AIM Program Sutter VNA & Hospice ADVANCED DIRECTIVE INTERVENTION LIST ( ADIL) 1. At this point in my life, taking into account my total state of being, if my condition gets worse, Iwant: Yes Yes Yes Yes No 1. To have my heart re-s tarted with elec tric shock, chest compression and medication. (If No: Do not attempt resuscitation [DNR]) 2. To have a plastic tube inserted in my windpipe and to No be attached to a machine for breathing. No No 3. To be fed through a feeding tube. 4. To be given fluids through intravenous (IV) lines.
2⸠If I knew in advance I were going to die, and if I could choose the location, I
would choose:
My present residence. The hospital (including emergency room, intens ive care). Other: o 3⸠If this box is checked, I d not want to go to the Emergency Room. Do not transport.
Print Patient Name
Patient (Surrogate) Signature
Date
Witness Signature Physician Signature Date
ΣςΝΑΗ 2003