ADVANCE HEALTH-CARE DIRECTIVE INSTRUCTIONS FOR HEALTH CARE

Declaration made this ______ day of ____________________, _____. I, Dorian Mayhew Rothschild, being of sound mind, willfully and voluntarily make know my desires that my dying shall not be artificially prolonged under the circumstances set forth below, hereby declare: A. LIFE-SUSTAINING TREATMENT. If at any time I should have an incurable and irreversible condition that will result in my death within a relatively short time or I become unconscious and to a reasonable degree of medical certainty, I will not regain consciousness, or the likely risks and burdens of treatment would outweigh the expected benefits, the I direct my health-care providers and others involved in my care provide, withhold or withdraw treatment in accordance with the following direction: I choose to LET MY AGENT DECIDE. My agent under my power of attorney for health care may make life-sustaining treatment decisions for me.

_________ (Initial) B. NUTRITION AND HYDRATION. If I have a condition stated above, it is my preference NOT TO RECEIVE artificially administered nutrition and hydration (food and fluids) procedures, except as deemed necessary to provide comfort care. C. RELIEF FROM PAIN. Regardless of the choices I have made in this form, I direct that the best medical care possible to keep me clean, comfortable and free of pain or discomfort be provided at all times so that my dignity is maintained, even if this care hastens my death. D. ANATOMICAL GIFT DESIGNATION. In regards to making an anatomical gift, upon my death I specify as follows: I CHOOSE to make an anatomical gift of all of my organs or tissue to be determined by medical suitability at the time of death, and artificial support may be maintained long enough for organs to be removed. __________ (Initial) If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable. In the absence of my ability to give directions regarding the use of such life-sustaining procedures,
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it is my intention that this declaration shall be honored by my family physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal. E. EFFECT OF COPY. A copy of this form has the same effect as the original. F. REVOCATION. I understand that I may revoke this ADVANCE HEALTH-CARE DIRECTIVE at any time, and that if I revoke it, I should promptly notify my supervising healthcare provider and any health-care institution where I am receiving care and any others to whom I have given copies of this power of attorney. I understand that I may revoke the designation of an agent either by a signed writing or by personally informing the supervising health-care provider. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. Date Signed: ____________________ ______, _____.

Signature: Name: Address:

________________________________________ Dorian Mayhew Rothschild San Rafael Albus County New Mexico 123-45-6789 July 11, 1969

SSN: Birthdate:

We, the undersigned witnesses, state that we have witnessed the signing of this document by Dorian Mayhew Rothschild and that Dorian Mayhew Rothschild is of sound mind and free of undue influence. We are each 18 years or older. Date Signed: _______________ _____, _____.

Witness Signature: Name: Address:

________________________________________ Ryan B. Jagger 35 Palm Circle Dr. Corte Vallarta, NM 20221

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Witness Signature: Name: Address:

_________________________________________ Alex R. Olsen 440 Montgomery St. San Ramon, NM 20223

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