ´×5*w›w8IÅe¯í £[ ñ‘añ"îèù8/¯³ãI×èe„Pjç¤i1äïÒ`ò4/‚IQÝ•e_¯NiÚ†àN‘*5¶:œŽW»j¬ §ž¢ÇÇe™1ä'~Áã²ÝB@;]ð4ihB'Ƨ YD_®×fœIïí| ðÂÜg¸¸·ëâg¡XÀÎæ›Â1‡ÃQU¶¤öŸT w&ÑÛ[ðÏØŠj ë7o²4ûQ9rB…¶´I(ä‰û’é¨d /tú]Ãk<5¤§{v©ÝxÀª24^Y\<‚Û{2³Á"èÙÙ7^¾ïe¥Ô©i¨¶3úú°s|â NN9 ó©ûi,½“ß,È`©³Âe§Ó^·5È3Š˜Â1k˜}´U]Œ¥Ob{º­åhjÀöqSÇTä>'æŰ,íS’{a(%õ³ Å\i…S›‡.¯u›ïF"‹Ë½zô”ë—%Sp[õݧ”“§RWFJ—ÞÊuùŸ×ýBJ“$€¬.×&ªGò(¯ÄÍŒ%ÌíÍ…/Pö#ÁÄUN… %Ó 0kÙUND^ ’wž4¢¶Å mÇ+Þ 0‡ ˜0(ÖÃ9 Z‹6Times New Roman RegularX(C$¡¡Ô€XxnXXXÔÔ  ÔÔ  ÔÓ  Ó(ÖÃ9 Z ‹6Times New Roman RegularÌ~*. I†e-ent<Þƒ3|xÿU‹ÿÀÀÀ !Ý ƒ ·f*ÝÔ€X|íXXXÔÔ  ÔÔ  ÔÓ  ÓÝ  ÝÔ_Ôòòò òÔ‡X|íXÐX|íÔóóòòDIRECTIVE€TO€PHYSICIANS€AND€FAMILY€OR€SURROGATESà€ ! ! !(#àPAGE€Ú  Ú1Ú  Úóóó óÔ#†X|íXXX|ít#Ô(_3·f$ªªÝ ƒ!ÝÔ€X|íXXXÔÔ  ÔÔ  ÔÓ  ÓÝ  ÝÝ ƒ!ÝÔ€X|íXXXÔÔ  ÔÔ  ÔÓ  ÓÝ  ÝÔ_ÔòòÔ‡X|íXXX|íÔÓ  Óòòò òóóÖ€ ÿÿÖDIRECTIVE€TO€PHYSICIANS€AND€FAMILY€OR€SURROGATESó óóóÐ ° ÐÌÓ  ÓInstructions€for€completing€this€document:€Ð Ê ÐÌà  àThis€is€an€important€legal€document€known€as€an€Advance€Directive.€€It€is€designed€to€help€youÐ ¾ Ðcommunicate€your€wishes€about€medical€treatment€at€some€time€in€the€future€when€you€are€unable€to€makeÐ ¸  Ðyour€wishes€known€because€of€illness€or€injury.€€These€wishes€are€usually€based€on€personal€values.€€InÐ ²  Ðparticular,€you€may€want€to€consider€what€burdens€or€hardships€of€treatment€you€would€be€willing€to€acceptÐ ¬ ü Ðfor€a€particular€amount€of€benefit€obtained€if€you€were€seriously€ill.Ð ¦ ö ÐÌà  àYou€are€encouraged€to€discuss€your€values€and€wishes€with€your€family€or€chosen€spokesperson,Ð šê  Ðas€well€as€your€physician.€€Your€physician,€other€health€care€provider,€or€medical€institution€may€provideÐ ”ä  Ðyou€with€various€resources€to€assist€you€in€completing€your€advance€directive.€€Brief€definitions€are€listedÐ ŽÞ  Ðbelow€and€may€aid€you€in€your€discussions€and€advance€planning.€€Initial€the€treatment€choices€that€bestÐ ˆØ  Ðreflect€your€personal€preferences.€€Provide€a€copy€of€your€directive€to€your€physician,€usual€hospital,€andÐ ‚Ò  Ðfamily€or€spokesperson.€€Consider€a€periodic€review€of€this€document.€€By€periodic€review,€you€can€bestÐ |Ì Ðassure€that€the€directive€reflects€your€preferences.Ð vÆ ÐÌà  àIn€addition€to€this€advance€directive,€Texas€law€provides€for€two€other€types€of€directives€that€canÐ jº Ðbe€important€during€a€serious€illness.€€These€are€the€Medical€Power€of€Attorney€and€the€Out-of-HospitalÐ d´ ÐDo-Not-Resuscitate€Order.€€You€may€wish€to€discuss€these€with€your€physician,€family,€hospitalÐ ^® Ðrepresentative,€or€other€advisers.€€You€may€also€wish€to€complete€a€directive€related€to€the€donation€ofÐ X¨ Ðorgans€and€tissues.Ð R¢ ÐÌÓ  ÓDIRECTIVEÐ F– ÐÌÓ  Óà  àI,€______________,€recognize€that€the€best€health€care€is€based€upon€a€partnership€of€trust€andÐ :Š Ðcommunication€with€my€physician.€€My€physician€and€I€will€make€health€care€decisions€together€as€long€asÐ 4„ ÐI€am€of€sound€mind€and€able€to€make€my€wishes€known.€€If€there€comes€a€time€that€I€am€unable€to€makeÐ . ~ Ðmedical€decisions€about€myself€because€of€illness€or€injury,€I€direct€that€the€following€treatment€preferencesÐ (!x Ðbe€honored:Ð ""r ÐÌà  àIf,€in€the€judgment€of€my€physician,€I€am€suffering€with€a€terminal€condition€from€which€I€amÐ $f  Ðexpected€to€die€within€six€months,€even€with€available€life-sustaining€treatment€provided€in€accordance€withÐ %` ! Ðprevailing€standards€of€medical€care:Ð  &Z!" ÐÌà8  à____à0` Ð Ð àI€request€that€all€treatments€other€than€those€needed€to€keep€me€comfortable€€beÐ þ'N#$ Ðdiscontinued€or€withheld€and€my€€physician€allow€me€to€die€as€gently€as€possible;Ð ø(H$% ÐORÐò)B%&` Ð ` Ð  ÐÌà8  à____à0` Ð Ð àI€€request€€that€I€be€kept€alive€in€this€€terminal€€condition€using€€availableÐ æ+6'( Ðlife-sustaining€€treatment.€€(THIS€SELECTION€DOES€NOT€APPLY€TOÐ ° ÐHOSPICE€CARE.)Ъú` Ð ` Ð  ÐÌà  àIf,€in€the€judgment€of€my€physician,€I€am€suffering€with€an€irreversible€condition€so€that€I€cannot€careÐ žî Ðfor€myself€or€make€decisions€for€myself€and€am€expected€to€die€without€life-sustaining€treatment€providedÐ ˜è Ðin€accordance€with€prevailing€standards€of€care:Ð ’ â ÐÌà8  à____à0` Ð Ð àI€request€that€all€treatments€other€than€those€needed€to€keep€me€comfortable€€beÐ † Ö Ðdiscontinued€or€withheld€and€my€€physician€allow€me€to€die€as€gently€as€possible;Ð € Ð ÐORÐz Ê ` Ð ` Ð  ÐÌà8  à____à0` Ð Ð àI€request€that€I€be€kept€alive€in€this€irreversible€condition€using€€available€Ð n¾  Ðlife-sustaining€treatment.€€(THIS€SELECTION€DOES€NOT€APPLY€TOÐ h¸  ÐHOSPICE€CARE.)Ðb² ` Ð ` Ð  ÐÌà  àAdditional€requests:€€(After€discussion€with€your€physician,€you€may€wish€to€consider€listingÐ V¦ Ðparticular€treatments€in€this€space€that€you€do€or€do€not€want€in€specific€circumstances,€such€as€artificialÐ P  Ðnutrition€and€fluids,€intravenous€antibiotics,€etc.€€Be€sure€to€state€whether€you€do€or€do€not€want€theÐ Jš Ðparticular€treatment.)Ð D” ÐÌÓ  Ó___________________________________________________________________Ð 8ˆ Ð___________________________________________________________________Ð 2‚ Ð___________________________________________________________________Ð ,| ÐÓ  Óà  àAfter€signing€this€directive,€if€my€representative€or€I€elect€hospice€care,€I€understand€and€agree€thatÐ &v Ðonly€those€treatments€needed€to€keep€me€comfortable€would€be€provided€and€I€would€not€be€givenÐ  p Ðavailable€life-sustaining€treatments.Ð j ÐÌà  àIf€I€do€not€have€a€Medical€Power€of€Attorney,€and€I€am€unable€to€make€my€wishes€known,€IÐ ^ Ðdesignate€the€following€person(s)€to€make€treatment€decisions€with€my€physician€compatible€with€myÐ  X Ðpersonal€values:Ð !R ÐÌÓ  Ó1._____________________Ð ö"F Ð2._____________________Ð ð#@  ÐÌÓ  Ó(If€a€Medical€Power€of€Attorney€has€been€executed,€then€an€agent€already€has€been€named€and€you€shouldÐ ä%4!" Ðnot€list€additional€names€in€this€document.)Ð Þ&."# ÐÌà  àIf€the€above€persons€are€not€available,€or€if€I€have€not€designated€a€spokesperson,€I€understandÐ Ò("$% Ðthat€a€spokesperson€will€be€chosen€for€me€following€standards€specified€in€the€laws€of€Texas.€€If,€in€theÐ Ì)%& Ðjudgment€of€my€physician,€my€death€is€imminent€within€minutes€to€hours,€even€with€the€use€of€all€availableÐ Æ*&' Ðmedical€treatment€provided€within€the€prevailing€standard€of€care,€I€acknowledge€that€all€treatments€mayÐ À+'( Ðbe€withheld€or€removed€except€those€needed€to€maintain€my€comfort.€€I€understand€that€under€Texas€lawÐ ° Ðthis€directive€has€no€effect€if€I€have€been€diagnosed€as€pregnant.€€This€directive€will€remain€in€effect€until€IÐ ªú Ðrevoke€it.€€No€other€person€may€do€so.Ð ¤ô ÐÌSigned__________________________________Date______________________Ð ˜è ÐÌCity,€County,€State€of€Residence€__________________________________Ð Œ Ü ÐÌà  àTwo€competent€adult€witnesses€must€sign€below,€acknowledging€the€signature€of€the€declarant.€Ð € Ð ÐThe€witness€designated€as€Witness€1€may€not€be€a€person€designated€to€make€a€treatment€decision€for€theÐ z Ê  Ðpatient€and€may€not€be€related€to€the€patient€by€blood€or€marriage.€€This€witness€may€not€be€entitled€to€anyÐ tÄ  Ðpart€of€the€estate€and€may€not€have€a€claim€against€the€estate€of€the€patient.€€This€witness€may€not€be€theÐ n¾  Ðattending€physician€or€an€employee€of€the€attending€physician.€€If€this€witness€is€an€employee€of€a€healthÐ h¸  Ðcare€facility€in€which€the€patient€is€being€cared€for,€this€witness€may€not€be€involved€in€providing€directÐ b²  Ðpatient€care€to€the€patient.€€This€witness€may€not€be€an€officer,€director,€partner,€or€business€officeÐ \¬  Ðemployee€of€a€health€care€facility€in€which€the€patient€is€being€cared€for€or€of€any€parent€organization€of€theÐ V¦ Ðhealth€care€facility.Ð P  ÐÌWitness1________________________Witness2_________________________Ð D” ÐÌDefinitions:Ð 8ˆ ÐÌà  à"Artificial€nutrition€and€hydration"€means€the€provision€of€nutrients€or€fluids€by€a€tube€inserted€in€aÐ ,| Ðvein,€under€the€skin€in€the€subcutaneous€tissues,€or€in€the€stomach€(gastrointestinal€tract).Ð &v ÐÌà  à"Irreversible€condition"€means€a€condition,€injury,€or€illness:Ð j ÐÌà  àà ` à(1)that€may€be€treated,€but€is€never€cured€or€eliminated;Ð ^ ÐÌà  àà ` à(2)that€leaves€a€person€unable€to€care€for€or€make€decisions€for€the€person's€own€self;Ð !R ÐandÐ ü!L ÐÌà  àà ` à(3)that,€without€life-sustaining€treatment€provided€in€accordance€with€the€prevailingÐ ð#@  Ðstandard€of€medical€care,€is€fatal.Ð ê$: ! ÐÌà  àExplanation:Many€serious€illnesses€such€as€cancer,€failure€of€major€organs€(kidney,€heart,€liver,Ð Þ&."# Ðor€lung),€and€serious€brain€disease€such€as€Alzheimer's€dementia€may€be€considered€irreversible€early€on.€Ð Ø'(#$ ÐThere€is€no€cure,€but€the€patient€may€be€kept€alive€for€prolonged€periods€of€time€if€the€patient€receivesÐ Ò("$% Ðlife-sustaining€treatments.€€Late€in€the€course€of€the€same€illness,€the€disease€may€be€considered€terminalÐ Ì)%& Ðwhen,€even€with€treatment,€the€patient€is€expected€to€die.€€You€may€wish€to€consider€which€burdens€ofÐ Æ*&' Ðtreatment€you€would€be€willing€to€accept€in€an€effort€to€achieve€a€particular€outcome.€€This€is€a€veryÐ À+'( Ðpersonal€decision€that€you€may€wish€to€discuss€with€your€physician,€family,€or€other€important€persons€inÐ ° Ðyour€life.Ð ªú ÐÌà  à"Life-sustaining€treatment"€means€treatment€that,€based€on€reasonable€medical€judgment,€sustainsÐ žî Ðthe€life€of€a€patient€and€without€which€the€patient€will€die.€€The€term€includes€both€life-sustaining€medicationsÐ ˜è Ðand€artificial€life€support€such€as€mechanical€breathing€machines,€kidney€dialysis€treatment,€and€artificialÐ ’ â Ðhydration€and€nutrition.€€The€term€does€not€include€the€administration€of€pain€management€medication,€theÐ Œ Ü Ðperformance€of€a€medical€procedure€necessary€to€provide€comfort€care,€or€any€other€medical€careÐ † Ö Ðprovided€to€alleviate€a€patient's€pain.Ð € Ð ÐÌà  à"Terminal€condition"€means€an€incurable€condition€caused€by€injury,€disease,€or€illness€thatÐ tÄ  Ðaccording€to€reasonable€medical€judgment€will€produce€death€within€six€months,€even€with€availableÐ n¾  Ðlife-sustaining€treatment€provided€in€accordance€with€the€prevailing€standard€of€medical€care.Ð h¸  ÐÌà  àExplanation:€€Many€serious€illnesses€may€be€considered€irreversible€early€in€the€course€of€the€illness,Ð \¬  Ðbut€they€may€not€be€considered€terminal€until€the€disease€is€fairly€advanced.€€In€thinking€about€terminalÐ V¦ Ðillness€and€its€treatment,€you€again€may€wish€to€consider€the€relative€benefits€and€burdens€of€treatment€andÐ P  Ðdiscuss€your€wishes€with€your€physician,€family,€or€other€important€persons€in€your€life.Ô#†X|íXXX|íq#Ô