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DAVIS HOSPITAL AND MEDICAL CENTER GEROPSYCHIATRIC UNIT

1600 WEST ANTELOPE DRIVE

LAYTON, UTAH 84041

MEDICAL TREATMENT PLAN

Patient’s name:    Mary Crane    Date: 12/28/95

I, 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: 12/30/95Attending Physician: (Signed) Robert A. Weitzel, M.D.

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

YES NO                                          YES NO

X ____ Do Not Resuscitate (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 tube - fluids feeding)

____ X CPR (CardioPulmResusc)     ____ X Gastric tube

____ X Chest compression                 X ___  Oral Antibiotics

____ X Cardiac medication                X ____ I.M. Antibiotics

____ X Defibrillation                          X ____ I.V. Antibiotics

(signed )Karen Bringhurst

Relationship to declarant of Signature of declarant or authorized agent/date

any signing for declarant

Facility Representative Complete Address

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

YES NO                                          YES NO

X ____ oxygen therapy                      ____ X IV fluids

X ____ respirator treatments                ___ X NG (nasal-gastric tube

X ____ suctioning                                                  for fluids feedings) 

____ X mechanical ventilation            ____ X gastric tube (for feedings/fluids)

____ X ventilator support                    X ___ oral antibiotics                  

____ X CPR                                       X ____ IM antibiotics

____ X chest compressions                 X ____ IV antibiotics

____ X cardiac medications                ____ X defibrillation

           during CPR                              ____ X surgery

____ X chemotherapy                         ____ X radiation

Date: 3/22/91Attending Physician: Sara Anderson M.D.(?)

Relationship to declarant of any    Signature of declarant or authorized agent

agent signing for declarant

Address of signer, including city, country and state of residence

Psych Eval   History & Physical   Discharge Summary   Chemistries   CBC's   CXR's

Living Will / Medical Treatment Plan    EKG   Graphic Chart   Nursing Admission Assessment

Physician's Orders   Progress Notes   Nursing Staff Notes   Medication Administration Record

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