DAVIS HOSPITAL AND MEDICAL CENTER GEROPSYCHIATRIC UNIT

Phone Intake COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL

1600 WEST ANTELOPE DRIVE

LAYTON, UTAH 84041

MEDICAL TREATMENT PLAN

Patient’s name:_Smith, Lydia__________________Date: 12/20/95________________

I, (signed) Robert Weitzel, M.D. certify that I am the attending physician for the patient listed above. The declarant, the above named patient, is currently suffering from the following disease or illness:

________________________________________________________________________________________________________________________________________________________________________________________________________________________I certify that I have explained to the declarant to the extent he/she is able to understand and to all available persons acting as proxy, the reasonable available alternatives for care and treatment. I certify that the care and treatment alternatives directed below are:

________directed by the declarant; or

________ that the declarant has a physical or mental condition which renders him or her unable to give personal direction for care and treatment and that the care and treatment alternatives directed below are in my opinion, and in the opinion of the declarant’s proxy, what the declarant would probably decide if able to give current direction concerning his/her care and treatment.

Date:_ 1/7/96Attending Physician (Signed) Robert Weitzel, M.D.

The following care and treatment is directed with respect to the declarant:

YES NO YES NO

X Do not resusitate (DNR) X Chemotherapy

X Oxygen therapy X Radiation

X Respiratory therapy X Surgery (advise family)

X Suctioning X I.V. fluids

X Mechanical ventilation X NG (Nasal gastric tubes - fluids)

X CPR (Cardio-Pulmonary Resuscitation) X Gastric tube

X Chest compression X Oral Antibiotics

X Cardiac medication X I.M. Antibiotics

X Defibrillaton X I.V. Antibiotics