English Translations of End-of-Life Health Care Forms
These texts are intended to be used by medical practitioners who are presented with our sample forms in Spanish. We offer this official English translation so that hospitals, professionals, and others need not have our Spanish-language documents translated in order to faithfully follow the wishes of someone presenting them. This text is not intended for duplication. Our full English-language Catholic Guide to End-of-Life Decisions, including sample forms, is available for purchase as a digital download or print copy.
Health Care Proxy
I, [Name], residing at [Address] on [Date], hereby create a Health Care Proxy and designate [Name, Telephone, Address] to be my health care agent for making any and all health care decisions on my behalf should I ever become incapacitated. If my agent is ever unable or unwilling to act as my agent, I hereby designate [Name, Telephone, Address] to be my alternative health care agent.
[Signature, Date]
My health care agent has the authority to make any and all medical decisions on my behalf should I ever be unable to do so for myself. I have discussed my wishes with my agent (and with my alternative agent) who shall base all decisions on my previous instructions. If I have not expressed a wish with respect to some future medical decision, my agent shall act in a manner that he/she deems to be in my best interests in accord with what he/she knows of my beliefs.
My agent has the further authority to request and receive all information regarding my medical condition and, when necessary, to execute any documents necessary for release of such information. My agent may execute any document of consent or refusal to permit treatment in accord with my intentions. My agent may also admit me to a licensed health care agency or facility as he/she deems appropriate and sign on my behalf any waiver or release from liability required by a physician or a hospital.
As a member of the Catholic Church, I believe in a God who is merciful and in Jesus Christ who is the Savior of the World. As the Giver of Life, God has sent us His only-begotten Son as Redeemer so that in union with Him we might have eternal life. Through His death and resurrection, Jesus has conquered sin so that death has lost its sting (1 Cor. 15:55). I wish to follow the moral teachings of the Catholic Church and to receive all the obligatory care that my faith teaches we have a duty to accept. However, I also know that death need not be resisted by any and every means and that I have the right to refuse medical treatment that is excessively burdensome or would only add to my suffering as I face inevitable death. I also know that I may morally receive medication necessary to relieve my pain even if it is foreseen that its use may have the unintended result of shortening my life.
[Witness, Date]
I affirm that the principal is at least eighteen years of age, of sound mind, and under no undue influence.
[Witness, Date]
I affirm that the principal is at least eighteen years of age, of sound mind, and under no undue influence.
When initialed here _____, the Advance Medical Directive on the reverse shall be considered an extension of this document. The Advance Medical Directive on the reverse may also be completed independently of this Health Care Proxy.
Advance Medical Directive
For the benefit of those who will make decisions on my behalf should I become incapacitated, I hereby express my desires about some issues that others may face in providing my care. Most of what I state here is general in nature since I cannot anticipate all the possible circumstances of a future illness. I direct that those caring for me avoid doing anything that is contrary to the moral teachings of the Catholic Church. If I fall terminally ill, I ask that I be told of this so that I might prepare myself for death, and I ask that efforts be made that I be attended by a Catholic priest and receive the Sacraments of Penance and Anointing as well as Viaticum.
Those making decisions on my behalf should be guided by the moral teachings of the Catholic Church contained in, but not limited to, the following documents: Declaration on Euthanasia, Congregation for the Doctrine of the Faith, 1980; Address to the Eighteenth International Congress of the Transplantation Society, August 2000; Ethical and Religious Directives for Catholic Health Care Services, United States Conference of Catholic Bishops, 2018; On Life-Sustaining Treatments and the Vegetative State, Pope John Paul II, March 20, 2004.
I want those making decisions on my behalf to avoid doing anything that intends or directly causes my death by deed or omission. Medical treatments may be forgone or withdrawn if they do not offer a reasonable hope of benefit to me or if they entail excessive burdens or impose excessive expense on my family or the community. In principle, I should receive nutrition and hydration so long as they are of benefit to me and alleviate suffering. In accord with the teachings of my Church, I have no moral objection to the use of medication or procedures necessary for my comfort even if they may indirectly and unintentionally shorten my life.
If, in the medical judgment of my attending physician, death is imminent, even in spite of the means which may be used to conserve my life, and if I have received the Sacraments of the Church, I direct that there be forgone or withdrawn treatment that will only maintain a precarious and burdensome prolongation of my life, unless those responsible for my care judge at that time that there are special and significant reasons why I should continue to receive such care (such as those listed below).
Believing that none of the following directives conflicts with the teachings of my Catholic faith, I hereby add the following special provisions and/or limitations to my future health care (for example, “I would like to donate tissue and organs after I am dead, in keeping with the teachings of my faith.” “I would like all reasonable steps to be taken to allow me to see my family—or be reconciled with someone from whom I may have become estranged.” “If at all possible, I would like to die at home, or at least in a hospice that has the appearance of a home setting”):
[Lines]
[Signature, Date]
[Witness, Date]
I affirm that the principal is at least eighteen years of age, of sound mind, and under no undue influence.
[Witness, Date]
I affirm that the principal is at least eighteen years of age, of sound mind, and under no undue influence.