Advanced Healthcare Directive


ADVANCED HEALTH DIRECTIVE

NOTE: THE ADVANCE DIRECTIVE FOR HEALTH CARE SHALL BE SUBSTANTIALLY IN THE FOLLOWING FORM, BUT IN ADDITION MAY INCLUDE OTHER SPECIFIC DIRECTIONS. SHOULD ANY SPECIFIC DIRECTIONS BE HELD TO BE INVALID, THE INVALIDITY SHALL NOT AFFECT OTHER DIRECTIONS OF THE ADVANCE DIRECTIVE FOR HEALTH CARE WHICH CAN BE GIVEN EFFECT WITHOUT THE INVALID DIRECTION, AND TO THIS END THE DIRECTIONS IN THE ADVANCE DIRECTIVE FOR HEALTH CARE ARE SEVERABLE.

 

This advance directive for health care is made this ____ day of _________(Month, year).

I,________________________________ , being 19 years of age or older, of sound mind, hereby revoke any prior advance directive for health care, and in lieu thereof hereby willfully and voluntarily make known my desires by my instructions to others through my living will, or by my appointment of a health care proxy, or both, that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

If my attending physician determines that I am no longer able to give directions to my health care providers regarding my medical treatment, I direct my attending physician and other health care providers to provide, withhold, or withdraw certain treatment from me under the circumstances I have indicated below by my initials. I understand that by initialing any of the paragraphs in this Living Will I am authorizing the withholding or withdrawal of certain treatments and this may lead to my death. I understand that I will be given treatment that is necessary for comfort or to alleviate my pain except where I specifically request otherwise.

(a) Terminal illness or injury. If my attending physician and another physician determine that I have an incurable terminal illness or injury which will lead to my death within six months or less:

I DO want medically indicated life-sustaining treatment, even if it will not cure me and will only prolong the dying process.

(1) I do NOT want life-sustaining treatment which would not cure me but which would only prolong the dying process.

In addition, before life-sustaining treatment is withheld or withdrawn as directed above, I direct that my attending physician shall discuss with the following persons, if they are available, the benefits and burdens of taking such action and my stated wishes in this advance directive:

________________________________________________________

 

(2) I understand that artificially provided nutrition and hydration (tube feeding of food and water) may be necessary to preserve my life.

(i)         I DO want medically indicated artificially provided nutrition and hydration, even if it will only prolong the dying process.

(ii)        I do NOT want artificially provided nutrition and hydration under the circumstance initialed below:

In addition, before artificially provided nutrition and hydration are withheld or withdrawn as directed above, I direct that my attending physician shall discuss with the following persons, if they are available, the benefits and burdens of taking such action and my stated wishes in this advance directive:

______________________________________________________

 

(3) I direct that (add other medical directives, if any) (if none, state “none”):

________________________________________________________

 

 

 

(b) Permanent unconsciousness. If in the judgment of my attending physician and another physician, I am in a condition of permanent unconsciousness:

(1) I DO want medically indicated life-sustaining treatment, even if it will not cure me and will only maintain me in a condition of permanent unconsciousness.

I do NOT want life-sustaining treatment which would not cure me but which would only maintain me in a condition of permanent unconsciousness.

In addition, before life-sustaining treatment is withheld or withdrawn as directed above, I direct that my attending physician shall discuss with the following persons, if they are available, the benefits and burdens of taking such action and my stated wishes in this advance directive:

________________________________________________________

 

(2) I understand that artificially provided nutrition and hydration (tube feeding of food and water) may be necessary to preserve my life.

(i)         I DO want medically indicated artificially provided nutrition and hydration, even if it will only maintain me in a condition of permanent unconsciousness.

(ii)        I do NOT want artificially provided nutrition and hydration under the circumstance initialed below:

_______________________________________________________

 

 

 

In addition, before artificially provided nutrition and hydration are withheld or withdrawn as directed above, I direct that my attending physician shall discuss with the following persons, if they are available, the benefits and burdens of taking such action and my stated wishes in this advance directive:

_______________________________________________________

 

 

(3) I direct that (add other medical directives, if any) (if none, state “none”):

______________________________________________________

 

 

I understand that my health care proxy is a person whom I may choose here to make medical treatment decisions for me as described below.

(a) I do NOT want to appoint a health care proxy.

(b) I DO want to appoint a health care proxy. If my attending physician determines that I am no longer able to give directions to my health care providers regarding my medical treatment, I direct my attending physician and other health care providers to follow the instructions of ________________________________, whom I appoint as my health care proxy. If my health care proxy is unable to serve, I appoint ________________________________ as my alternate health care proxy with the same authority. My health care proxy is authorized to make whatever medical treatment decisions I could make if I were able, including decisions regarding the withholding or withdrawing of life-sustaining treatment.

(i)         I specifically do [  ] do not [  ] authorize my health care proxy to make decisions regarding whether artificially provided nutrition and hydration be withheld or withdrawn.

(ii)        I specifically direct my health care proxy to (add other medical directives, if any) (if none, state “none”):

________________________________________________________

 

 

If the decisions made by the person I have appointed as my health care proxy disagree with the instructions in my Living Will:

_______________________________________________________

 

 

I understand that if I do not initial either of the above, then my health care proxy will make the final decision.

 

 

As used in this advance directive for health care, the following terms have the meaning set forth below:

(a) Artificially provided nutrition and hydration. A medical treatment consisting of the administration of food and water through a tube or intravenous line, where I am not required to chew or swallow voluntarily. Artificially provided nutrition and hydration does not include assisted feeding, such as spoon or bottle-feeding.

(b) Life-sustaining treatment. Any medical treatment, procedure, or intervention that, in the judgment of the attending physician, when applied to me, would serve only to prolong the dying process where I have a terminal illness or injury, or would serve only to maintain me in a condition of permanent unconsciousness. These procedures shall include, but are not limited to, assisted ventilation, cardiopulmonary resuscitation, renal dialysis, surgical procedures, blood transfusions, and the administration of drugs and antibiotics. Life-sustaining treatment shall not include the administration of medication or the performance of any medical treatment where, in the opinion of the attending physician, the medication or treatment is necessary to provide comfort or to alleviate pain.

(c) Permanent unconsciousness. A condition that, to a reasonable degree of medical certainty:

a. Will last permanently, without improvement; and

b. In which thought, sensation, purposeful action, social interaction, and awareness of self and environment are absent; and

c. Which condition has existed for a period of time sufficient, in accordance with applicable professional standards, to make such a diagnosis; and

d. Which condition is confirmed by a physician who is qualified and experienced in making such a diagnosis.

(d) Terminally ill or injured patient. A patient whose death is imminent or whose condition, to a reasonable degree of medical certainty, is hopeless unless he or she is artificially supported through the use of life-sustaining procedures.

(a) I understand that if I have been diagnosed as pregnant and that diagnosis is known to my attending physician, directions in this advance directive for health care concerning the providing, withholding, and withdrawal of life-sustaining treatment and artificially provided nutrition and hydration shall have no force or effect during the course of my pregnancy.

(b) In the absence of my ability to give directions regarding the use of life-sustaining treatment, it is my intention that this advance directive for health care shall be honored by my family, my physician(s), and health care provider(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

(c) I understand the full import of this declaration and I am emotionally and mentally competent to make this advance directive for health care.

(d) Nothing herein shall be construed as a directive to exclude from consultation or notification any relative of mine about my health condition or dying. Written directives by me as to whether to notify or consult with certain family members shall be respected by health care workers, attorneys in fact, or surrogates.

(e) I understand that I may revoke this directive at any time.

___________________________

Signature

Name and Address: _______________________________________

The declarant has been personally known to me and I believe him or her to be of sound mind. I did not sign the declarant’s signature above for or at the direction of the declarant and I am not appointed as the health care proxy therein. I am not related to the declarant by blood, adoption, or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of declarant or codicil thereto, or directly financially responsible for declarant’s medical care.

_______________________

Witness

_______________________

Witness

Date: _______________________

I,_______________________________ , accept the proxy designation of the declarant and I, _______________________________ , accept the alternate proxy designation of the declarant.

________________________

Signed by Proxy

State Specific Power of Attorney Forms

—-For State Specific Power of Attorney Forms you can download in Word Format go to

http://www.uslegalforms.com/powerofattorney/