COLEGIO DE STA. LOURDES OF LEYTE FOUNDATION INC.
TABONTABON, LEYTE
COLLEGE OF NURSING
Complete this portion of advance directive form
I, JINKY C. PONTILLAS, write this document as a directive regarding my medical
care.
PART 1. My Durable Power of Attorney for Health Care
I appoint this person to make decisions about my medical care if there
ever comes a time when I cannot make those decisions myself. I want the
person I have appointed, my doctors, my family and others to be guided by the
decisions I have made in the parts of the form that follow.
Name: Atty. Granney R. Varona
Home telephone: 09171110088 Work telephone: (053)832-3105
Email: yenrv@[Link]
Address: 137 Imelda Blvd., Brgy. San Miguel, Tanauan, Leyte
If the person above cannot or will not make decisions for me, I appoint this
person:
Name: Adrian Glenn R. Aranda
Home telephone: 091543369559
Address: Brgy. San Pablo, Tabontabon, Leyte
PART 2. My Living Will
These are my wishes for my future medical care if there ever comes a time when I
can't make these decisions for myself.
A. These are my wishes if I have a terminal condition
Life-sustaining treatments
I do not want a life-sustaining treatment including CPR if my body decline. If
life-sustaining treatments are started, I want them stopped.
I want the life-sustaining treatments that my doctors think is best for me.
Artificial nutrition and hydration
COLEGIO DE STA. LOURDES OF LEYTE FOUNDATION INC.
TABONTABON, LEYTE
COLLEGE OF NURSING
I do not want artificial nutrition and hydration started if they would be the main
treatments keeping me alive. If artificial nutrition and hydration are started, I
want them stopped.
B. These are my wishes if I am ever in a persistent
vegetative state
Life-sustaining treatments
I do not want life-sustaining treatments (including CPR) started. If life-
sustaining treatments are started, I want them stopped.
I want the life-sustaining treatments that my doctors think are best for me.
Artificial nutrition and hydration
I do not want artificial nutrition and hydration started if they would be the main
treatments keeping me alive. If artificial nutrition and hydration are started, I
want them stopped.
I want artificial nutrition and hydration even if they are the main treatments
keeping me alive.
Comfort care
I want to be kept as comfortable and free of pain as possible, even if such
care prolongs my dying or shortens my life.
PART 3. Other Wishes
A. Organ donation
I want to donate my organs (heart, kidney, and etc.) if they are in good
condition.
I want to donate my body for a scientific research and for education purposes.
PART 4. Signatures
You and two witnesses must sign this document before it will be legal.
COLEGIO DE STA. LOURDES OF LEYTE FOUNDATION INC.
TABONTABON, LEYTE
COLLEGE OF NURSING
A. Your signature
By my signature below, I show that I understand the purpose and the effect of this
document.
Signature ___________________________Date ____________________
Address: Brgy. Dagami, Leyte
B. Your witnesses' signatures
I believe the person who has signed this advance directive to be of sound mind, that
he/she signed or acknowledged this advance directive in my presence and that
he/she appears not to be acting under pressure, duress, fraud or undue influence. I
am not related to the person making this advance directive by blood, marriage or
adoption nor, to the best of my knowledge, am I named in his/her will. I am not the
person appointed in this advance directive. I am not a health care provider or an
employee of a health care provider who is now, or has been in the past, responsible
for the care of the person making this advance directive.
Witness #1
Signature ______________________________ Date
____________________
Address: Brgy. Dagami, Leyte
Witness #2
Signature _______________________________ Date
____________________
Address: Brgy. Calipayan Dagami, Leyte
COLEGIO DE STA. LOURDES OF LEYTE FOUNDATION INC.
TABONTABON, LEYTE
COLLEGE OF NURSING
ADVANCE
DIRECTIVE
(BIOETHICS)
NAME: MAYNARD R. ARANDA
YR&SEC.: BSN 2-D
INSTRUCTOR: DR. RUSTICO B. BALDERIAN
