Dataset viewer

Mom health care agent form 3-14-23

personas/caregiver/files/documents/doc-poa-healthcare.pdf
documentlook: clean style: legal2 pages render unknown

Text layer

347 words

347 words on 2 pages, from pdftotext. This is what search finds in the file.

Show the text
                                                                                             Attorneys at Law
                                                                                     88 Courthouse Mews NE

Castellaw & Byrd, PLLC                                                                   Cleveland, TN 37311
                                                                                               (423) 555-0151



     APPOINTMENT OF HEALTH CARE AGENT AND
              ADVANCE CARE PLAN
I, Lorraine Mae Pruitt, born February 11, 1945, of 2217 Larkmoor Lane NW, Cleveland,
Tennessee, give this direction about my health care.

Part 1. My health care agent
I appoint the following person to make health care decisions for me whenever I cannot make
them myself:

                         Name                               Relationship           Telephone

 Agent                   Walter Eugene Pruitt Jr.           Son                    (423) 555-0148

 Alternate agent         Russell Dean Pruitt                Son                    (423) 555-0124

My agent may talk with my doctors, see my medical records, choose or refuse treatment for me,
and choose where I am cared for. The alternate serves only if my agent cannot be reached or
cannot serve.

Part 2. What matters to me
I want to be cared for in my own home for as long as that can be done safely. If I cannot know
my family or care for myself and there is no reasonable hope that I will get better, I do not want
my life prolonged by machines.

Part 3. Treatment

 Treatment                     My choice

 CPR if my heart stops         Yes for now. I ask my agent to talk with my doctor about this again if
                               my health gets worse.

 Breathing machine             No, except for a short trial if my doctor expects me to recover
 (ventilator)

 Feeding tube                  No

 Antibiotics and IV fluids     Yes
 Treatment                   My choice

 Comfort care and pain       Always
 relief

 Organ and tissue donation   No


Part 4. Other instructions
Please call Pastor Jim Holloway of New Harmony Baptist Church. I want my sister, Betty
Maddox, told.

Signed March 14, 2023.

Lorraine Mae Pruitt
Witnesses: Darlene Biggs and Thomas Rutledge. Neither witness is the agent, and neither is
related to the patient or entitled to any part of her estate.

State of Tennessee, County of Bradley. Acknowledged before me on March 14, 2023. Marcy L.
Ensley, Notary Public.

A copy of this form is as valid as the original. Copies given to: Walter E. Pruitt Jr.; Samuel
Tolbert, MD; Whitlow Memorial Hospital.

Comments

0

Comments are added in the local viewer; this copy is read-only.

Record

Mom health care agent form 3-14-23 Document · saved Mar 14, 2023

Values from records

1render unknown

The record values this file is made from: the ones its text names with {{record.field}}, and the fields its template reads. A value here is in the file's source; whether it is readable depends on the look.

ValueNow
lorraine.date_of_birth 1945-02-11

The values at render time were not recorded: the file was rendered before files/rendered.json existed. Rendering it again records them.

attachments.yaml 
record: doc-poa-healthcare
template: document
style: legal
org:
  name: Castellaw & Byrd, PLLC
  lines:
  - Attorneys at Law
  - 88 Courthouse Mews NE
  - Cleveland, TN 37311
  phone: '4235550151'
  color: '#3a3a3a'
title: Appointment of Health Care Agent and Advance Care Plan
body: 'I, **Lorraine Mae Pruitt**, born {{lorraine.date_of_birth}}, of 2217 Larkmoor Lane NW, Cleveland,
  Tennessee, give this direction about my health care.


  ## Part 1. My health care agent


  I appoint the following person to make health care decisions for me whenever I cannot make them myself:


  | | Name | Relationship | Telephone |

  |---|---|---|---|

  | Agent | Walter Eugene Pruitt Jr. | Son | (423) 555-0148 |

  | Alternate agent | Russell Dean Pruitt | Son | (423) 555-0124 |


  My agent may talk with my doctors, see my medical records, choose or refuse treatment for me, and choose
  where I am cared for. The alternate serves only if my agent cannot be reached or cannot serve.


  ## Part 2. What matters to me


  I want to be cared for in my own home for as long as that can be done safely. If I cannot know my family
  or care for myself and there is no reasonable hope that I will get better, I do not want my life prolonged
  by machines.


  ## Part 3. Treatment


  | Treatment | My choice |

  |---|---|

  | CPR if my heart stops | Yes for now. I ask my agent to talk with my doctor about this again if my
  health gets worse. |

  | Breathing machine (ventilator) | No, except for a short trial if my doctor expects me to recover |

  | Feeding tube | No |

  | Antibiotics and IV fluids | Yes |

  | Comfort care and pain relief | Always |

  | Organ and tissue donation | No |


  ## Part 4. Other instructions


  Please call Pastor Jim Holloway of New Harmony Baptist Church. I want my sister, Betty Maddox, told.


  Signed March 14, 2023.


  <span class="sig">Lorraine Mae Pruitt</span>


  Witnesses: Darlene Biggs and Thomas Rutledge. Neither witness is the agent, and neither is related to
  the patient or entitled to any part of her estate.


  State of Tennessee, County of Bradley. Acknowledged before me on March 14, 2023. *Marcy L. Ensley*,
  Notary Public.


  A copy of this form is as valid as the original. Copies given to: Walter E. Pruitt Jr.; Samuel Tolbert,
  MD; Whitlow Memorial Hospital.

  '