In the event that my health condition is considered to be hopeless,

Level ______ best represents my wishes.

1. Palliative Level 1

Keep me comfortable here at _______________

Give me personal care and pain relief

Do not transfer me to hospital

Do not give me medication to prolong my life

Do not attempt to resuscitate me if my heart stops or I cease to breathe

Summary: Let me die comfortably and peacefully

2. Supportive Care Level 2

Keep me comfortable here at _______________

Give me personal care and pain relief

Do not transfer me to hospital

Do not attempt to resuscitate me if my heart stops or I cease to breathe

Get me antibiotics and other medications to attempt to cure my illness and prolong my life

Summary Try to cure my illness here at _____ but do not hospitalize me

3. Moderate Care Level 3

Send me to the hospital for further care if necessary

Give me intravenous material if recommended by the physician

Operate on me if recommended by the physician

Do not attempt to resuscitate me if my heart stops or I cease to breathe

Do not put me on life-support systems

Summary: Try to cure my illness and hospitalize me if necessary but no heroic measures

4. Acute care Level 4

Do everything medically and surgically possible to prolong my life

Resuscitate me in the event of a witnessed event at ______ or I cease to breathe

Move me to hospital on life-support systems if necessary, including CPR

Summary: Do everything possible to cure my illness and prolong my life including heroic measures