End-of-Life Care Directive
Personal Information
Full Name
Date of Birth
Address
Healthcare Agent/Proxy
Name of Healthcare Agent/Proxy
Contact Information
Medical Treatment Preferences
Life-Sustaining Treatments (e.g., CPR, ventilation, feeding tube)
Pain Management & Comfort Care
Other Wishes/Instructions
Organ & Tissue Donation
Organ/Tissue Donation Preferences
Signatures
Your Signature
Date
Witness Signature
Date