Advance Directive

What is an Advance Directive?

Advance Directive are documents that state your choices for health care, or name someone to make those
decisions, if you are unable to make your wishes known in the future because of illness or injury.
By putting your wishes in writing, you take the burden off your family and doctors for making those most

Why Do I Need an Advance Directive?

Even, if you’re young and healthy, it is never too soon to put your wishes is writing. No doubt, the middle of
a medical crisis is the worst time to begin thinking about these critical questions, when your family is upset
and you may be disoriented or in pain.
We encourage you to think through these issues, share your wishes with your loved ones, and put them in
writing while you are healthy.

What are My Options for Advance Directives?

There are four types of advance directives. You can execute one, or several, depending on your needs and situation. Share copies with your doctor and your family, and take copies with you to the hospital. If you
have questions or need assistance with filling out an advance directive please call the hospital at 647-2191 to make an appointment.

Directive to Physicians and Family or Surrogates

- This directive allows you to specify for the provision, withdrawal or withholding of medical care in
the event of a terminal or irreversible condition.

Click here to download a printable version of Directive to Physicians form

Medical Power of Attorney

- This directive allows you to designate another person as your agent for making health care decisionsif you become incompetent. 
- You do not have to have a terminal or irreversible condition for a medical power of attorney to be

Click here to download a printable version of Medical Power of Attorney form

Out-of-Hospital Do-Not-Resusciate Order

- This directive allows you to refuse certain life-sustaining treatments in nonĀ­hospital settings where health care professionals are called to assist, including hospital ERS and Outpatient settings.
- You should carry a photocopy of your written form or wear a designated ID bracelet.
- This directive cannot be executed for minors unless a physician states the minor has a terminal or
irreversible condition. 

Click here lo download a printable version of Ont of Hospital Do No Resuscitate form

Declaration of Mental Health Treatment

 - This directive allows a court to determine when you become incapacitated, and when that declaration
becomes effective. 
- This document allows you to make decisions in advance about mental health treatment and
specifically three types of mental health treatment: psychoactive medications, convulsive therapy, and
emergency mental health treatment. 

Click here to download a printable version of Mental Health Treatment form

Legal Aspects of Advance Directive

Although an Advance Directive does not need to be notarized, your signature should, however, be
witnessed by two qualified witnesses. Plains Memorial Hospital or your Physician can not require you to
execute an advance directive as a condition for admission or receiving treatment in this or any other
hospital. The fact that you have executed an advance directive will not affect any insurance policies that
you may have. Advance directive can be changed or cancelled at anytime.