Living Will

My Living Will:

Note: A printed, signed, and noterized copy of this information is located on my work desk, under the laptop sitting on the keyboard slide out. 

I, D#o#u#g#l#as# #H#u#g#h# #H#e#a#t#w#o#l#e, with a mailing address of  1#1#1#3# #E# #9#t#h# #S#t, #M#e#s#a, #A#Z# #9#5#2#0#3, (Hereinafter may be referred to as the ‘Principal’) desire to advise my doctors and medical providers of my wishes for my health care in the event I am not able to communicate my wishes.

LIFE SUPPORT: 

I desire that my doctor make a concerted effort to return me to an acceptable quality of life using then available treatments and therapies. However, if my quality of life becomes unacceptable as I have defined below and my doctors have determined that my condition will not improve (is irreversible), I direct that all treatments that extend my life be withdrawn.

An unacceptable quality of life means:

• Chronic coma or persistent vegetative state

• No longer able to communicate my needs

• No longer able to recognize family or friends

• Total dependence on others for daily care

If I have the quality of life described above, I DO NOT wish to be treated with food and water by tube or intravenously (IV).

CERTAIN LIFE-SUSTAINING TREATMENT: 

I DO wish to have the following life sustaining treatments if recovery IS certain or very probable: 

• Cardiopulmonary Resuscitation (CPR)

• Ventilation (breathing machine)

• Feeding tube

• Dialysis

I DO NOT wish to have the following life sustaining treatments if recovery IS NOT probable: 

• Cardiopulmonary Resuscitation (CPR)

• Ventilation (breathing machine)

• Feeding tube

• Dialysis

HEALTH CARE (MEDICAL) POWER OF ATTORNEY WITH MENTAL HEALTH AUTHORITY

I, D#o#u#g#l#a#s#####H#u#g#h#####H#e#a#t#w#o#l#e,  as Principal, designate  R#e#b#e#k#a#h#####O#l#s#o#n,  as my agent to act in all matters relating to my health care (including my mental health care) and including, without limitation, the power to give or refuse consent to all medical and surgical treatments, hospitalizations and related health care. This power of attorney is effective at the point when I am not longer able to communicate my health care wishes. My agent's decisions under this power of attorney, during any period when I am unable to make and/or communicate my health care decisions or when there is uncertainty as to whether I am dead or alive, are binding on my heirs, devisees and personal representatives.

My agent’s address and phone number are as follows:

Phone: (#4#8#0#) #8#1#5#-#8#4#1#5

Address: 4#5#5# #S# #R#e#c#k#e#r# #R#d#, ##A#p#t# #2#1#2#4,# #G#i#l#b#e#r#t,# #A#Z# #8#5#2#9#6

• I specifically consent to giving my agent the power to admit me to an inpatient or partial psychiatric hospitalization program ONLY IF ordered by my physician. (Initial if this is your choice)

• This Health Care Directive including Mental Health Care Power of Attorney may not be revoked if I am incapacitated. (Initial if this is your choice)

If my agent is unwilling or unable to serve, I hereby appoint as my successor agent:

Successor Agent’s Name:  K#a#r#l#a#####V#a#l#l#e

Phone: (#3#1#0#) #7#3#5#-#7#9#0#2

Address: 1#1#6#2#0# #P#o#p#e# #A#v#e, #L#y#n#w#o#o#d, #C#A #9#0#2#6#2

I intend for my agent to receive any and all of my health records and information as if I were the one requesting such information. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1420D and 45 CFR 160-164.