Advance Directive (Medical Power of Attorney & Living Will)

I am creating this for

I am creating this for MyselfSomeone else

Who is this for?

This individual will be known as the "patient" on this document.

What is the patient's mailing address?

Street Address

Address Line 2

City

State

ZIP Code

Who will be making medical decisions for the patient?

This individual will be known as the "agent" on this document.

What is the agent's mailing address?

Street Address

Address Line 2

City

State

ZIP Code

Agent's phone number

Agent's email address

Does the patient want to appoint an alternate agent?

Does the patient want to appoint an alternate agent? YesNo

In case the original agent is unavailable or unwilling to make a decision on the patient's behalf.

Name of alternate agent

Phone number

Mailing address

Street Address

Address Line 2

City

State

ZIP Code

Does the patient want to appoint a second alternate agent?

Does the patient want to appoint a second alternate agent? YesNo

In case both the original agent and the first alternate agent are unavailable or unwilling to make a decision on the patient's behalf.

Name of second alternate agent

Phone number

Mailing address

Street Address

Address Line 2

City

State

ZIP Code

Will there be any limitations to the agent's powers?

Will there be any limitations to the agent's powers? Yes, there will be limitations.No, there will not be any limitations.

Without any limitations, the agent may have the power to choose to withdraw life-sustaining care, drinking, and/or feeding.

The agent is authorized to make all healthcare decisions for me, except as I state here:

Will the agent be granted access to your medical records?

Will the agent be granted access to your medical records? YesNo

Statement of Desires

I desire that my life be prolonged to the greatest extent possible, without regard to my condition, my chances for recovery or long-term survival, or the cost of the procedures.

I desire that my life be prolonged to the greatest extent possible, without regard to my condition, my chances for recovery or long-term survival, or the cost of the procedures. YesNo

I do not want life-sustaining or prolonging treatments to be used if: (check all that apply)

I do not want life-sustaining or prolonging treatments to be used if: (check all that apply) I am in a coma which my doctors have reasonably concluded is irreversible.I have an incurable or terminal illness/condition and no reasonable hope of long-term recovery or survival.The burdens of the treatment outweigh the expected benefits.Other

Provide details:

Liquid and Food

Even if staying alive requires me to get liquid or food through a tube or other means for the rest of my life, it should always be given to me.

Even if staying alive requires me to get liquid or food through a tube or other means for the rest of my life, it should always be given to me. YesNo

Liquid and food should NOT be given to me if: (check all that apply)

Liquid and food should NOT be given to me if: (check all that apply) I have an incurable condition that is expected to cause my death soon.I am unconscious and I am not expected to be conscious again.Other

Liquid or food should NOT be given to me if:

Pain Relief

If I am in significant pain, pain relief meds should ALWAYS be given to me even if it shortens my life.

If I am in significant pain, pain relief meds should ALWAYS be given to me even if it shortens my life. YesNo

Pain relief should only be given to me when:

Priorities

Staying alive as long as possible even if I have substantial physical limitations is:

Staying alive as long as possible even if I have substantial physical limitations is: Very importantSomewhat importantNot important

Staying alive as long as possible even if I have substantial mental limitations is:

Staying alive as long as possible even if I have substantial mental limitations is: Very importantSomewhat importantNot important

Being free from significant pain is:

Being free from significant pain is: Very importantSomewhat importantNot important

Having my agent talk with my family before making decisions about my care is:

Having my agent talk with my family before making decisions about my care is: Very importantSomewhat importantNot important

Having my agent talk with my friends before making decisions about my care is:

Having my agent talk with my friends before making decisions about my care is: Very importantSomewhat importantNot important

Does the patient wish to donate any of their organs after their death?

Does the patient wish to donate any of their organs after their death? YesNo

Which parts of the body may be donated?

Which parts of the body may be donated? All parts of the bodyOnly specified organs

List the following body parts that may be used for organ donation:

The patient's organs may be used for:

The patient's organs may be used for: TransplantTherapyResearchEducation

Execution

Under Nevada law, the patient is required to sign with either two witnesses or a notary public.

Under Nevada law, the patient is required to sign with either two witnesses or a notary public. I understand.

If the patient decides to sign with two witnesses, they cannot be blood-related, a beneficiary in the patient's will, or medical staff.

Save and finish later

Nevada Advance Directive (Medical Power of Attorney & Living Will)

Statement of Desires

Liquid and Food

Pain Relief

Priorities

Execution