State of Florida
DO NOT RESUSCITATE ORDER

(please use ink)

Patient’s Full Legal Name: ________________________________________________Date:____________________
(Print or Type Name)

PATIENT’S STATEMENT
Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn.

(If not signed by patient, check applicable box):

q Surrogate q Proxy (both as defined in Chapter 765, F.S.)
q Court appointed guardian q Durable power of attorney (pursuant to Chapter 709, F.S.)

________________________________________________________________________________________________
(Applicable Signature) (Print or Type Name)

PHYSICIAN’S STATEMENT
I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the
patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation
(artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient
in the event of the patient’s cardiac or respiratory arrest.

________________________________________________________________________________________________
(Signature of Physician) (Date) Telephone Number (Emergency)

________________________________________________________________________________________________
(Print or Type Name) (Physician’s Medical License Number)

DH Form 1896, Revised December 2002

PHYSICIAN’S STATEMENT

I, the undersigned, a physician licensed pursuant to Chapter 458
or 459, F.S., am the physician of the patient named above.
I hereby direct the withholding or withdrawing of cardiopulmonary
resuscitation (artificial ventilation, cardiac compression,
endotracheal intubation and defibrillation) from the patient in the
event of the patient’s cardiac or respiratory arrest.

________________________________________________________
(Signature of Physician) (Date) Telephone Number (Emergency)

________________________________________________________
(Print or Type Name) (Physician’s Medical License Number)

DH Form 1896,Revised December 2002

State of Florida
DO NOT RESUSCITATE ORDER

________________________________________________________________
Patient’s Full Legal Name (Print or Type) (Date)

PATIENT’S STATEMENT
Based upon informed consent, I , the unders i g n e d ,h e r e by direct that CPR
be withheld or withdrawn. (If not signed by patient, check applicable box):
q Surrogate
q Proxy (both as defined in Chapter 765, F.S.)
q Court appointed guardian
q Durable power of attorney (pursuant to Chapter 709, F.S.)

________________________________________________________________
(Applicable Signature) (Print or Type Name)

CATHOLIC DECLARATION ON LIFE AND DEATH
ADVANCE DIRECTIVE

(HEALTH SURROGATE DESIGNATION/LIVING WILL) OF

_________________________________________________________
(Name)

Introduction
I am executing this Catholic Declaration on Life and Death while I am of sound mind. It is intended to
designate a surrogate and provide guidance in making medical decisions in the event I am
incapacitated or unable to express my own wishes.

Statement of Faith
I believe that I have been created for eternal life in union with God. The truth that my life is a
precious gift from God has profound implications for the question of stewardship over my life. I have
a duty to preserve my life and to use it for God’s glory, but the duty to preserve my life is not
absolute, for I may reject life-prolonging procedures that are insufficiently beneficial or excessively
burdensome. Suicide and euthanasia are never morally acceptable options.

1
If I should become

irreversibly and terminally ill, I request to be fully informed of my condition so that I can prepare
myself spiritually for death and witness to my belief in Christ’s redemption.

Designation of Health Care Surrogate
In the event that I become incapacitated, I designate as my surrogate for health care decisions (if no
surrogate is to be appointed, please write “none” in place of “name” below):

Name:_________________________________________________________________

Address:_______________________________________________________________

Phones (H, W, C):________________________________________________________

If my surrogate is unwilling or unable to perform his or her duties or cannot be contacted, I wish to
designate as my alternate surrogate (if no alternate surrogate is to be appointed, please write “none”
in place of “name” below):

Name:_________________________________________________________________

Address:_______________________________________________________________

Phones (H, W, C):________________________________________________________

This directive will permit my surrogate to make health care decisions, and to provide, withhold, or
withdraw consent on my behalf; to apply for public benefits to defray the cost of health care; to
receive my personal health care information; and to authorize my admission to or transfer from a
health care facility. My surrogate is further appointed as my “Personal Representative.”

2
This

directive is not being made as a condition of treatment or admission to a health care facility. This
document must be signed and witnessed on the other side to be valid.

1
Cf United States Conference of Catholic Bishops, Ethical & Religious Directives for Catholic Health Care Services (USCCB: Washington,

DC 2009), Part Five.

2
As defined by 45 CFR 164.502(g), for purposes of compliance with Federal HIPAA Laws and Regulations (the Health Insurance Portability

and Accountability Act of 1996).

Living Will
The following gives guidance for carrying out my wishes at the end of life. If at any time I am incapacitated and I
have a terminal condition or I have an end-stage condition, and if my attending or treating physician and another
consulting physician have determined that there is no reasonable medical probability of my recovery from such
condition(s), my health care surrogate (designated above, if any) will be authorized to make decisions for me in
accordance with my wishes expressed in this Declaration. If my surrogate cannot be contacted (or I have not
named a surrogate), then I request and direct that each of the following be considered in making a decision for
me.

That:

1. I be provided care and comfort, and that my pain be relieved.

2. No inappropriate, excessively burdensome nor disproportionate means be used to prolong my life. This
can include medical or surgical procedures.

3. There should be a presumption in favor of providing nutrition and hydration to me, including medically
assisted nutrition and hydration, unless:

 They cannot reasonably be expected to prolong my life; or

 The means used to deliver the nutrition and hydration are excessively burdensome and do not
offer sufficient benefit or would cause me significant physical discomfort; or

 I am imminently dying from an irreversible condition.

4. Nothing be done with the intention of causing my death.

5. Spiritual care be provided, including sacraments whenever possible.

Additional Instructions

_______________________________________________________________________________________

_______________________________________________________________________________________

Signatures Required
It is my intention that my surrogate, family and physicians honor this declaration as the expression of my
treatment wishes. I understand the full import of this declaration, and I am emotionally and mentally competent
to make this declaration.

__________________________________________ _______________________________________

DECLARANT Date
Last 4 Social Security Number: ____________

__________________________________________ _______________________________________

Witness Signature Witness Signature

__________________________________________ _______________________________________

Printed/Typed Name Printed/Typed Name

The Health Care Surrogate cannot serve as a witness; at least one witness must not be a spouse or blood
relative of the person signing.

December 7, 2015

Copies of this form are available from the Florida Catholic Conference, 201 West Park Avenue, Tallahassee, FL 32301-7760
www.flaccb.org

END OF LIFE

CONSENT

ADVANCE DIRECTIVES

POWER OF ATTORNEY

DO NOT RESUSCITATE

POLST

MOLST

CONSENT

• FREE AND INFORMED (ERD 28, 27, 26, 59)

28. Each person or the person’s surrogate
should have access to medical and moral
information and counseling so as to be able to
form his or her conscience. The free and
informed health care decision of the person or
the person’s surrogate is to be followed so long
as it does not contradict Catholic principles.

CONSENT

• FREE AND INFORMED (ERD 28, 27, 26, 59)

27. Free and informed consent requires that
the person or the person’s surrogate receive all
reasonable information about the essential
nature of the proposed treatment and its
benefits; its risks, side-effects, consequences,
and cost; and any reasonable and morally
legitimate alternatives, including no treatment
at all.

CONSENT

• FREE AND INFORMED (ERD 28, 27, 26, 59)

26. The free and informed consent of the
person or the person’s surrogate is required
for medical treatments and procedures,
except in an emergency situation when
consent cannot be obtained and there is no
indication that the patient would refuse
consent to the treatment.

CONSENT

• FREE AND INFORMED (ERD 28, 27, 26,
59)

59. The free and informed judgment made
by a competent adult patient concerning
the use or withdrawal of life-sustaining
procedures should always be respected
and normally complied with, unless it is
contrary to Catholic moral teaching.

CONSENT

• PROXY (ERD 25, 24)

25. Each person may identify in advance a representative
to make health care decisions as his or her surrogate in
the event that the person loses the capacity to make
health care decisions. Decisions by the designated
surrogate should be faithful to Catholic moral principles
and to the person’s intentions and values, or if the
person’s intentions are unknown, to the person’s best
interests. In the event that an advance directive is not
executed, those who are in a position to know best the
patient’s wishes—usually family members and loved
ones—should participate in the treatment decisions for
the person who has lost the capacity to make health care
decisions.

CONSENT

• PROXY (ERD 25, 24)

24. In compliance with federal law, a Catholic health
care institution will make available to patients
information about their rights, under the laws of
their state, to make an advance directive for their
medical treatment. The institution, however, will not
honor an advance directive that is contrary to
Catholic teaching. If the advance directive conflicts
with Catholic teaching, an explanation should be
provided as to why the directive cannot be honored.

PROXY CONSENT (LEGAL):

Process by which people with the legal right to consent to medical treatment for
themselves or for a minor or a ward delegate that right to another person.

3 fundamental constraints:

1. Person making the delegation must have the right to consent.

2. Person must be legally and medically competent to delegate the right to consent.

3. Right to consent must be delegated to a legally and medically competent adult.

ADVANCE DIRECTIVES

• Written instructions

• Regarding medical care preferences

• When unable to make one’s own health care decisions

• Guide for one’s family and doctors

• Can help reduce confusion or disagreement

• Generally legally binding

Advance directives include:

• Living will

• Medical or health care power of attorney (POA)

• Do not resuscitate (DNR) order

LIVING WILL

Florida Conference of Catholic Bishops (https://flaccb.org/)

CATHOLIC DECLARATION ON LIFE AND DEATH, BOTH:

• ADVANCE DIRECTIVE

• HEALTH SURROGATE DESIGNATION

https://www.flacathconf.org/declaration-on-life-and-death

POWER OF ATTORNEY (POA)

Medical or health care power of attorney (POA). The medical POA is a
legal document that designates an individual — referred to as your
health care agent or proxy — to make medical decisions for you in the
event that you’re unable to do so.

• DURABLE POA: EVEN WHEN PERSON IS MENTALLY INCAPACITATED

• RECORD IT IN THE COUNTY COURT

Do not resuscitate (DNR) order

Request to not have cardiopulmonary resuscitation
(CPR) if your heart stops or if you stop breathing.

Advance directives do not have to include a DNR order,
and you don’t have to have an advance directive to have
a DNR order.

Your doctor can put a DNR order in your medical chart.

PHYSICIAN ORDERS for LIFE-SUSTAINING TREATMENTS (POLST)

MEDICAL ORDERS for LIFE-SUSTAINING TREATMENTS (MOLST)

DURABLE POWER OF ATTORNEY

State of Florida
County of ____________________________

KNOW ALL MEN BY THESE PRESENTS, that I,__________________________________, of ____________________,
(name) (county)
Florida, as authorized by Florida law, do hereby appoint,_______________________________________________________
(name)

To manage and conduct my affairs. This power of attorney shall be non-delegable except as otherwise provided in Florida Statutes,

and shall be valid and effective from date hereof until such time as I shall die or revoke the power. This durable power of attorney is

not affected by subsequent incapacity of the principal except as provided in Florida Statutes.

The property subject to this durable power of attorney shall include all real and personal property owned by me, my

interest in al property held in joint tenancy, my interest in all non-homestead property held in tenancy by the entirety, and all

property over which I hold power of appointment and shall also include authority to sell, mortgage or convey my homestead

property.

Without limiting the broad powers intended to be conferred by the preceding provisions, I expressly authorize my attorney

acting hereunder in a fiduciary capacity to do and execute all or any of the following acts, deeds, and things for my benefit an d on

my behalf.

1. COLLECTION POWERS: To ask, demand, sue for, recover, collect, receive all sums of money, bank deposits, chattels

and other real or personal property, tangible or intangible, of whatsoever nature or description that may be due,

owing, payable or belonging to me, and to execute and deliver receipts, releases, cancellations or discharges.

2. PAYMENT POWERS: To settle any account or reckoning whatsoever wherein I now am or at any time hereafter shall

be in any way interested or concerned with any person whomsoever, and to pay or receive the balance thereof as the

case may require.

3. SAFE DEPOSIT BOXES: To enter any safe deposit or other place of safekeeping standing in my name with full authority

to remove any and all the contents thereof and to make additions, substitutions and replacements, specifically

including any safe deposit box in my name jointly with my spouse or any other person.

4. BANKING POWERS:

(a) To borrow any sum or sums of money on such terms and with such security, whether real or personal property

belonging to me, as my attorney may think fit, and to execute any and all notes, mortgages and other

instruments which my attorney may deem necessary or desirable.

(b) To draw, accept, make, endorse or otherwise deal with any checks, promissory notes, bills of exchange or

other commercial or mercantile instruments, specifically including the right to make withdrawals from any

savings account or building or loan deposits.

(c) To redeem or cash in any/or all bonds issued by the United States Government or any of its agencies, any

other bonds and any certificates of deposit or other similar assets or securities belonging to me.

(d) To sell all or any bonds, shares of stock, warrants, debentures, or other securities belonging to me, and to

execute all assignments and other instruments necessary or proper for transferring the same to the purchaser

or purchasers thereof, and to give good receipts and discharges for all monies payable in respect thereof.

(e) To invest the proceeds of any redemptions or sales aforesaid, and any other of my monies, in such, bonds,

shares of stock and other securities as my attorney shall think fit, and from time to time to vary the said

investments or any of them.

*POA*
*POA* Page 1 of 3

5. MANAGEMENT POWERS: To vote at all meetings of stockholders of any company or corporation, and otherwise to act

as my attorney or proxy in respect of my shares of stock or other securities or investments which now or hereafter shall

belong to me, and to appoint substitutes or proxies with respect to any such shares of stock.

6. TAX POWERS: To sign and execute in my behalf any tax return, state or federal relating to income, gift, ad valorem,

intangible or other taxes, state or federal, and to act for me in any examinations, audits, hearings, conferences or

litigation relating to any such taxes, including authority to file and prosecute refund claims, and to enter into an effect

any settlements.

7. TRUST POWERS:

(a) To execute a revocable or irrevocable trust which provides that all income and principal shall be paid to me or

the guardian of my estate, or applied for my benefit in such manner as I or my attorney hereunder shall

request or as the trustee shall determine, and that on my death any remaining assets, including income, shall

pass according to my will or intestate succession if I have no will.

(b) To make additions of funds and assets, real and personal, to any trust established by me.

8. BUSINESS INTERESTS:

(a) To sell, rent, lease for any term, or exchange, any real estate or interests therein, for such considerations and

upon such terms and conditions as my attorney may see fit; specifically including the power and authority to

execute acknowledge and deliver deeds, mortgages, leases and other instruments conveying or encumbering

title to property owned by me and my spouse jointly.

(b) To commence, prosecute, discontinue or defend all actions or other legal proceedings touching my estate or

any part thereof, or touching any matter in which I or my estate may be in any way concerned.

(c) The powers herein conferred upon my attorney shall extend to and include all of my right, title and interest in

and to any real and personal property, tangible or intangible, in which I may have an estate by the entirety,

joint tenancy, tenancy in common, as trustee or beneficiary of any trust, or in any other manner.

9. PERSONAL INTERESTS:

(a) To make gifts, outright or in trust, in an amount not greater than $10,000.00 per donee per year or the

amounts allowed without gift tax consequences under the appropriate Internal Revenue code provisions

(including my attorney hereunder appointed).

(b) To arrange for my entrance to and care at any hospital, nursing home, health center, convalescent home,

retirement home or similar institution.

(c) To renounce or disclaim any interest acquired by testate or intestate succession or by inter vivos transfer.

10. HEALTH CARE POWERS:

(a) To authorize, arrange for, consent to, waive and terminate any and all medical and surgical procedures on my

behalf ( including any election or election and agreement under the Life-Prolonging Procedures Act of Florida

with request to providing, withholding or withdrawing life-prolonging procedures should I fail to make a

declaration hereunder) and to pay or arrange compensation for my care.

(b) To make health care decisions for me and to provide informed consent if I am incapable of making health care

decisions or providing informed consent.

(i) To be the final authority to act for me and to make health care decisions for me in matters

regarding my health care during any period in which I have the incapacity to consent.

(ii) To expeditiously consult with appropriate health care providers to provide informed consent in

my best interest and make health care decisions for me which my said Surrogate believes I would

have made under the circumstances if I were capable of making such decisions.

(iii) To give any consent in writing using the appropriate consent form.

(iv) To have access to appropriate clinical records regarding me and have authority to authorize the

release of information and clinical records to appropriate persons to insure the continuity of my

health care.

*POA*

*POA* Page 2 of 3

(v) To apply for public benefits, where necessary, such as Medicare and Medicaid, for me and have

access to information regarding my income and assets to the extent required to make such

application if necessary.

(vi) To make all health care decisions on my behalf including but not limited to those set forth in F.S.

Chapter 765.

11. GENERAL POWERS:

(a) In general to do all other acts, deeds, matters and things whatsoever in or about my estate, property and

affairs, or to concur with persons jointly interested with me therein in doing all acts, deeds, matters and things

herein particularly or generally described, as fully and effectually to all intents and purposes as I could do

myself.

(b) This instrument is executed by me in the State of Florida but it is my intention that the powers and authority

herein conferred upon my attorney as authorized by the laws of Florida now or hereafter in force and effect

shall be exercisable in any other state or jurisdiction where I may have any property or assets.

I hereby ratify and confirm, and promise at all times to ratify and confirm all and whatsoever my duly authorized attorney

hereunder shall lawfully do or cause to be done by virtue of these presents, including anything which shall be done

between the revocation of this instrument by my death or in any other manner and notice of such revocation reaching my

attorney; and I hereby declare that as against me and all persons claiming under me everything which my said attorney

shall do or cause to be done in pursuance hereof after such revocation as aforesaid shall be valid and effectual in favor of

any persons claiming the benefit thereof who, before the doing thereof, shall not have had notice of such revocation.

IN WITNESS WHEREOF, I have executed this Durable Power of Attorney.

___________________________________ ____________________________________________

Witness Signature Date Signature Date

___________________________________ ____________________________________________

Witness Signature Date Print Name

State of Florida

County of ___________________________

Before me, the undersigned authority, duly authorized to take acknowledgements and administer oaths, personally

appeared ________________________________, personally known to me to be the person described above, who being by

me first duly sworn states that (His or Her) is the person who executed the foregoing instrument for the reasons expressed

therein.

Dated this ___________day of ____________,____________.

_______________________________________________________

NOTARY PUBLIC

My Commission Expires:__________________________________

*POA*
*POA* 11/2010 Page 3 of 3

• UNIFORM DETERMINATION OF DEATH ACT (UDDA):

• DYING -> W/IN CONTEXT OF FAITH

• ORDINARY / EXTRAORDINARY MEANS OF LIFE SUPPORT

• ASSIST / SUBSTITUTE VITAL ORGANS

• DIALYSIS

• VENT

• CPR

• KILLING OR ALLOWING TO DIE?

DETERMINATION OF DEATH

ORDINARY / EXTRAORDINARY MEANS OF LIFE SUPPORT

Uniform Determination of Death Act (UDDA):

• model state law

• approved 1981

• NATIONAL CONFERENCE OF COMMISSIONERS ON UNIFORM STATE LAWS

• AMERICAN MEDICAL ASSOCIATION (AMA)

• AMERICAN BAR ASSOCIATION (ABA)

• PRESIDENT’S COMMISSION FOR THE STUDY OF ETHICAL PROBLEMS IN MEDICINE
AND BIOMEDICAL AND BEHAVIORAL RESEARCH

Determination of Death:

(1) irreversible cessation of circulatory and respiratory functions
or

(2) irreversible cessation of all functions of the entire brain, including the brain stem

UNIFORM DETERMINATION OF DEATH:
1. STANDARD CRITERIA (CARDIO-PULMONARY):

 NO HEARTBEAT AND NO BREATHING
or

2. NEUROLOGICAL CRITERIA; ELECTROENCEPHALOGRAM (EEG)
x PARTIAL BRAIN DEATH (NOT ACCEPTABLE)
 TOTAL BRAIN DEATH (YES ACCEPTABLE)

MEDULLA OBLONGATA

DYING -> W/IN CONTEXT OF FAITH

HUMAN LIFE: YES FUNDAMENTAL VALUE / NOT ABSOLUTE VALUE

USA LIFE EXPECTANCY:

• WOMEN: 81 YEARS

• MEN: 76 YEARS

• COMBINED: 79 YEARS

MANAGEMENT, RELIEF: PAIN / SUFFERING

ANALYSIS: BENEFIT / BURDEN

DIAGNOSIS -> PROGNOSIS

BIOETHICAL MEANS OF LIFE SUPPORT:

• ORDINARY (PROPORTIONATE) / EXTRAORDINARY (DISPROPORTIONATE)

CLINICAL MEANS OF LIFE SUPPORT:

• STANDARD MEDICAL PRACTICE / EXPERIMENTAL TREATMENT

ERD 56. A person has a moral
obligation to use ordinary or
proportionate means of preserving
his or her life. Proportionate means
are those that, in the judgment of
the patient, offer a reasonable
hope of benefit and do not entail
an excessive burden or impose
excessive expense on the family or
the community.

ERD 57. A person may forgo
extraordinary or disproportionate
means of preserving life.
Disproportionate means are those
that, in the patient’s judgment, do
not offer a reasonable hope of
benefit or entail an excessive
burden, or impose excessive
expense on the family or the
community.

ETHICAL OBLIGATION RE. VITAL ORGANS: ASSIST / SUBSTITUTE

WHEN TO WITHHOLD OR WITHDRAW LIFE SAVING TREATMENT?

DIALYSIS: SUBSTITUTES KIDNEYS

RESPIRATOR; ASSISTS IN PROVIDING OXYGEN

VENTILATOR; DEPENDS ON THE SETTINGS: ASSIST OR SUBSTITUTE BREATHING

RESPIRATORS: ASSIST BREATHING

(NOT VENTILATOR)

VENTILATOR: PERFUSION

WEANING PROCESS

VENT ~ 2-3 WEEKS BEFORE TRACHEOTOMY

EXTUBATION

TRACHEOTOMY

(TRACHEOSTOMY)

CARDIOPULMONARY RESUSCITATION (CPR):

• ASSISTS / SUBSTITUTES HEART

Defibrillation

• treatment for cardiac dysrhythmias

• Ex. ventricular fibrillation (VF) and ventricular tachycardia (VT)

• delivers a dose of electric current to the heart

KILLING OR ALLOWING TO DIE?