Advanced Directives Form - Little River Healthcare

Advanced Directives are documents allowing patients to give direction about future medical care. An individual
instruction or written statement relating to the subsequent provision of health care for the individual, including,
but not limited to the following:
Advanced Care Plan/Living Will: Written instructions explaining wishes regarding health care should
the patient have a terminal condition.
Durable Power Of Attorney: Written document naming a person to make decisions for the patient if
the patient becomes unable to do so.
Appointment of a Health Care Agent: Written document naming a person to make decisions for the
patient if the patient becomes unable to do so.
Living Will: A written document stating the patient’s desires for medical care or non-care, including
palliative care and other related matters, such as organ donation and body disposal .
Physician Order for Scope of Treatment (Post) Form: A physician order sheet based upon the
medical conditions and wishes of the person identified on the form that accompanies the patient when
the patient is discharged and transferred from one health care provider to another.
Outpatient Surgery Center Policy
Policy: It is the policy of Temple Surgery Center for our patients with an Advanced Directive, to
temporarily suspend the Advanced Directive until they are discharged from the facility. If life support
measures are required during the procedure or the recovery period, such measures will be continued by
the facility until the patient can be transferred to the nearest hospital, at which time the patient, family
and attending physicians may discontinue such support according to the wishes of the patient.
Purpose: The purpose of the suspension of the Advanced Directive relates to the fact that the potential
for arrhythmias (irregular heartbeats), hypotension (low blood pressure) and respiratory depression are
common side effects from anesthesia and, as such, treatment should be rendered.
Patient Statement:
By my signature below, I attest that I have been provided with a definition of Advanced Directives, a description of
the types of advanced directives and the opportunity to complete an Advanced Directive if I so choose. I have been
provided a copy of the policy and purpose of LITTLE RIVER HEALTHCARE – Temple Surgery Center regarding
suspension of Advanced Directives while at the facility. I further attest that I have had the opportunity to ask
questions and that I have had them answered to my satisfaction.
Print Patient Name: _______________________________________
Signature of patient or representative: __________________________________
Date of receipt of document: _____________________
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