CAUTION:
This Health Care Advance Directive is a general form provided for your convenience. While it meets the legal requirements of most states, it may or may not fit the requirements of your particular state. Many states have special forms or special procedures for creating Health Care Advance Directives. If your state’s law does not clearly recognize this document, it may still provide an effective statement of your wishes if you cannot speak for yourself. The directions for filling out the form are given first, followed by the form itself on this page.
Print your full name in this spot as the principal or creator of the health care advance directive.
Print the full name, address, and telephone number of the person (age 18 or older) you appoint as your health care agent. Appoint only a person with whom you have talked and whom you trust to understand and carry out your values and wishes.
Many states limit the persons who can serve as your agent. If you want to meet all existing state restrictions, do not name any of the following as your agent, since some states will not let them act in that role:
This appendix is adapted from the booklet Shape Your Health-Care Future with Health-Care Advance Directives.
It is a good idea to name alternate agents in case your first agent is not available. Of course, only appoint alternates if you fully trust them to act faithfully as your agent and if you have talked to them about serving as your agent. Print the appropriate information in this section. You can name as many alternate agents as you wish, but place them in the order in which you wish them to serve.
This sample document is effective if and when you cannot make health care decisions. Your agent and your doctor determine if you are in this condition. Some state laws include specific procedures for determining your decision-making ability. If you wish, you can include other effective dates or other criteria for determining that you cannot make health care decisions (such as requiring two physicians to evaluate your decision-making ability). You also can state that the power will end at some later date or event before death.
In any case, you have the right to revoke, or take away, the agent’s authority at any time. To revoke, notify your agent or health care provider orally or in writing. If you revoke, it is best to notify in writing both your agent and physician and anyone else who has a copy of the directive. Also destroy the health care advance directive document itself.
This grant of power is intended to be as broad as possible. Unless you set limits, your agent will have authority to make any decision you could make to consent to or to stop any type of health care.
Even under this broad grant of authority, your agent still must follow your wishes and directions, communicated by you in any manner now or in the future.
To specifically limit or direct your agent’s power, you must complete Part II of the advance directive, section 6, on this page.
The subject of end-of-life treatment is particularly important to many people. In this section, you can give general or specific instructions on the subject. The four main paragraphs are options—choose only one. Write your desires or instructions in your own words if you choose paragraph four. If you choose paragraph two, you have three additional options, from which you can choose one, two, or all three. If you are satisfied with your agent’s knowledge of your values and wishes and you do not want to include instructions in the form, initial the first option and do not give instructions in the form.
Any instructions you give here will guide your agent. If you do not appoint an agent, they will guide any health care providers or surrogate decision makers who must make a decision for you if you cannot do so yourself.
Directive in Your Own Words: If you would like to state your wishes about end-of-life treatment in your own words instead of choosing one of the options provided, you can do so in this section. Since people sometimes have different opinions on whether nutrition and hydration should be refused or stopped under certain circumstances, be sure to address this issue clearly in your directive. Nutrition and hydration means food and fluids given through a nasogastric tube or tube into your stomach, intestines, or veins, and does not include non-intrusive methods such as spoon feeding or moistening of lips and mouth.
Some states allow the stopping of nutrition and hydration only if you expressly authorize it. If you are creating your own directive and you do not want nutrition and hydration, state so clearly.
In this section, you can provide instructions about other health care issues that are not end-of-life treatment or nutrition and hydration. For example, you might want to include your wishes about issues such as nonemergency surgery, elective medical treatments, or admission to a nursing home. Again, be careful in these instructions not to place limitations on your agent that you do not intend. For example, while you may not want to be admitted to a nursing home, placing such a restriction may make things impossible for your agent if other options are not available.
You also may limit your agent’s powers in any way you wish. For example, you can instruct your agent to refuse any specific types of treatment that are against your religious beliefs or unacceptable to you for any other reasons. These might include blood transfusions, electroconvulsive therapy, sterilization, abortion, amputation, psychosurgery, or admission to a mental institution. Some states limit your agent’s authority to consent to or to refuse some of these procedures, regardless of your health care advance directive.
Be very careful about stating limitations because the specific circumstances surrounding future health care decisions are impossible to predict. If you do not want any limitations, simply write in “No limitations.”
In most states, health care providers cannot be forced to follow the directions of your agent if they object. However most states also require providers to help transfer you to another provider who is willing to honor your instructions. To encourage compliance with the health care advance directive, this paragraph states that providers who rely in good faith on the agent’s statements and decisions will not be held civilly liable for their actions.
In this section you can state your intention to donate bodily organs and tissues at death. If you do not wish to be an organ donor, initial the first option. The second option is a donation of any or all organs or parts. The third option allows you to donate only those organs or tissues you specify. Consider mentioning the heart, liver, lung, kidney, pancreas, intestine, cornea, bone, skin, heart valves, tendons, ligaments, and saphenous vein. Finally, you may limit the use of your organs by crossing out any of the four purposes listed that you do not want (transplant, research, therapy, or education). If you do not cross out any of these options, your organs may be used for any of these purposes.
Appointing a health care agent helps to avoid a court-appointed guardian for health care decision making. However, if a court becomes involved for any reason, this paragraph expressly names your agent to serve as guardian. A court does not have to follow your nomination, but normally it will honor your wishes unless there is good reason to override your choice.
These items address miscellaneous matters that could affect the implementation of your health care advance directive.
Required state procedures for signing this kind of document vary. Some require only a signature, while others have very detailed witnessing requirements. Some states simply require notarization.
The procedure in this book is likely to be far more complex than your state law requires because it combines the formal requirements from virtually every state. Follow it if you do not know your state’s requirements and you want to meet the signature requirements of virtually every state.
1. Sign and date the document in the presence of two witnesses and a notary. Your witnesses should know your identity personally and be able to declare that you appear to be of sound mind and under no duress or undue influence.
In order to meet the different witnessing requirements of most states, do not have the following people witness your signature:
If you are in a nursing home or other institution, a few states have additional witnessing requirements. This form does not include witnessing language for this situation. Contact a patient advocate or an ombudsman to find out about the state’s requirements in these cases.
2. Have your signature notarized. Some states permit notarization as an alternative to witnessing. Doing both witnessing and notarization is more than most states require, but doing both will meet the execution requirements of most states. This form includes a typical notary statement, but it is wise to check state law in case it requires a special form of notary acknowledgment.
I,_______________________________________, hereby appoint
PRINCIPAL
AGENT’S NAME
ADDRESS
HOME PHONE # WORK PHONE #
as my agent to make health and personal care decisions for me as authorized in this document.
If
I revoke my Agent’s authority; or
my Agent becomes unwilling or unavailable to act; or
my agent is my spouse and I become legally separated or divorced,
I name the following (each to act alone and successively, in the order named) as alternates to my Agent:
A. First Alternate Agent____________________________________
Address___________________________________________
Telephone_________________________________________
B. Second Alternate Agent_____________________________
Address___________________________________________
Telephone_________________________________________
By this document I intend to create a health care advance directive. It is effective upon, and only during, any period in which I cannot make or communicate a choice regarding a particular health care decision. My Agent, attending physician, and any other necessary experts should determine that I am unable to make choices about health care.
I give my Agent full authority to make health care decisions for me. My Agent shall follow my wishes as known to my Agent either through this document or through other means. In interpreting my wishes, I intend my Agent’s authority to be as broad as possible, except for any limitations I state in this form. In making any decision, my Agent shall try to discuss the proposed decision with me to determine my desires if I am able to communicate in any way. If my Agent cannot determine the choice I would want, then my Agent shall make a choice for me based upon what my Agent believes to be in my best interests.
Unless specifically limited by Section 6, below, my Agent is authorized as follows:
(Initial only ONE of the following FOUR main statements):
1. ______ NO SPECIFIC INSTRUCTIONS. My Agent knows my values and wishes, so I do not wish to include any specific instructions here.
2. ______ DIRECTIVE TO WITHHOLD OR WITHDRAW TREATMENT. Although I greatly value life, I also believe that at some point life has such diminished value that medical treatment should be stopped, and I should be allowed to die. Therefore, I do not want to receive treatment, including nutrition and hydration, when the treatment will not give me a meaningful quality of life.
(If You Initialed this Paragraph, Also initial Any or All of the Following Three Statements With Which You Agree):
By this I mean that I do not want my life prolonged …
______ … if the treatment will leave me in a condition of permanent unconsciousness, such as in an irreversible coma or a persistent vegetative state.
______ … if the treatment will leave me with no more than some consciousness and in an irreversible condition of complete, or nearly complete, loss of ability to think or communicate with others.
______ … if the treatment will leave me with no more than some ability to think or communicate with others, and the likely risks and burdens of treatment outweigh the expected benefits. Risks, burdens, and benefits include consideration of length of life, quality of life, financial costs, and my personal dignity and privacy.
3. ______ DIRECTIVE TO RECEIVE TREATMENT. I want my life to be prolonged as long as possible, no matter what my quality of life.
4. ______ DIRECTIVE ABOUT END-OF-LIFE TREATMENT IN MY OWN WORDS:
No person who relies in good faith on any representations by my Agent or Alternate Agent(s) shall be liable to me, my estate, or my heirs or assigns for recognizing the Agent’s authority.
Upon my death: (Initial one)
______ I do not wish to donate any organs or tissues, OR
______ I give any needed organs, tissues, or parts, OR
______ I give only the following organs, tissues, or parts:
(please specify)
My gift (if any) is for the following purposes:
(Cross out any of the following you do not want)
If a guardian of my person should for any reason need to be appointed, I nominate my Agent (or his or her alternate then authorized to act), named above.
(All apply)
I revoke any prior health care advance directive.
This health care advance directive is intended to be valid in any jurisdiction in which it is presented.
A copy of this advance directive is intended to have the same effect as the original.
BY SIGNING HERE, I INDICATE THAT I UNDERSTAND THE CONTENTS OF THIS DOCUMENT AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT.
I sign my name to this Health Care Advance Directive on this ______ day of __________________________, 20______.
My Signature______________________________________
My Name________________________________________
My current home address is________________________________
I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this health care advance directive in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence.
I am not:
the person appointed as agent by this document;
the patient’s health care provider;
an employee of the patient’s health care provider;
financially responsible for the person’s health care;
related to the principal by blood, marriage, or adoption; and,
to the best of my knowledge, a creditor of the principal or entitled to any part of his/her estate under a will now existing or by operation of law.
Witness #1:
Notarization
STATE OF_____________.) My Commission Expires:
) ss.
COUNTY OF_____________)
On this____day of_____, 20_____
the said__________,_________________
known to me (or satisfactorily NOTARY PUBLIC
proven to be the person named
in the foregoing instrument)
personally appeared before me,
a Notary Public, within and for
the State and County aforesaid,
and acknowledged that he or she
freely and voluntarily executed
the same for the purposes stated
therein.