Advance
Healthcare Directive of
Constance
Elizabeth Kronlokken
PART
1
POWER OF ATTORNEY FOR HEALTH CARE
(1.1) DESIGNATION OF AGENT:
I designate the following individual as my agent to make health care decisions
for me:
If I revoke my agent's authority or if my agent is not willing, able, or
reasonably available to make a health care decision for me, I designate as my
first alternate agent:
If I revoke the authority of my
agent and first alternate agent or if neither is willing, able, or reasonably
available to make a health care decision for me, I designate as my second
alternate agent:
(1.2) AGENT'S AUTHORITY: My agent is authorized to make all health care
decisions for me, including decisions to provide, withhold, or withdraw
artificial nutrition and hydration and all other forms of health care to keep
me alive.
(1.3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority
becomes effective when my primary physician determines that a healthcare
decision must be made and my agent determines that I am unable to in some way
signal, communicate or specify my own healthcare decisions.
(1.4) AGENT'S OBLIGATION: My agent shall make health care decisions for
me in accordance with this power of attorney for health care, any instructions
I give in Part 2 of this document, and my other wishes to the extent known to
my agent. To the extent my wishes are unknown, my agent shall make health care
decisions for me in accordance with what my agent determines to be in my best
interest. In determining my best interest, my agent shall consider my personal
values to the extent known to my agent.
(1.5) AGENT'S POSTDEATH AUTHORITY: My agent is authorized to make any
anatomical gifts, authorize an autopsy if he
or she deems it necessary and arrange for the disposition of my body and
remains as I’ve directed in Part 3 of this document.
(1.6) NOMINATION OF CONSERVATOR: If a conservator of my person needs to
be appointed for me by a court, I nominate the agent designated in this
document. If that agent is not willing, able, or reasonably available to act as
conservator, I nominate the alternate agents whom I have named, in the order
designated.
PART
2
INSTRUCTIONS FOR HEALTH CARE
(2.1) END-OF-LIFE DECISIONS:
I do not want my life to be prolonged if (1) I have an incurable and
irreversible condition that will result in my death within a relatively short
time, (2) I become unconscious and, to a reasonable degree of medical
certainty, I will not regain consciousness, or (3) the likely risks and burdens
of treatment would outweigh the expected benefits. I direct that my health care
providers and others involved in my care provide, withhold, or withdraw
treatment in accordance with this document.
(2.2) RELIEF FROM PAIN: I direct that treatment for alleviation of pain
or discomfort be provided at all times, even if it hastens my death, unless I
am able to specify otherwise.
(2.3) OTHER WISHES: If I am conscious or able to signal or communicate,
as determined by my agent, I direct my agent, health care providers and others
involved in my care to solicit, regard, follow and enact my healthcare
decisions. I direct that I be cared for in a quiet place.
PART
3
DONATION OF ORGANS AND DISPOSITION OF MY REMAINS AT DEATH
(3.1) Upon my death I give any
needed organs, tissues, or parts for the following purposes:
(1)
Transplant
(2) Therapy
(3) Research
(4) Education
I direct that the rest of my
remains, if any, be cremated and that the ashes be scattered in a wooded area.
PART 4
PRIMARY PHYSICIAN
(4.1)
I designate the following physician as my primary physician:
If the physician I have designated above is not willing, able, or reasonably
available to act as my primary physician, I direct my agent to arrange for a
suitable primary physician.
* * * * * * * * * * * * * * * * *
PART 5
(5.1) EFFECT OF COPY: A copy of
this document has the same effect as the original.
(5.2) SIGNATURE:
February 12, 2004 _______________________________
Constance Elizabeth Kronlokken
(5.3)
STATEMENT OF WITNESSES: I declare under penalty of perjury under the
laws of California (1) that the individual who signed or acknowledged this
advance health care directive is personally known to me, or that the
individual's identity was proven to me by convincing evidence (2) that the
individual signed or acknowledged this advance directive in my presence, (3)
that the individual appears to be of sound mind and under no duress, fraud, or
undue influence, (4) that I am not a person appointed as agent by this advance
directive, and (5) that I am not the individual's health care provider, an
employee of the individual's health care provider, the operator of a community
care facility, an employee of an operator of a of a community care facility,
the operator of a residential care facility for the elderly, nor an employee of
an operator of a residential care facility for the elderly.
First witness Second
witness
__________________________ __________________________
(print name) (print
name)
__________________________ __________________________
(address) (address)
__________________________ __________________________
(city) (state) (zip) (city) (state) (zip)
__________________________
__________________________
(signature of witness) (signature
of witness)
February 12, 2004 February 12, 2004
(5.4)
ADDITIONAL STATEMENT OF WITNESSES: I further declare under penalty of
perjury under the laws of California that I am not related to the individual
executing this advance health care directive by blood, marriage, or adoption,
and to the best of my knowledge, I am not entitled to any part of the
individual's estate upon his or her death under a will now existing or by
operation of law.
__________________________
__________________________
(signature of
witness)
(signature of witness)