Advance Directive for Terminal Cancer Patients
Personal Information
Name
Date of Birth
Address
Phone
Medical Information
Diagnosis
Physician's Name
Hospital/Clinic
Advance Directives
Life-sustaining treatment preferences
Pain management and comfort care
Artificial nutrition and hydration
Organ and tissue donation
Healthcare Proxy/Representative
Name
Relationship
Phone Number
Address
Additional Instructions
Signature
Date
Witness Signature
Date