Instructions for Completing an Advance Directive

Page 1: Write your name at the top of the page.

Page 2: On the first line name the person you want to be your decision maker if you were ever unable to make health care decisions for yourself. This person should be someone you most trust to carry out your wishes regarding medical treatment. This person will be considered your "surrogate decision maker".  The next several lines are optional; these should only be filled in if you choose to name alternate decision makers.  In the next section, if you have any speical wishes you would want your decision maker to be aware of this; this is where they should be listed.

The bottom of page 2 should ONLY be signed, if you want your decision maker to act for you from this date forward, otherwise leave it blank.

Page 3: Read through the boxed statement. If it reflects your feelings regarding long-term life support, you should initial it. If it is not a reflection of your wishes, leave it blank. The next section reflects your feelings about organ donation, if any. You can initial one or the other, or leave it blank if you desire.

Page 4: This page is where you sign your name in the presence of two witnesses, or in the presence of a notary public. Either is equally legal. However, there are several rules about the witnesses. Your witness CANNOT be: 1) named as your decision maker or 2) employed by our physician or your hospital. Additionally, only ONE of your witnesses can be related to you by blood, marriage, or adoption.  (Neighbors are often good choices.) One of your witnesses must sign the very bottom line, under the statement that he or she is NOT related to you.

After the document is signed and witnessed, you should make copies for 1) anyone named as your decision maker; 2) your Primary Care Physician; 3) the hospital(s) you are most likely to use. The original document should be kept by you in a safe, but ACCESSIBLE place. If you wish you can send one to Doctors Medical Center addressed to the Social Services - 1441 Florida Ave., Modesto, CA 95350 or call 209-578-1211 ext. 3655.