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MEDICAL

TREATMENT PLAN

                                                                               

I, (signed)Michael H. Sumko , certify that I

am the attending physician for ELLEN T., Anderson

of Brigham City, Utah , who is presently under

my care this 17 day of July , 1995

and who has been under my care since the 19 day of June , 1995.

The declarant, the above names patient, is currently suffering from the following injury, disease or illness: Right hip fracture

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 declarants proxy, what the declarant would probably decide if able to give current direction concerning his/her care and treatment.

Date:_17/July /95 (Signed)Michael H. Sumko, M.D.

Attending Physician

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

Withhold treatment of oxygen therapy, respiratory treatments, suctioning, mechanical ventilation, ventilatory support, CPR, chest compressions, cardiac medications during CPR, defibrillation, chemotherapy, radiation, surgery, IV fluids, NG, gastric tube and speak with authorized agent before using antibiotics

Daughter                                                                 (Signed) Barbara A. Poelman

Relationship to declarant of any agent signing            Signature of declarant or authorized

for declarant agent

901 Douglas Drive

Brigham City, Box Elder County, Utah

84302

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

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