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11.2. Appendices - Document for Your Substitute Decision-Maker

My Life Statement
(Summary of Paragraph 1, page 23)
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(Summary of Paragraph 2, page 24)
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(Summary of Paragraph 3, page 24)
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My Medical Treatment Preferences (see page 25)

Transfusion of blood and blood products___________________________________________________________________________
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Cardio-pulmonary resuscitation__________________________________________________________________________________
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Diagnostic tests _______________________________________________________________________________________________
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Dialysis _____________________________________________________________________________________________________
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Pharmaceuticals ______________________________________________________________________________________________
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Nutrients &/or hydration by tube __________________________________________________________________________________
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Mechanical Respirator _________________________________________________________________________________________
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Surgery _____________________________________________________________________________________________________
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Pain management _____________________________________________________________________________________________
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Organ transplant _____________________________________________________________________________________________
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Previous experiences with medical technology (using a mechanical respirator, dialysis, tube feeding, transfusions, etc.) and what I’ve learned from that experience.
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Other concerns: _______________________________________________________________________________________
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Summary of My Preferences for Personal Care (see page 28)
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Summary of My Preferences for Support (see page 29)
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Making A Will To Live - Contents