Hospice-Care Advance Directive
Patient Information
Full Name
Date of Birth
Address
Phone Number
Medical Record Number
Designation of Healthcare Agent
Agent's Name
Relationship to Patient
Agent's Phone
Alternate Agent (optional)
Hospice Care Preferences
Select the statements that best reflect your wishes:
I wish to receive comfort care only.
I do not wish to have life-sustaining treatments.
I do not wish to receive artificial nutrition or hydration.
Other instructions
Pain Management Preferences
Please specify your wishes regarding pain management:
Spiritual/Emotional Support Preferences
Please specify if you have any specific needs:
Other Instructions or Requests
Additional preferences or instructions for your care:
Signatures
Patient Signature
Date
Healthcare Agent Signature (optional)
Date
Witness Signature
Date