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<br /> � ' �" �.. ,Y.11«!i�If � . --
<br /> w�ll-tHing, and ta �a►X Ch��n� ax �ny a� �ham, remann�bl.e =--
<br /> �c�raprri��x�i,c�n a �
<br /> 3, xa g�v� canp�nt .to +�ny m�dice�l p�oc�dur��� Csnto nr
<br /> tret�traents. including nurg�ryo '�� a+�ian�a !or my 1�nr�n��A1�.za�t�.on, ,
<br /> convmlescent cmre� hos�ice ox h�cw aare� ta eurco�wn p�eatmen� �or
<br /> other emergency n►e�diaal perea�nn�eZr3ate;�and under�circumetanc�e in
<br /> �, �►p ony Agent ehall deem app P
<br /> which mY Agent deCermined tha�G An ai�g��i��'t rOm�d or �,baa d on..
<br /> t��at�nent� a�ra x�o longer o y �� az� not deaixec� �X �
<br /> inst�uctione �rev3.au�cly given by
<br /> . rega�dlees of ben�etit� to revoke� v�riChdraw, moditY ol change
<br /> � .. �..r+ ri��cedures, testa and treatd►ents� a� '�.al�. �e
<br /> cv�i��n� �.� �t�_._. .� r�a�� wa�a�l��a�;a �s �
<br /> hoapita�i�ta�i�� ��xv�s.Ae�cenC care, haepice or 1��°
<br /> my Ageri�..'��y ��*�'� ��re�nacrnn,��.1+' ��.��'�d ox cont��n��ei t� �ra� w�ic2n ma;P
<br /> '` � c c�ond�.��nna. My Age����should �x;y:
<br /> have b�•���s�..'3.mplied �tue ���.�tr�r3+en � ` : • �
<br /> � c��ed decision �eL-�'1xding mY .
<br /> . to di.s�:�#e the speci�a�;Z�b;:�af ��~;P� �"," , . `��; .
<br /> tiriedi.cal care and trea�r,.��t �i�10,��'
<br /> lf I an4 a}ale to camnwn�.�a��;rj�� �, ..
<br /> ��:�.�ing � eye�, � If i am urnc��ry$�a�p�,c.'� ta�., .
<br /> ma►�er, even lby ,-, �, , . . - � �,� ' ;.
<br /> p h�xx�;��e una�ble +to c�snuniaate w���n :o,it�r: Agent�,. tikn�:.?��', A � ,�, '
<br /> ' � .. r d i �,n�u f or�Gt�.�a.
<br /> , . :����c��i�:'�n should be gu�ded by ,�ax.�.ng ���ii:;� tl4"i,:�!au,4,'u` .�o - ,. �
<br /> b -��a� Pre�����r�ce� tha� I �Y
<br /> ,. .;,. . .; �,'G r2e ��i l-;,. ., �.
<br /> � � `��prav��°:�:t�ias of th1�3 ��� ,:�� 1�?��',..'.�, ., . . .
<br /> ���rs��d on thes :����uiaj�ect r i c� v►hat mY j►9�nt .
<br /> previo�i��.y have ex�r .
<br /> bslieves I wauld waii� done in t he ci r c u a v s t a n c:e s i� I Nere aple to
<br /> intorioa�ntion given to my A�eat bpr the
<br /> ex�ree�$ myselt; and id) auaY ais;
<br /> ptiYeiciane txRating aae as to my m�e�clic3l disi.gnosi• and pro9no.
<br /> 4. To arrax►9e (upcan the execution of a �tr�itieate �y t�ro
<br /> indape.nQent psy
<br /> chiatri.ats �+2no have exan�ned m�., a� ia nhooe
<br /> opinions Y am in i�enediate nead of h�spitalization be�1�C p�
<br /> mentai di�orcXere. �lcoh�oliem or dru9. �it�,ition � trea�t�
<br /> aehniegion to aui �pprAPr�ate hoapital or ine
<br /> . a�. thQ diagnoged problem or disox�der; eo arxan9e �ar private
<br /> � ,'�paych��i:atric a:ul paych4l��ac�ica�. tr�atmeut for ine: aind to revoke,
<br /> :.;:�,�:�.�,�t�, r►ithdra►w or Ch.aizge consen� � to euch hospitialization,
<br /> ��,�I�;��,�;��i'aBG�tutfon.ali�atiom or private treatment Nhiah I or my A�ent ronaY
<br /> ' � � lv Th� con�ent ot my Agent tA ��aY
<br /> . h��,..,:��c��eviously g' .�n. .. , abuse ,.
<br /> ''�� �ep�:;���ization f�r.. �sycha.atric he�;�a,;� alcohol�,em or dru8 .
<br /> � '��. ehall 'have th�:s�xpe �e�al e����'C� s'.ib�eet to applicabl� local lav�,
<br /> � ' as a� voluntary::admiia�fon made by me? .
<br /> , 5. To exerci�e m,y right of,,.�rivacy �o m�ke decxsions
<br /> regard9.ng my �nedic�+3 Creatim�ne and my��right Co be le�t a3one �ven
<br /> tlsough the exerciae of my right might haete�a �►` death or be again�t
<br /> . ���_, ...�.asN�1 nrlvIae: _
<br /> .. (,'DIjVCI1L.LV11�ti atcra��.w�- �--�•..--. . � . .- . . —
<br /> , 6. To consen� to and arrang� f�ar� the admina.$tration of pain-
<br /> reli�ving drugs of any kind, or ather su�gica3. or cnc-'�dical .
<br /> groceduree calculated to relieve�my pa�.n even Chc�ugh their use m�y
<br /> lead ro perntianent physi.cal c2amage, addictian or evem hasten tne
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