Advanced Directive Statement of Limitation

I have been made aware that this facility does not provide implementation of advance directives; on the basis of conscience (the scheduled procedure is an elective procedure), regardless of the contents of any advance directive or instructions from a health care surrogate or attorney. If an adverse event occurs at this facility, resuscitative or other stabilizing measures will be initiated and I will be transferred to an acute care hospital for further evaluation. The receiving hospital will implement further treatment or withdrawal of treatment measures already begun in accordance with my wishes, my advance directive or health care power of attorney.