Get the free Withdrawal of Life Prolonging Procedures (Form 3495)

Determination of Patient s Condition And Authorization by Legal Decision-Maker to Withdraw Life-Prolonging Procedures for Incapacitated Patients PART ONE Determination of Patient s Condition 1. Documentation

How to fill out withdrawal of life prolonging

How to fill out withdrawal of life prolonging:

1. Begin by obtaining the necessary form from your healthcare provider or the hospital where you or your loved one is receiving medical treatment.
2. Carefully read and understand the instructions provided with the form. It may be helpful to consult with a healthcare professional or legal advisor for any questions or concerns you may have.
3. Complete the form accurately and legibly, providing all required personal information such as name, date of birth, and contact details. Ensure all information is up to date and correct.
4. In the designated section, clearly state your intention to withdraw life prolonging treatments or interventions. Be specific about the treatments or interventions you wish to refuse, if applicable.
5. Consider including any additional instructions or preferences regarding end-of-life care or alternative treatments, if desired. This can help guide healthcare providers in understanding your wishes and providing appropriate care.
6. Review the form thoroughly to ensure all information is accurate and complete. Make any necessary revisions or additions before finalizing the document.
7. Sign and date the form according to the provided instructions. Some forms may require witnesses or notarization, therefore, ensure you comply with all necessary requirements.
8. Keep a copy of the completed form for your records and provide a copy to your healthcare provider. It is advisable to also share copies with any designated healthcare proxies or family members who may need to advocate for your wishes in the future.

Who needs withdrawal of life prolonging:

1. Individuals who have been diagnosed with a terminal illness or a condition with no chance of recovery may consider withdrawing life prolonging treatments. This can allow them to focus on quality of life rather than prolonging the dying process.
2. Patients who have previously expressed a desire to refuse certain treatments or interventions, even if they are not terminally ill, may benefit from completing a withdrawal of life prolonging form. This ensures that their wishes are respected and followed in case they become unable to communicate or make decisions for themselves.
3. Family members or healthcare proxies who are responsible for making medical decisions on behalf of a loved one who is incapacitated may need to consider withdrawal of life prolonging if it aligns with the wishes expressed by the patient or if it is deemed to be in their best interest based on medical advice and ethical considerations.

For pdfFiller’s FAQs

What is withdrawal of life prolonging?

Withdrawal of life prolonging refers to the decision to remove or stop the use of medical treatments or interventions that are keeping a patient alive.

Who is required to file withdrawal of life prolonging?

The patient's legal guardian or designated healthcare proxy is typically required to file withdrawal of life prolonging.

How to fill out withdrawal of life prolonging?

Withdrawal of life prolonging should be filled out by completing the necessary forms provided by the healthcare facility or legal counsel, and ensuring all relevant information is accurately reported.

What is the purpose of withdrawal of life prolonging?

The purpose of withdrawal of life prolonging is to honor the patient's wishes, improve quality of life, and allow for a peaceful and natural end of life process.

What information must be reported on withdrawal of life prolonging?

Information reported on withdrawal of life prolonging typically includes the patient's details, reason for withdrawal, healthcare provider's input, and any supporting documentation.

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