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MEDICAL
TREATMENT PLAN
I, Dr. Gregory Stevens, certify that I am the attending physician for Judith Larsen of ______, who is presently under my care this
day of , 19.
The declarant, the above named patient, is currently suffering from the
following injury, disease or illness:
I certify that I have explained to the declarant to the extent he/she is able to understand, and to the available person(s) acting as proxy, the reasonably available alternatives for care and treatment. I certify that the care and treatment alternatives directed below are:
directed by the declarant: or
X that the declarant has a physical or mental condition which renders him/her unable to give personal directions for care ad 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 directions concerning his/her care and treatment.
Date: September 19, 1985 (Signed)
Greg Stevens
Attending Physician
The following care and treatment or withholding of treatment is directed with respect to the declarant:
No CPR. No IVs for nutrition, hydration, medication. No feeding tubes. No
mechanical respiratory assistance. No electric shock for defibrillation. No
treatment for cancer. Oxygen and oral medication may be given for relief of
pain and for comfort.
Son
(Signed) Merlin N. Larsen
Relationship to declarant Signature of declarant or authorized agent Agent signing for declarant.
Address of signer, including city, county and state of residence
1) On this 25th day of May, 1995, I Judith V. Larsen, being of sound mind, hereby willfully and voluntarily make known my desire that my life not be artificially prolonged by life-sustaining procedures except as I may otherwise provide in this directive. I understand that the term "life-sustaining procedure," as defined by law i) means any medical procedure or intervention which, when applied to a person who has a terminal condition would, in the judgement of the attending physician, serve only to prolong the dying process, ii) does not mean medication, sustenance, or medical procedures for providing comfort care or for alleviating pain, unless I so specify below.
2) I declare that if at any time I should have an injury, disease or illness, which is certified in writing to be a terminal condition or persistent vegetative state by two physicians who have personally examined me, and in the opinion of those physicians the application of life-sustaining procedures would serve only to unnaturally prolong the moment of my death and to unnaturally postpone or prolong the dying process, I direct that these procedures be withheld or withdrawn and my death be permitted to occur naturally.
3) I expressly intend this directive to be a final expression of my legal right to refuse medical or surgical treatment and to accept the consequences from this refusal, which shall remain in effect notwithstanding my future inability to give current medical directions to treating physicians and other providers of medical services.
4) I understand that the term "life-sustaining procedure" includes
artificial nutrition and hydration and any other procedures that I specify
below to be considered life-sustaining but does not include the administration
of medication r the performance of any medical procedure which is intended to
provide comfort care or to alleviate pain: If my condition is certified to
be terminal as in paragraph 2, I request that sustenance (meaning nutrition and
hydration and respiration) be terminated or withheld. Medication to relieve
pain may be given if obviously needed.
5) I reserve the right to give current medical directions to physicians and other providers of medical services so long as I am able, even though these directions may conflict with the above-written directive that life-sustaining procedures be withheld or withdrawn.
6) I understand the full import of this directive and declare that I am emotionally and mentally competent to make this directive.
(Signed) Judith V. Larsen
Declarant Signature
Salt Lake City, Utah
City, County, State of Residence
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