This required section includes the name of the person who the document is prepared for ("Grantor"). This document provides the Grantor's health care instructions. [Press Ctrl+F1] for more information.
This optional section provides for the designation of a "Surrogate" to make health care decisions on behalf of the Grantor, if the Grantor is unable to do so. Press [Ctrl+F1] for more information.
This required section states the preferences of the Grantor regarding life-prolonging treatment if the Grantor has a terminal condition or is permanently unconscious. Press [Ctrl+F1] for more information.
This required section explains the circumstances under which the Grantor does or does not wish to receive artificially administered nutrition and fluids. Press [Ctrl+F1] for more information.
This optional section allows the Grantor to state her preference regarding how much effect should be given to this document if she is pregnant. Press [Ctrl+F1] for more information.
This optional section lists procedures the Grantor wishes to receive or not receive. Circumstances at the time a decision is made and a free form option are also presented. Press [Ctrl+F1] for more information.
This required section enhances the enforceability of the document by allowing the severance of any provision that may be declared invalid. Press [Ctrl+F1] for more information.
This required section provides for the Grantor's signature and requests additional information regarding the Grantor. Press [Ctrl+F1] for more information.
This section requires that two persons or a notary public witness the Grantor's signature. There are limits on who may serve as a witness. Press [Ctrl+F1] for more information.
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Advance Health Care Directive
ADDIKY
The Kentucky Advance Directive document allows a person to state health care preferences, and designate a person who will have authority to make health care decisions for the person, if the person is unable to do so.
Enter the name of the person this Directive is being prepared for (the Grantor) or edit the information as desired. Use the P.I. Manager to select and paste a record. This document allows the Grantor to provide instructions and wishes regarding health care if the Grantor is unable to make such decisions.
AKY01
! Living Will Section (1 of 9)
[Access Document Information for an explanation of any terms contained in the Directive.]
LIVING WILL DIRECTIVE
Declaration made this _____ day of ____________, 19___.
I, !, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
My wishes regarding life-prolonging treatment and artificially provided nutrition and hydration to be provided to me if I no longer have decisional capacity, have a terminal condition,
! [optional COMA provision] or become permanently unconscious,
have been indicated by checking and initialing the appropriate lines below. By checking and initialing the appropriate lines, I specifically provide the following authorization:
Enter the name of the person this Directive is being prepared for (the Grantor) or edit the information as desired. Use the P.I. Manager to select and paste a record. This document allows the Grantor to provide instructions and wishes regarding health care if the Grantor is unable to make such decisions.
Enter an X to include a "permanently unconscious" condition in this Directive. This condition is characterized by an absence of cerebral cortical functions indicative of consciousness or behavioral interaction with the environment. A determination of such a condition is required by two physicians.
AKY02
! Optional Designation of Health Care Surrogate Section (2 of 9)
!. _____ DESIGNATION OF HEALTH CARE SURROGATE. I designate:
Surrogate Name:
Address 1: !
Address 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: !
Relation, if any: !
as my health care surrogate(s) to make health care decisions for me in accordance with this directive when I no longer have decisional capacity.
! If ! refuses or is not able to act for me, I designate:
Alternate Surrogate Name:
Address 1: !
Address 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: !
Relation, if any: !
as my health care surrogate(s).
Any prior designation is revoked.
(Note: An employee, owner, director, or officer of a health care facility where the grantor is a resident or patient shall not be designated or act as surrogate unless a close relative of the grantor or a member of the same religious order.)
The surrogate may make any health care decisions for me which I could make individually if I had decisional capacity, provided all the decisions shall be made in accordance with my desires as indicated in this Directive.
! Whenever making any health care decision for me, my surrogate shall consider the recommendation of my attending physician, and honor the decision expressed in this Directive.
My surrogate may not make a health care decision in any situation in which my attending physician has determined in good faith that I have decisional capacity. My attending physician shall proceed as if there were no designation if the surrogate is unavailable or refuses to make a health care decision.
If the person I designate as surrogate or an alternate surrogate is or ever becomes my spouse, he or she shall be ineligible to serve as my surrogate
! if we are separated,
if our marriage is annulled or we are divorced.
Enter an X to designate a "Surrogate". A surrogate is a person who is authorized by the Grantor to make medical and health care decisions for the Grantor if the Grantor is unable to do so. This provision must be initialed by the Grantor on the printed document when the Directive is signed. Press [Ctrl+F1] for more information.
Enter the Surrogate's name(s) or use the P.I. Manager to select and paste a record. Two Surrogates may be designated and together they must agree on the health care decisions being made on behalf of the Grantor. NOTE THAT CERTAIN INDIVIDUALS SHOULD NOT BE DESIGNATED AS A HEALTH CARE SURROGATE. Press [Ctrl+F1] for more information.
Enter the Surrogate's street address or edit the information as desired.
Enter the Surrogate's extended street address or edit the information as desired.
Enter the Surrogate's city or edit the information as desired.
Enter the Surrogate's state/province or edit the information as desired.
Enter the Surrogate's zip/postal code or edit the information as desired.
Enter an X to include the Surrogate's country, if outside the United States.
Enter the country or edit the information as desired.
Enter the Surrogate's phone number or edit the information as desired.
Enter the relation, if any, between the Grantor and the Surrogate.
Enter an X to designate an Alternate Surrogate to act on behalf of the Grantor, if the first choice is unable or unwilling to do so.
Enter the Alternate Surrogate's name(s) or use the P.I. Manager to select and paste a record. Two Alternate Surrogates may be designated and together they must agree on the health care decisions being made on behalf of the Grantor. NOTE THAT CERTAIN INDIVIDUALS SHOULD NOT BE DESIGNATED AS A HEALTH CARE SURROGATE.
Enter the Alternate Surrogate's street address or edit the information as desired.
Enter the Alternate Surrogate's extended street address or edit the information as desired.
Enter the Alternate Surrogate's city or edit the information as desired.
Enter the Alternate Surrogate's state/province or edit the information as desired.
Enter the Alternate Surrogate's zip/postal code or edit the information as desired.
Enter an X to include the Alternate Surrogate's country, if outside the United States.
Enter the Alternate Surrogate's phone number or edit the information as desired.
Enter the relation, if any, between the Grantor and the Alternate Surrogate.
Enter an X if the Surrogate should consider the recommendation of the Grantor's physician when making any health care decision, in addition to following the Surrogate's instructions.
Enter an X if the person named as surrogate is or ever becomes the Grantor's spouse, and the Grantor desires that his or her spouse not serve as agent if they are divorced or their marriage is annulled.
Enter an X if the Grantor desires that the Grantor's spouse not serve as surrogate, if the Grantor is separated from such spouse.
AKY03
! Instructions Section (3 of 9)
[This section states the preferences of the Grantor regarding life-prolonging treatment if the Grantor has a terminal condition. Access Document Information for an explanation of terminology.]
!. INSTRUCTIONS. If I do not designate a surrogate, the following are my directions to my attending physician. If I have designated a surrogate, my surrogate shall comply with my wishes as indicated below:
If at any time I should have a terminal condition
! [optional COMA provision] or a permanently unconscious condition,
and my attending and one other physician in their discretion, have determined such condition is incurable and irreversible and will result in death within a relatively short time,
! [additional phrase if COMA option selected] or that I will remain in a permanently unconscious condition,
and where the application of life-prolonging treatment would serve only to artificially prolong the dying process,
! _____ I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical treatment deemed necessary to alleviate pain.
! _____ I DO NOT authorize that life-prolonging treatment be withdrawn or withheld.
Enter an X to include the preferences of the Grantor regarding life-prolonging treatment if the Grantor is "permanently unconscious." This condition is characterized by an absence of cerebral cortical functions indicative of consciousness or behavioral interaction with the environment.
Enter an X if life-prolonging treatment should be withdrawn or withheld if the Grantor is in the above condition(s). Medication and treatment to alleviate pain would still be provided to the Grantor. This provision must be initialed by the Grantor when the Directive is signed.
Enter an X if life-prolonging treatment should NOT be withdrawn or withheld if the Grantor is in the above condition(s). This provision must be initialed by the Grantor when the Directive is signed.
AKY04
! Nutrition/Hydration Section (4 of 9)
!. NUTRITION/HYDRATION. Kentucky law provides that a health care surrogate may authorize the withdrawal or withholding of artificially provided nutrition and hydration in the following circumstances:
(a) When inevitable death is expected, by reasonable medical judgment, within a few days;
(b) When authorized by a patient in an advance directive, and the patient becomes permanently unconscious;
(c) When the provision of artificial nutrition cannot be physically assimilated by the person;
(d) When the burden of the provision of artificial nutrition and hydration itself outweighs its benefits.
Artificially provided nutrition in exceptions (a), (b), and (c) shall not be withheld or withdrawn if it is needed for comfort or the relief of pain.
Based upon my understanding of Kentucky law,
! _____ I Authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids.
! _____ I DO NOT authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids.
! _____ I Authorize my surrogate, designated above, to withhold or withdrawal artificially provided nourishment or fluids, or other treatment if the surrogate determines that withholding or withdrawing is in my best interest; but I do not mandate that withholding or withdrawing.
Enter an X if the Grantor DOES NOT wish to receive artificially administered nutrition and/or fluids. This provision must be initialed by the Grantor when the Directive is signed. Press [Ctrl+F1] for more information regarding artificial nutrition/hydration.
Enter an X if the Grantor WISHES to receive artificially administered nutrition and/or fluids. This provision must be initialed by the Grantor when the Directive is signed.
Enter an X if the Surrogate will be authorized to determine whether or not artificially administered nutrition/fluids should be withheld or withdrawn. The Surrogate can base this decision on information available at the time a decision is required. This provision must be initialed by the Grantor when the Directive is signed.
AKY05
! Optional Pregnancy Section (5 of 9)
!. PREGNANCY. If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this directive shall have no force or effect during the course of my pregnancy.
! [Optional sentence]
However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with the continued application of life-prolonging treatment, it is my preference that this document be given effect at that point.
! [Additional optional sentence]
If life-prolonging treatment will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
Enter an X to include a pregnancy paragraph. Kentucky law provides that a Directive will not be enforced if the Grantor is pregnant. This provision allows the Grantor to state certain exceptions as provided in the Kentucky law. Press [Ctrl+F1] for more information.
Enter an X to provide an exception to the invalidity of the Directive if the Grantor is pregnant. This exception permits enforcement of the Declaration if the fetus could not develop to the point of live birth with the continued application of life-prolonging treatment.
Enter an X to provide an exception to the invalidity of the Directive if the Grantor is pregnant. This exception requests that physical harm or pain to the Grantor be considered in determining whether life-prolonging treatment should be withheld or withdrawn.
'AKY06
! Optional Specific Requests Section (6 of 9)
!. SPECIFIC REQUESTS. Notwithstanding any other provision of this document, it is my general desire (i) to RECEIVE the following procedures or treatment that are so marked, if such procedures are deemed appropriate by my attending physician and any surrogate that I may have designated to make health care decisions for me, and (ii) NOT TO RECEIVE the following procedures or treatment that are so marked, although such procedures are deemed appropriate by my attending physician.
NOT TO
RECEIVE RECEIVE
! Artificial or mechanical respiration
! Cardiopulmonary resuscitation
! Blood or blood products
! Any form of surgery or
invasive diagnostic procedures
! Kidney dialysis
! Antibiotics
! Chemotherapy
! Radiation
! For any item that I have marked
! above, my surrogate shall determine whether the above procedures or treatment will be provided to me, considering my medical diagnosis, the prognosis, the benefits and risks of the proposed health care and the alternatives to the proposed health care. Health care directed to my comfort, dignity and pain relief shall be provided.
! "RECEIVE", I do not wish to receive such procedure or treatment if I
! have a terminal condition,
! am permanently unconscious,
! have a terminal condition or am permanently unconscious,
except to the extent necessary to provide comfort for me and freedom from pain.
Enter an X to include a paragraph that specifies certain procedures that the Grantor wishes to receive or not to receive at any time. Additional options consider the circumstances at the time a decision is made, and a free-form option is available. Press [Ctrl+F1] for more information.
Enter an X to indicate whether or not the Grantor wishes to receive artificial or mechanical respiration.
Enter an X if the Grantor wishes to receive artificial or mechanical respiration.
Enter an X if the Grantor does not wish to receive artificial or mechanical respiration.
Enter an X to indicate whether or not the Grantor wishes to receive cardiopulmonary resuscitation.
Enter an X if the Grantor wishes to receive cardiopulmonary resuscitation.
Enter an X if the Grantor does not wish to receive cardiopulmonary resuscitation.
Enter an X to indicate whether or not the Grantor wishes to receive blood or blood products.
Enter an X if the Grantor wishes to receive blood or blood products.
Enter an X if the Grantor does not wish to receive blood or blood products.
Enter an X to indicate whether or not the Grantor wishes to receive any form of surgery or invasive diagnostic procedures.
Enter an X if the Grantor wishes to receive any form of surgery or invasive diagnostic procedures.
Enter an X if the Grantor does not wish to receive any form of surgery or invasive diagnostic procedures.
Enter an X to indicate whether or not the Grantor wishes to receive kidney dialysis.
Enter an X if the Grantor wishes to receive kidney dialysis.
Enter an X if the Grantor does not wish to receive kidney dialysis.
Enter an X to indicate whether or not the Grantor wishes to receive antibiotics.
Enter an X if the Grantor wishes to receive antibiotics.
Enter an X if the Grantor does not wish to receive antibiotics.
Enter an X to indicate whether or not the Grantor wishes to receive chemotherapy.
Enter an X if the Grantor wishes to receive chemotherapy.
Enter an X if the Grantor does not wish to receive chemotherapy.
Enter an X to indicate whether or not the Grantor wishes to receive radiation.
Enter an X if the Grantor wishes to receive radiation.
Enter an X if the Grantor does not wish to receive radiation.
Enter an X to specify another procedure or treatment the Grantor wishes to receive or not to receive.
Enter the name of the procedure or treatment the Grantor wishes to receive or not to receive.
Enter an X if the Grantor wishes to receive this procedure or treatment.
Enter an X if the Grantor does not wish to receive this procedure or treatment.
Enter an X to select additional options which consider the circumstances at the time any of the above procedures or treatments are prescribed.
Enter an X if the Grantor desires that his or her Health Care Surrogate consider the circumstances at the particular time any of the above procedures are prescribed, and the Surrogate determine whether the procedure or treatment should be provided.
Enter an X if the Grantor does not wish to receive the above procedures if the Grantor has a "terminal condition" or is "permanently unconscious".
Enter an X if the Grantor does not wish to receive the above procedures if the Grantor suffers from a "terminal condition".
Enter an X if the Grantor does not wish to receive the above procedures if the Grantor is "permanently unconscious".
Enter an X if the Grantor does not wish to receive the above procedures if the Grantor suffers from a "terminal condition" or is "permanently unconscious".
Enter an X to state other specific requests or instructions of the Grantor. For example, any other wishes, values, religious beliefs, philosophy or other personal preferences that are relevant, such as location of care, or limits on the Surrogate's authority. Press [Ctrl+F1] for more information.
Enter other specific requests or instructions.
AKY07
! Severability Section (7 of 9)
!. SEVERABILITY. If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
AKY08
! Signature Section (8 of 9)
In the absence of my ability to give directions regarding the use of life-prolonging treatment and artificially provided nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family and any surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of such refusal. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
Signed this _____ day of __________________, 19___.
______________________________________
Signature
Grantor Name: !
Grantor Address:
City: !
State: !
! Country: !
! SSN: !
! Birthdate: !
Enter the Grantor's city or edit the information as desired. If no information was pasted, use the P.I. Manager to select and paste a record.
Enter the Grantor's state/province or edit the information as desired.
Enter an X to include the Grantor's county.
Enter the Grantor's country or edit the information as desired.
Enter an X to include the Grantor's social security number (SSN). By including the social security number, a health care facility is able to file Advance Health Care Directives for future reference. Press [Ctrl+F1] for more information on the Patient Self-Determination Act.
Enter the Grantor's social security number.
Enter an X to include the Grantor's date of birth. By including the date of birth, a health care facility is able to file the Advance Health Care Directive for future reference. Press [Ctrl+F1] for more information on the Patient Self-determination Act.
Using the format MM/DD/YYYY, enter the Grantor's date of birth.
AKY09
! Witness Section (9 of 9)
! [WITNESS OPTION]
In our joint presence, the Grantor, who is of sound mind and eighteen years of age, or older, voluntarily dated and signed this writing or directed it to be dated and signed for the Grantor. Further, the witnesses declared that neither of them is (i) a blood relative of the Grantor, (ii) a beneficiary of the Grantor under descent and distribution statutes of Kentucky, (iii) an employee of a health care facility in which the Grantor is a patient, (iv) an attending physician of the Grantor, or (v) a person directly financially responsible for the Grantor's health care.
STATE OF KENTUCKY, COUNTY OF ____________________, ss:
Before me, the undersigned authority, came the Grantor who is of sound mind and eighteen (18) years of age, or older, and acknowledged that he/she voluntarily dated and signed this writing or directed it to be signed and dated as above.
Done this _____ day of _______________, 19___.
_________________________________________
Notary Public or other officer
Date Commission Expires: ________________
Enter an X if two individuals will be signing this Directive as witnesses. Review the limits on who may be a witness. If document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the name of the first witness or use the P.I. Manager to select and paste a record. The name may be left blank and completed when the document is signed. The witness may not be a beneficiary, blood relative, employee of the Grantors health care facility, attending physician, or financially responsible for the Grantor.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the name of the second witness or use the P.I. Manager to select and paste a record. The name may be left blank and completed when the document is signed. The witness may not be a beneficiary, blood relative, employee of the Grantors health care facility, attending physician, or financially responsible for the Grantor.
Enter an X if a Notary Public will acknowledge that the Grantor signed this document. Press [Ctrl+F1] for more information.
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