Name: Elizabeth (Liz) Salmi

Date: August 24, 2017

Note: Printed and signed copies of this advance directive are on file with all health systems where Ms. Salmi receives care, and have been emailed as PDF copies to all named health care agents.

(1.1) DESIGNATION OF AGENT:

I designate the following individual as my agent to make health care decisions for me:

Name of agent: Brett S.
Relationship: Spouse
Address: Sacramento, CA
Telephone numbers: See print form

ALTERNATE AGENT (Optional): If I revoke my agent’s authority or if my agent is not willing, able, or reasonably available to make a health care decision for me, I designate as my first alternate agent:

Name of first alternate agent: Christi B.
Relationship: friend
Address: West Sacramento, CA
Telephone numbers: See print form

SECOND ALTERNATE AGENT (Optional): If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate agent:

Name of second alternate agent: Robert L.
Relationship: friend
Address:
Novato, CA
Telephone numbers: See print form

(1.2) AGENT’S AUTHORITY:

My agent is authorized to 1) make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, 2) choose a particular physician or health care facility, and 3) receive or consent to the release of medical information and records, except as I state here:

n/a

(1.3) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE:

My agent’s authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I initial the following line. If I initial this line, I want my agent to make health care decisions for me immediately even though I am still able to make them for myself.

n/a

(1.4) AGENT’S OBLIGATION:

My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

(1.5) AGENT’S POST DEATH AUTHORITY:

My agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains, except as I state here or in Part 3 of this form:

If my death is due to unknown causes, I would like an autopsy. In keeping consistent with how I have lived my life (openly), I would like my cause of death known publicly through my online blog (thelizarmy.com), unless my agent decides there is good reason to keep this information private.

(1.6) NOMINATION OF CONSERVATOR:

If a conservator of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not willing, able, or reasonably available to act as conservator, I nominate the alternate agents whom I have named.

Initials: ES

If you fill out this part of the form, you may strike out any wording you do not want.

(2.1) END-OF-LIFE DECISIONS:

I direct my health care providers and others involved in my care to provide, withhold, or withdraw treatment in accordance with the choice I have marked below:

a) Choice Not To Prolong
I do not want my life to be prolonged if the likely risks and burdens of treatment would outweigh the expected benefits, or if I become unconscious and, to a realistic degree of medical certainty, I will not regain consciousness, or if I have an incurable and irreversible condition that will result in my death in a relatively short time.

Or

b) Choice To Prolong
I want my life to be prolonged as long as possible within the limits of generally accepted medical treatment standards.

(2.2) OTHER WISHES:

If you have different or more specific instructions other than those marked above, such as: what you consider a reasonable quality of life, treatments you would consider burdensome or unacceptable, write them here:

Should my doctor not be surprised if I had a year or left to live, I plan to complete a Physician Orders for Life-Sustaining Treatment (POLST) form, which will specify life-sustaining treatments (e.g., CPR, tube feeding) that I either want or do not want. Information specified in that form will help my health care agent communicate with my medical team by providing more specific details regarding my care at the end of life.

I have put much thought into the kind of environment I would like created if I should be nearing the end of my life due to disease, accident, or old age.

My first preference is to die at home in a hospice kind of situation. This is most important to me. If it is determined I should be in too much pain if my body was transferred from a medical setting to home, and I would die before arriving home, then I would like my health care agent and medical team to work as partners to make my environment as home-like as possible by adhering to the preferences listed below.

I would like my bed to be placed near a window to have access to natural sunlight. Depending on the time of year and noise outside, I would like the window to be opened from time to time to have access to fresh air. It would be nice to have a cat in the house that will sit on my lap or provide comfort to me.

I would like to listen to the radio. I take great pleasure from listening to what is happening in the world, so please set the radio to NPR or a fun podcast (or podcast equivalent depending on what people are listening to in this future time period). I understand that from time to time, events occurring in the world (and in politics) can be upsetting, so if I am days away from death and someone like Donald J. Trump were to be elected again I would be OK if my caregivers were to shelter me from this information by turning off the live news radio and instead began playing more podcasts, baseball and relaxing music.

If people who are caring for me would like to watch a movie or show on television, I would appreciate being in the room, able to watch the show with them, whether I am alert or not.

I would like to be in the room when people are having conversations, laughing, crying, etc. I want to be part of my loved one’s lives as much as possible, even if I am unconscious.

If my caregivers are talking with my medical team, I would like to be in the room when these discussions are taking place—even if they are discussing details about my care that are related to “how much time” I have left. I prefer to know everything about my health and condition, and even if I can’t speak for myself I would like to be present while these discussions are taking place.

If I am still eating, I would prefer to not be placed on diets restricting me from food I enjoyed eating, unless the food interferes with my comfort, causes pain when swallowing, or if I were to develop an allergy that would interfere with my quality of life.

If the people who are caring for me ever had disagreements or arguments during my life, I want them to refrain from arguing around me or within my ability to hear them. Really, I would wish these people make amends with one another, but if they can’t get over that petty bullshit I would hope they respect me enough to shut the hell up.

If I were to ever harbor bad feelings or an on-going argument with anyone in my life, I want those people to know that everything has been forgiven now that I am dying. These people (and hopefully they are few and far between) are welcome to come and visit me and talk and hold my hand (as long as they aren’t there to be mad at me).

I want my health care agent to know I understand they are taking on a lot of stress and work to take care of me, and they should not feel guilty for taking a respite from their time caring for me, whether they need a day, a weekend or longer vacation.

Because I have lived much of my life online, I would like the following to be done with my online accounts:

  • TheLizArmy.com: I want a person whom I have authorized to post to my blog about my passing and/or link to my obituary.
  • Personal Facebook account: I want my agent to submit a request to Facebook to submit turn my profile into a memorial page.
  • Facebook page for this blog: I want my agent to post a link to the blog post and/or obituary.
  • Twitter: I want my agent to send a final tweet from my account linking to the blog post and/or obituary.
  • LinkedIn: I want my agent to submit a request to LinkedIn to have my profile removed.
  • Instagram: I want my agent to post a photo of me during a healthy point in my life with information about my passing.

(3.1) Upon my death:

  • I give any needed organs, tissues, or parts
  • I give the following organs, tissues or parts only: ___
  • I do not wish to donate organs, tissues or parts.

My gift is for the following purposes (strike out any of the following you do not want):

  • Transplant
  • Therapy
  • Research
  • Education

Please note the following:

My health care agent should ask about the ability of my organs to be donated. I am under the impression that people who have received chemotherapy are unable to donate specific organs, but that my corneas are fair game.

I am OK with all of my organs being donated.

I am registered as an organ donor at https://donatelifecalifornia.org.

(4.1) I designate the following physician as my primary physician:

Name of Physician: Dr. C (See paper form)
Address: See paper form
Telephone: See paper form

(5.1) EFFECT OF A COPY:

A copy of this form has the same effect as the original.

(5.2) SIGNATURE:

Sign name: See print form
Date: August 24, 2017

(5.3) STATEMENT OF WITNESSES:

I declare under penalty of perjury under the laws of California (1) that the individual who signed or acknowledged this advance health care directive is personally known to me, or that the individual’s identity was proven to me by convincing evidence, (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a person appointed as agent by this advance directive, and (5) that I am not the individual’s health care provider, an employee of the individual’s health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly nor an employee of an operator of a residential care facility for the elderly.

FIRST WITNESS: See print form

SECOND WITNESS: See print form

(5.4) ADDITIONAL STATEMENT OF WITNESSES:

At least one of the above witnesses must also sign the following declaration:
I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this advance directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual’s estate on his or her death under a will now existing or by operation of law.

Signature of Witness: See print form

Signature of Witness: See print form