Catholic Advance Directive  

Page 1

This Declaration of Life and Death, made while I am of sound mind, is intended to convey my desires and directions regarding treatment or care for me in the event I become irreversibly and terminally ill or incapable of expressing my wishes for medical treatment.

Because of my Catholic belief in the dignity of the human person and my eternal destiny with God, I ask my family, physicians, lawyer, pastor, and friends to fully inform me of my condition and prognosis, if I should become irreversibly and terminally ill, so that I can prepare myself spiritually for death.

I have the right to make my own decisions concerning medical treatment beyond the limits dictated by any physician or hospital ethics committee's  judgment. This Declaration applies in the event that I have an incurable injury, disease or illness from which I will inevitably soon die, or should I become incapacitated and unable to express my wishes. As determined by two physicians who have examined me, one of whom shall be my attending physician, if this condition will directly cause my death even with appropriate medical care, and that the use of life sustaining procedures would serve only to artificially prolong the immediate dying process then I request and direct: 

1) that my pain be alleviated, 

2) that no excessively burdensome or disproportionate means be used to prolong my life, and 

3) that nothing should be done with the intention of causing my death.

I believe nutrition and hydration are not excessively burdensome or disproportionate, whether being administered orally or artificially. Therefore they are not to be withheld or withdrawn from me unless there is clear and convincing evidence that they would cause me harm, cannot effectively sustain my life or are excessively burdensome to me.

Excessively burdensome means that the administration of nutrition and hydration for me would worsen my condition, cause excessive pain, suffering or death and would in no way benefit my existence.

I ask my family, friends and the Catholic community to join me in prayer and sacrifice as I prepare for death and request that my rights as a Catholic to receive the Holy Sacraments according to my faith be respected and provided. Finally, I seek prayers after my death, that I may enjoy eternal life.

Signed this _____ day of ____________ , 20 ___.

____________________________ (Signature) _________________________ (Address)

                                                                           _________________________

     The Declarant is personally known to me and I believe him/her to be of sound mind. (Only one witness can be a spouse or relative.)

___________________________ (Witness) __________________________ (Witness)

___________________________ (Address) __________________________ (Address)

___________________________                 __________________________

___________________________ (Phone)    __________________________ (Phone)

Page 2

DESIGNATION OF HEALTH CARE SURROGATE

of

_______________________________ (Name)

     Should I become comatose, incompetent or otherwise mentally or physically incapable of communication, then I designate as my surrogate, to make health care decisions for me, including decisions to apply for public benefits, authorize my admission or transfer to a health care facility, and to initiate, continue, withhold or withdraw life prolonging procedures only as indicated on Page 1 of this document, the following:

____________________________ (Name)

____________________________ (Address) ___________________ (Phone)

____________________________

If that person is unwilling or unable to act, then as my alternate surrogate:

____________________________ (Name)

____________________________ (Address) _____________________(Phone)

____________________________

Signed this _____ day of ____________ , 20 ___.

____________________________ (Signature) ____________________________ (Address)

                                                                            ____________________________

     The Declarant is personally known to me and I believe him/her to be of sound mind.

____________________________ (Witness) ___________________________ (Witness)

____________________________ (Address) ___________________________ (Address)

____________________________                   ___________________________

____________________________  (Phone)    ___________________________ (Phone)