Advance Directive

I, ____________ of the (city or town) _____________, in the state of Rhode Island, as duly appointed Guardian of _______________, of the (city or town) _______________, of __________ pursuant to an order of the ___________ Probate Court on the _____ day of _________, _____, hereby make this statement on behalf of _____________, the ward, with regard to his/her medical care. I am mindful of my obligations and responsibilities as Guardian of _____________ to make such decisions, which are in the best interest of the ward. I am aware of his/her health condition and his/her needs.

Exercising this authority, I shall make health care decisions that are consistent with the desires of ______________ with regard to obtaining or refusing or withdrawing life prolonging care, treatment, services and procedures. I am authorized to make these statements as an Advance Directive to the health care facility pursuant to section 23-4.10-2.1 of the general laws of the state of Rhode Island. In general the statement that I make is that if there is no reasonable expectation of his/her recovery from physical or mental disabilities, I request that he/she be allowed to die and not be kept alive by artificial means or heroic measures. I direct the attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to his/her comfort or to alleviate pain. I understand that death is as much a reality as birth, growth, maturity and old age. It is the one certainty facing all of us. Death brings unwanted separation but it has to be weighed against not permitting the ward to suffer the indignity and deterioration, dependence and hopeless pain that would be brought on by life sustaining procedures. I ask that drugs be mercifully administered to him/her for his/her terminal suffering even if they would hasten the moment of his/her death.

It is my desire in the capacity as Guardian that he/she be permitted to die with dignity and in that accord I specifically make these requests:

(A) I direct that he/she not be resuscitated which includes no CPR, no intubation and no defibrillation.

(B) I direct that comfort measures only be utilized which would include the use of oxygen and medications to relieve pain.

(C) I also direct that the following not be utilized: feeding tube, nasogastric tube, tracheal suctioning, blood transfusions, respiratory treatment, intravenous fluids, lab work, EKGs, or dialysis.

(D) I also direct that no medications be administered except those which would alleviate pain.

(E) I direct that hospitalization may be utilized if such is necessary to stabilize his/her condition and for the administration of pain medications.

I have signed my name in the capacity as Guardian of _______________________ to this Advance Directive on this ________ day of _________, _____, in the (city/town) , Rhode Island.

____________________ ___________________________

Witness____________________ _____________ Name: Guardian of

State of Rhode Island

County of ____________

Subscribed and Sworn to before me by _________________________, known to me and known by me as his/her free act and deed and in the capacity as Guardian of _____________ on this ________ day of _______, ____.

Spousal Agreement

I, _________________, Husband/Wife of ________________, have read the Advance Directive and hereby agree to its content, purpose and proposed implementation which protects my Husband's/Wife's interests.

_____________________________ __________________________

state of Rhode Island

county of__________

Witness____________________ ______________Husband/Wife

Subscribed and Sworn to before me by ___________________________on this ________ day of _______, ___.

Affix Notarial Seal hereto