Advance Directive Summary Sheet
This Advance Directive Summary Sheet is designed to provide a summary of the resident's overall values pertaining to medical care in different clinical situations. The document is to be used as a guide the event the resident is unable to speak for themselves and as an informational tool but only in the context of discussion with family and the care team. This document is not an order and is thus, only a guide to aid persons making decisions on behalf of the resident.
Resident Name:
Date of Completion of Form:
Summary
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In the event of one of the following events this resident requests the following:
- Severe confusion
- Yes No Doctor visit here at Manor Care
- Yes No Hospitalization
- Yes No CPR
- Yes No Mechanical ventilation
- Yes No Tube feeding
- Yes No Palliative care
- Fall with injury
- Yes No Doctor visit here at Manor Care
- Yes No Hospitalization
- Yes No CPR
- Yes No Mechanical ventilation
- Yes No Tube feeding
- Yes No Palliative care
- Cough, fever, abnormal chest X-ray suggestive of Pneumonia
- Yes No Doctor visit here at Manor Care
- Yes No Hospitalization
- Yes No CPR
- Yes No Mechanical ventilation
- Yes No Tube feeding
- Yes No Palliative care
- Focal weakness, difficulty speaking suggesting a Stroke
- Yes No Doctor visit here at Manor Care
- Yes No Hospitalization
- Yes No CPR
- Yes No Mechanical ventilation
- Yes No Tube feeding
- Yes No Palliative care
