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Worksheet
2 - Medical Situations & their Treatment
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| This worksheet presents possible treatment plans for a variety of common medical situations. You may use these examples to discuss your views with your healthcare agent and others, or you may write down your choices as a help to your agent and healthcare team. (If you fill out this worksheet and want it to be part of your DPA/HC, sign it in the presence of witnesses and attach it to your DPA/HC form.) | |||
| Possible Treatment Plans: | |||
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A.
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I would want all possible efforts to preserve life as long as possible. | ||
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B.
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I would want comfort care only, and would not want medical treatment, including tube-feeding, to prolong my life. | ||
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C.
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I would want comfort care and tube-feeding, but would not want other types of medical treatment to prolong my life. | ||
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D.
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My agent should consider the possible benefits and burdens of disease-fighting treatment, and consent only to treatment that he or she believes is in my best interests, as we have discussed them. My agent may refuse any active treatment or may consent to a trail of treatment and then stop treatment if it is not beneficial. | ||
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E.
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Treatment plan D, as described above, except that I would always want tube-feeding | ||
| Possible Medical Situations: | |||
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1.
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Suppose you have a fatal ("terminal") condition. You are unconscious and death is expected soon, with or without treatment. What treatment plan would you want? (Select from above, or write your-own.)
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2.
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Suppose you are permanently unconscious from an accident or severe illness. There is no reasonable hope of recovering awareness, but life support could keep your body alive for years. (This is called "persistent vegetative state" or "permanent coma.") What treatment plan would you want? (Select from above, or write your own.)
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3.
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Suppose you are in a state of very advanced loss of mental capability, due perhaps to stroke or Alzheimer's disease. You cannot recognize or communicate with those close to you, and can do almost nothing for yourself. You could survive in this state for some time with medical treatment. What treatment plan would you want? (Select from above, or write your own.)
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4.
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Suppose you were in a state of permanent but not total confusion, perhaps from a stroke or Alzheimer's disease. You are legally "incompetent" and cannot recognize people and interact with them in a meaningful way, but you are up and around and people are taking care of you. You are not in distress and seem to be able to experience some satisfactions in daily life, such as in eating or hearing music. Then you get an illness that might be fatal. What treatment plan would you want? ( Select from above, or write you own.)
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5.
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Suppose you are frail, chronically ill and uncomfortable, with a limited range of activities available to you. Then you become unconscious, at least temporarily, due to an acute illness. The illness is likely to be fatal unless vigorously treated in a hospital, but even intensive care offers only a small chance of recovery to your former condition. It is much more likely that you will end up worse off than before, or will die in spite of all heroic measures. What treatment plan would you want? (Select from above, or write your own.)
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6.
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Suppose you unexpectedly suffer a serious injury or illness. You have less than a 5 percent chance of good recovery and, if you survive, will have serious brain damage. What treatment plan would you want? (Select from above, or write your own).
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7.
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Use this space to describe any other medical situations you'd like to address:
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| Date: _____________ Signature: ___________________________ Date of Birth: ____________ | |||
| Address: ________________________________________________________________________ | |||
| Witness: _________________________________ Witness: ______________________________ | |||
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Vermont Ethics Network, 89 Main Street (City Center), Drawer 20, Montpelier, VT 05620-3601 (802)828-2909, www.vtethicsnetwork.org, ethics@vtethicsnetwork.org |
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