Catholic Declaration
On
Health Care Decision Making
Instructions for My Health Care
Appointment of My Health Care Agent
State of
Instructions For My Health Care
My Catholic faith teaches that human life is a precious gift from God. We are not its owners but its guardians. No one must ever presume to adopt a course of action or inaction which is intended to cause my death, even if the motive is to alleviate my suffering.
Having thought seriously about my beliefs and the principles which the Church teaches regarding end-of-life decision making, I have set down the following instructions for my health care for those who must make decisions for me should I become incompetent, i.e., unable to make these decisions for myself.
Medical Care and Treatment
I wish to receive medical care and treatment appropriate to my condition as long as it is useful and offers a reasonable hope of benefit and is not excessively burdensome to me, i.e., does not impose serious risk, excessive pain, grave inconvenience, prohibitive cost or some other extreme burden.
Food and Fluids (nutrition and
hydration)
If I am unable to eat and drink on my own, medically assisted food and fluids should be provided to me, unless death is inevitable and imminent so that the effort to sustain my life is futile, or unless I am unable to assimilate food or fluids, or unless their provision is determined to be excessively burdensome or dangerous.
Imminent Death from Terminal Illness
If
my death from a terminal illness is imminent, I wish to refuse treatment that
would only secure a precarious and burdensome prolongation of my life.
Pregnancy
If I am pregnant, I wish
every means to be taken to preserve and nurture the life of my unborn child,
including the continuation of life-sustaining procedures.
______________________________ ___________________________
Signature
Date
______________________________ ____________________________
Witness Witness
Appointment of My Health Care Agent
I, _______________________________________, hereby designate and appoint:
Name:___________________________________________________
Address:_________________________________________________
City/State/Zip:____________________________________________
Phone No.: (h) ____________________ (w) ___________________
as my health care agent to make health care decisions for me should I be diagnosed as comatose, incompetent or otherwise mentally or physically incapable of communication. My agent is to make decisions for me only for the duration of my incompetency. I have carefully discussed my preferences for medical treatment with the above named agent and I direct my agent to choose on my behalf the appropriate course of treatment or non-treatment which is consistent with the attached “Instructions for My Health Care.” I charge my agent and all those attending me neither to approve nor commit any action or omission which by intent will cause my death. In all decisions regarding my health care, I instruct my agent to act in accordance with Catholic teaching.
If the person named as my agent is not available or is unable to act as my health care agent, I appoint the following persons(s) to act on my behalf:
Alternate Agent 1 Alternate Agent 2
Name: ________________________ _____________________________
Address: _______________________ _____________________________
_______________________ _____________________________
Phone: _______________________ ______________________________
I request that my family, my parish community, and my friends support me through and sacrifice as I prepare for death or face serious illness.
______________________________ ______________________________
Signature Date
______________________________ _______________________________
Witness Witness
Note: Your appointed health care agent(s) may not serve as witness to your declaration. One witness may not be someone who will benefit from your death.