This required section describes how to complete this document for the "Principal". Certain provisions must be initialed or signed. Press [Ctrl+F1] for more information.
This required section designates a "Representative" to make medical and health care decisions on behalf of the Principal, if he/she is unable to do so. Press [Ctrl+F1] for more information.
This required section prints various life support and tube feeding provisions stated in the Oregon form. ANY DESIRED PROVISION MUST BE INITIALED BY THE PRINCIPAL. Press [Ctrl+F1] for more information.
This required section provides for the Principal's signature of the document, and provides other general statements regarding the Principal's intentions. Press [Ctrl+F1] for more information.
This section requires that two persons witness the Principal's signature, and states the limits on who may serve as a witness to an Advance Directive. Press [Ctrl+F1] for more information.
This required section requires the Representative and Alternate Representative's signatures. They agree to act according to the desires of the Principal, expressed or known. Press [Ctrl+F1] for more information.
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Advance Health Care Directive
ADDIOR
The Oregon 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 who this Directive is being prepared for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information. Oregon law requires the use of its statutory form, and certain provisions must be initialed when the document is signed.
Enter an X to include an optional section which provides for a "trial period" of life support. If life support does not improve the Principal's condition, the provision states that life support should then be withdrawn.
Enter an X to include a paragraph that specifies certain procedures that the Principal wishes to receive or not receive at any time. Additional options provide consideration of particular circumstances at the time such a procedure may be prescribed. Press [Ctrl+F1] for more information.
Enter an X to include a pregnancy paragraph stating that this Directive will not be effective if the Principal is pregnant. Optional provisions provide for the enforcement of this Directive in some circumstances. Press [Ctrl+F1] for more information.
Enter an X to include a section regarding the donation of organs, tissue or other body parts. Such donations are referred to as "anatomical gifts". Press [Ctrl+F1] for more information.
Enter an X to include a provision regarding an autopsy after the Principal's death. Under local law an autopsy may be required in certain situations, such as homicide, or death due to certain diseases. Press [Ctrl+F1] for more information.
Enter an X to include a free-form paragraph where you may provide additional information, or state your desires or instructions in your own words.
Enter an X to include a provision which enables the Representative to request and review health care information, sign releases, and make arrangements for health care.
Enter the Representative's name or use the P.I. Manager to select and paste a record. The attending physician; physician's employee; owner, operator, or a health care facility employee where the Principal resides or is a patient may not be the representative, unless related to the principal. This section must be signed to be effective.
Enter the Alternate Representative's name or use the P.I. Manager to select and paste a record. THE ATTENDING PHYSICIAN; EMPLOYEE OF THE ATTENDING PHYSICIAN; OR THE OWNER, OPERATOR, OR EMPLOYEE OF A HEALTH CARE FACILITY WHERE THE PRINCIPAL RESIDES OR IS A PATIENT MAY NOT BE THE REPRESENTATIVE, UNLESS RELATED TO THE PRINCIPAL.
AOR01
! Information Statement Section (1 of 6)
[The Oregon Health Care Decisions Act requires that the form of an Advance Directive, Power of Attorney for Health Care, and/or Health Care Instruction must be in the form provided in the Act to be valid. The following Information Statement advises individuals that they cannot be required to execute an Advance Directive and explains the purposes of the various parts of the Directive.]
ADVANCE DIRECTIVE
(You do not have to fill out and sign this form.)
PART A: IMPORTANT INFORMATION ABOUT THIS ADVANCE DIRECTIVE
This is an important legal document. It can control critical decisions about your health care. Before signing, consider these important facts:
FACTS ABOUT PART B (APPOINTING A HEALTH CARE REPRESENTATIVE). You have the right to name a person to direct your health care when you cannot do so. This person is called your "health care representative". You can do this by using Part B of this form. Your representative must accept on Part E of this form.
You can write in this document any restrictions you want on how your representative will make decisions for you. Your representative must follow your desires as stated in this document or otherwise made known. If your desires are unknown, your representative must try to act in your best interest. Your representative can resign at any time.
FACTS ABOUT PART C (GIVING HEALTH CARE INSTRUCTIONS). You also have the right to give instructions for health care providers to follow if you become unable to direct your care. You can do this by using Part C of the form.
FACTS ABOUT COMPLETING THIS FORM. This form is valid only if you sign it voluntarily and when you are of sound mind. If you do not want an advance directive, you do not have to sign this form.
Unless you have limited the duration of this advance directive, it will not expire. If you have set an expiration date, and you become unable to direct your health care before that date this advance directive will not expire until you are able to make those decisions again.
You may revoke this document at any time. To do so, notify your representative and your health care provider of the revocation.
Despite this document, you have the right to decide your own health care as long as you are able to do so.
If there is anything in this document that you do not understand, ask a lawyer to explain it to you.
You may sign Part B, Part C, or both Parts. You may cross out words that don't express your wishes or add words that better express your wishes. Witnesses must sign Part D.
Principal Name: !
Date of Birth: !
Address 1: !
Address 2: !
City: !,
State: !
Zip Code: !
! Country: !
! SSN: !
Unless revoked or suspended, this Advance Directive will continue for (initial one):
_____ My entire life
_____ Other period:
! [Specify the other period]
! ! years
Enter the name of the person who this Directive is being prepared for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information. Oregon law requires the use of its statutory form, and certain provisions must be initialed when the document is signed.
Using the format MM/DD/YYYY, enter the Principal's date of birth. By including the date of birth, a health care facility is able to file the Advance Directive for future reference.
Enter the Principal's street address or edit the information as desired.
Enter the Principal's extended street address or edit the information as desired.
Enter the Principal's city or edit the information as desired.
Enter the Principal's state/province or edit the information as desired.
Enter the Principal's zip/postal code or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Principal's social security number (SSN). By including the social security number, a health care facility is able to file the Advance Directive for future reference. Press [Ctrl+F1] for more information on the Patient Self-Determination Act.
Enter the Principal's social security number or edit the information as desired.
Enter an X to specify the period of time that this Directive will remain effective, if other than the life of the Principal. Otherwise, the Directive shall remain effective during the Principal's lifetime or until revoked by the Principal.
Enter an X if the Principal wishes to state the number of years this Directive will remain effective.
Enter the number of years the Principal wishes this Directive to remain effective. For example, "5" years.
Enter an X if the Principal wishes to describe an event or condition upon which the validity of this Directive will cease.
Enter an event or condition upon which the validity of this Directive ceases. For example, "This Directive shall cease to be effective if I am in a coma."
AOR02
! Appointment of Health Care Representative Section (2 of 6)
[A "Representative" is a person who is authorized by the Principal to make medical and health care decisions on behalf of the Principal if the Principal is unable to do so. This section must be signed by the Principal to be effective.]
PART B: APPOINTMENT OF HEALTH CARE REPRESENTATIVE
I appoint !, as my health care representative.
My representative's address is
Street 1: !,
Street 2: !,
City: !,
State: !
Zip Code: !,
! Country: !
and telephone number is !.
I appoint !, as my alternate health care representative.
My alternate's address is
Street 1: !,
Street 2: !,
City: !,
State: !
Zip Code: !,
! Country: !
and telephone number is !.
I authorize my representative (or alternate) to direct my health when I can't do so.
Note: You may not appoint your doctor, an employee of your doctor, or an owner, operator or employee of your health care facility, unless that person is related to you by blood, marriage or adoption or that person was appointed before your admission into the health care facility.
1. LIMITS. Special conditions or instructions:
INITIAL IF THIS APPLIES:
_____ I have executed a Health Care Instruction or Directive to Physicians. My representative is to honor it.
2. LIFE SUPPORT. "Life Support" refers to any medical means for maintaining life, including procedures, devices and medications. If you refuse life support, you will still get routine measures to keep you clean and comfortable.
INITIAL IF THIS APPLIES:
_____ My representative may decide about life support for me. (If you don't initial this space, then your representative may not decide about life support.)
3. TUBE FEEDING. One sort of life support is food and water supplied artificially by medical device, known as Tube Feeding.
INITIAL IF THIS APPLIES:
_____ My representative may decide about tube feeding for me. (If you don't initial this space, then your representative may not decide about tube feeding.)
Enter the Representative's name or use the P.I. Manager to select and paste a record. The attending physician; physician's employee; owner, operator, or a health care facility employee where the Principal resides or is a patient may not be the representative, unless related to the principal. This section must be signed to be effective.
Enter the Representative's street address or edit the information as desired.
Enter the Representative's extended street address or edit the information as desired.
Enter the Representative's city or edit the information as desired.
Enter the Representative's state/province or edit the information as desired. When naming a representative, consider the availability of the Representative to confer with your health care provider and access medical records or information.
Enter the Representative's zip/postal code or edit the information as desired.
Enter an X to include the Representative's country, if outside the United States. If the Representative resides in a different country, he/she may not be available to discuss medical decisions with the health care provider.
Enter the country or edit the information as desired.
Enter the Representative's phone number or edit the information as desired.
Enter the Alternate Representative's name or use the P.I. Manager to select and paste a record. THE ATTENDING PHYSICIAN; EMPLOYEE OF THE ATTENDING PHYSICIAN; OR THE OWNER, OPERATOR, OR EMPLOYEE OF A HEALTH CARE FACILITY WHERE THE PRINCIPAL RESIDES OR IS A PATIENT MAY NOT BE THE REPRESENTATIVE, UNLESS RELATED TO THE PRINCIPAL.
Enter the Alternate's street address or edit the information as desired.
Enter the Alternate's extended street address or edit the information as desired.
Enter the Alternate's city or edit the information as desired.
Enter the Alternate's state/province or edit the information as desired. When naming a representative, consider the availability of the Representative to confer with your health care provider and access medical records or information.
Enter the Alternate's zip/postal code or edit the information as desired.
Enter an X to include the Alternate's country, if outside the United States. If the Representative resides in a different country, he or she may not be available to discuss medical decisions with the health care provider.
Enter the Alternate's phone number or edit the information as desired.
Enter any limitations on the Representative's authority, or special instructions regarding the location or provision of the Principal's health care. SEVERAL ALTERNATIVE PROVISIONS REGARDING HEALTH CARE INSTRUCTIONS, LIFE SUPPORT AND TUBE FEEDING ARE PRINTED IN THE DIRECTIVE AND MUST BE INITIALED BY THE PRINCIPAL TO BE EFFECTIVE.
AOR03
! Health Care Instructions Section (3 of 6)
[The printed form includes various provisions stated in the Oregon Advance Directive regarding life-support and tube feeding if the Principal is in various conditions. TO BE EFFECTIVE, THE PRINCIPAL MUST INITIAL ANY DESIRED PROVISIONS.]
PART C: HEALTH CARE INSTRUCTIONS
NOTE: In filling out these instructions, keep the following in mind:
* "Life support" and "Tube feeding" are defined in Part B above.
* If you refuse tube feeding, you should understand that malnutrition, dehydration and death will probably result.
* You may either give specific instructions by filling out Items 1 to 4 below, or you may use the general instruction provided by Item 5.
Here are my desires about my health care if my doctor and another knowledgeable doctor confirm that I am in a medical condition described below:
1. CLOSE TO DEATH. If I am close to death and life support would only postpone the moment of my death:
A. INITIAL ONE:
_____ I want to receive tube feeding.
_____ I want tube feeding only as my physician recommends.
_____ I do not want tube feeding.
B. INITIAL ONE:
_____ I want any other life support that may apply.
_____ I want life support only as my physician recommends.
_____ I want no life support.
2. PERMANENTLY UNCONSCIOUS. If I am unconscious and it is very unlikely that I will ever become conscious again:
A. INITIAL ONE:
_____ I want to receive tube feeding.
_____ I want tube feeding only as my physician recommends.
_____ I do not want tube feeding.
B. INITIAL ONE:
_____ I want any other life support that may apply.
_____ I want life support only as my physician recommends.
_____ I want no life support.
3. ADVANCED PROGRESSIVE ILLNESS. If I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and permanently unable to communicate by any means, swallow food and water safely, care for myself and recognize my family and other people, and it is very unlikely that my condition will substantially improve:
A. INITIAL ONE:
_____ I want to receive tube feeding.
_____ I want tube feeding only as my physician recommends.
_____ I do not want tube feeding.
B. INITIAL ONE:
_____ I want any other life support that may apply.
_____ I want life support only as my physician recommends.
_____ I want no life support.
4. EXTRAORDINARY SUFFERING. If life support would not help my medical condition and would make me suffer permanent and severe pain:
A. INITIAL ONE:
_____ I want to receive tube feeding.
_____ I want tube feeding only as my physician recommends.
_____ I do not want tube feeding.
B. INITIAL ONE:
_____ I want any other life support that may apply.
_____ I want life support only as my physician recommends.
_____ I want no life support.
5. GENERAL INSTRUCTION.
INITIAL IF THIS APPLIES:
_____ I do not want my life to be prolonged by life support. I also do not want tube feeding as life support. I want my doctors to allow me to die naturally if my doctor and another knowledgeable doctor confirm I am in any of the medical conditions listed in Items 1 to 4 above.
6. ADDITIONAL CONDITIONS OR INSTRUCTIONS. In addition, I direct that my representative shall have authority to make decisions regarding the following:
[Check any of the following to include related provisions.]
! Medical records, releases, arrangements
! Temporary life support
! Specific Medical Procedures
! Pregnancy
! Organ donation
! Autopsy
! Free form option
Enter an X to include a provision which enables the Representative to request and review health care information, sign releases, and make arrangements for health care.
Enter an X to include an optional section which provides for a "trial period" of life support. If life support does not improve the Principal's condition, the provision states that life support should then be withdrawn.
Enter an X to include a paragraph that specifies certain procedures that the Principal wishes to receive or not receive at any time. Additional options provide consideration of particular circumstances at the time such a procedure may be prescribed. Press [Ctrl+F1] for more information.
Enter an X to include a pregnancy paragraph stating that this Directive will not be effective if the Principal is pregnant. Optional provisions provide for the enforcement of this Directive in some circumstances. Press [Ctrl+F1] for more information.
Enter an X to include a section regarding the donation of organs, tissue or other body parts. Such donations are referred to as "anatomical gifts". Press [Ctrl+F1] for more information.
Enter an X to include a provision regarding an autopsy after the Principal's death. Under local law an autopsy may be required in certain situations, such as homicide, or death due to certain diseases. Press [Ctrl+F1] for more information.
Enter an X to include a free-form paragraph where you may provide additional information, or state your desires or instructions in your own words.
AOR04
! Optional Medical Records, Releases, Arrangements Section (3 of 6)
!. MEDICAL RECORDS, RELEASES, ARRANGEMENTS.
I authorize my health care representative to:
! !. Request, receive and review any information, verbal or written, regarding my physical or mental health including medical and hospital records and to consent to the disclosure of such records to others.
! !. Execute on my behalf any releases or other documents that may be required in order to obtain this information.
! !. Make all necessary arrangements for health care services on my behalf, including the authority to select, employ and discharge health care providers.
! !. Make decisions regarding admission to or discharge, even against medical advice, from any health care facility or service.
! !. Sign any documents titled or purporting to be "Consent to Permit Treatment" or "Refusal to Permit Treatment", necessary waivers or releases from liability required by a hospital, physician, or other health care provider.
Enter an X to authorize the Representative to review the Principal's medical records, and consent to the disclosure of records to others.
Enter an X to authorize the Representative to sign release forms which may be required to obtain health care information.
Enter an X to authorize the Representative to select, employ and discharge health care providers, and to make all arrangements necessary for the Principal's health care.
Enter an X to authorize the Representative to make decisions regarding the admission or discharge of the Principal from any health care facility, including discharge against medical advice.
Enter an X to authorize the Representative to sign consent or refusal of consent documents for any proposed health care, including waivers of liability.
AOR05
! Optional Temporary Life Support Provision Section (3 of 6)
!. TEMPORARY LIFE SUPPORT. If my doctor believes that any life support may lead to a significant recovery, I direct my doctor to implement life support for a reasonable period of time. If it does not improve my condition, I direct that life support be withdrawn even if it shortens my life. I also direct that I be given medical treatment to relieve pain or to provide comfort, even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit-forming.
&AOR06
! Optional Specific Medical Procedures Provision Section (3 of 6)
!. SPECIFIC MEDICAL PROCEDURES. Notwithstanding any other provision of this document, it is my general desire (i) to RECEIVE the following treatment or procedures that are so marked, if such treatment or procedures are deemed appropriate by my attending physician and any representative that I may have designated to make health care decisions for me, and (ii) NOT TO RECEIVE the following treatment or procedures that are so marked, although such treatment or 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 Representative 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 my doctor and another knowledgeable doctor confirm that I am close to death,
! permanently unconscious,
! suffering from an advanced progressive illness,
! or that life support would cause extraordinary suffering,
except to the extent necessary to provide comfort for me and freedom from pain.
Enter an X to indicate whether or not the Declarant wishes to receive artificial or mechanical respiration.
Enter an X if the Declarant wishes to receive artificial or mechanical respiration.
Enter an X if the Declarant does not wish to receive artificial or mechanical respiration.
Enter an X to indicate whether or not the Declarant wishes to receive cardiopulmonary resuscitation.
Enter an X if the Declarant wishes to receive cardiopulmonary resuscitation.
Enter an X if the Declarant does not wish to receive cardiopulmonary resuscitation.
Enter an X to indicate whether or not the Declarant wishes to receive blood or blood products.
Enter an X if the Declarant wishes to receive blood or blood products.
Enter an X if the Declarant does not wish to receive blood or blood products.
Enter an X to indicate whether or not the Declarant wishes to receive any form of surgery or invasive diagnostic procedures.
Enter an X if the Declarant wishes to receive any form of surgery or invasive diagnostic procedures.
Enter an X if the Declarant does not wish to receive any form of surgery or invasive diagnostic procedures.
Enter an X to indicate whether or not the Declarant wishes to receive kidney dialysis.
Enter an X if the Declarant wishes to receive kidney dialysis.
Enter an X if the Declarant does not wish to receive kidney dialysis.
Enter an X to indicate whether or not the Declarant wishes to receive antibiotics.
Enter an X if the Declarant wishes to receive antibiotics.
Enter an X if the Declarant does not wish to receive antibiotics.
Enter an X to indicate whether or not the Declarant wishes to receive chemotherapy.
Enter an X if the Declarant wishes to receive chemotherapy.
Enter an X if the Declarant does not wish to receive chemotherapy.
Enter an X to indicate whether or not the Declarant wishes to receive radiation.
Enter an X if the Declarant wishes to receive radiation.
Enter an X if the Declarant does not wish to receive radiation.
Enter an X to specify another procedure or treatment the Declarant wishes to receive or not to receive.
Enter the name of the procedure or treatment the Declarant wishes to receive or not to receive.
Enter an X if the Declarant wishes to receive this procedure or treatment.
Enter an X if the Declarant 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 Principal desires that his or her Health Care Representative consider the circumstances that the particular time any of the above procedures are prescribed, and the Representative determine whether the procedure or treatment should be provided.
Enter an X if the Principal does not wish to receive the above procedures if the Principal's doctor confirms that the Principal is in a medical condition described below.
Enter an X if the Principal does not wish to receive the above procedures if he/she is permanently unconscious, except to the extent necessary to provide comfort or pain relief.
Enter an X if the Principal does not wish to receive the above procedures if he/she suffers from an advanced progressive illness, except to the extent necessary to provide comfort or pain relief.
Enter an X if the Principal does not wish to receive the above procedures if they would cause the Principal to experience or continue to experience extraordinary suffering.
AOR07
! Optional Pregnancy Provision Section (3 of 6)
!. PREGNANCY. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! [Optional additional 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 support, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life support 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 request that life support systems be withheld or withdrawn if it is determined that the fetus could not develop to the point of live birth with the continued application of life support. Press [Ctrl+F1] for more information.
Enter an X to request that consideration be given to the impact of physical harm or pain to the Principal in determining whether life support systems should be withheld or withdrawn if the Principal is pregnant.
AOR08
! Optional Organ Donation Provision Section (3 of 6)
!. DONATION OF ORGANS.
! I desire that no anatomical gifts be made from my body.
! Notwithstanding the other provisions of this document, if I have been determined to be dead according to law, I direct my attending physician to maintain my organs on artificial support systems only for the period of time required to maintain the viability of and to remove the organs and/or tissues which
! I have specified and agreed to donate in another document upon my death.
! are to be donated.
! I hereby make this anatomical gift, if medically acceptable, to take effect upon my death. I give
! any needed organs, tissues or parts
! only the following organs, tissues or parts:
to be donated for
! any purpose permitted by law.
! these limited purposes:
Enter an X if the Principal desires that no anatomical gifts be made upon his or her death. Press [Ctrl+F1] for more information regarding organ donation.
Enter an X if the Principal desires that anatomical gifts be made upon his or her death, and directs that artificial support procedures be used to maintain the Principal's body until organ donation wishes can be met.
Enter an X if the Principal's organ donation has been provided for in another document or designation, such as a uniform donor card or a driver's license designation.
Enter an X if the Principal has not signed an organ donation in another document. The next option permits the Principal to make such a donation.
Enter an X if the Principal wishes to state his or her specific desires regarding anatomical gifts in this Advance Directive.
Enter an X if the Principal authorizes the donation of any needed organs, tissues, or body parts.
Enter an X if the Principal authorizes the donation of only certain organs, tissue or body parts.
Enter the names of any organs or parts which may be donated upon the Principal's death.
Enter an X if the above anatomical gifts may be made for any purpose permitted by law.
Enter an X if the above anatomical gifts may only be made for limited purposes, such as transplant, therapy, research and/or education.
Enter the limited purposes for which the above anatomical gifts may be made.
AOR09
! Optional Autopsy Provision Section (3 of 6)
!. AUTOPSY.
! I do not consent to an autopsy.
! I consent to an autopsy.
! My health care representative may give consent to or refuse an autopsy.
Enter an X if the Principal does not consent to any autopsy. Press [Ctrl+F1] for more information.
Enter an X if the Principal consents to an autopsy.
Enter an X if the Principal authorizes his or her Representative to consent or refuse to consent to an autopsy of the Principal's body after death.
AOR10
! Optional Free Form Provision Section (3 of 6)
!. [Enter your own provisions here:]
Use this space to enter any other specific requests or instructions. For example, wishes, values, religious beliefs, personal philosophy, or other relevant personal preferences.
AOR11
! Hold Harmless/Severability Provisions Section (3 of 6)
!. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them, except for willful misconduct or gross negligence.
!. 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, thus the directions in this document are severable.
I recognize that different states and jurisdictions have somewhat different statutes regarding advance directives. I direct that this document be interpreted in any applicable jurisdiction under both present and future law in a manner that gives the broadest interpretation to my desires.
If any provision is not legally enforceable, it is my intent that this document be taken as a formal statement of my wishes and desires concerning health care decisions, and the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
I hope that my health care providers and other persons responsible for my care will regard themselves as morally bound by these provisions.
Enter an X to include a provision that the Principal's wishes be interpreted broadly. It is important to include this provision if there is any possibility that the Principal would need to use the Advance Directive in another state.
Enter an X to include a provision that asks health care providers and other persons to enforce the Advance Directive as much as possible.
Enter an X to include a sentence which encourages health care providers and other decision makers to follow the Principal's instructions and wishes as stated in this document.
AOR12
! Other Document Section (4 of 6)
7. OTHER DOCUMENTS. A "Health Care Power of Attorney" is any document you may have signed to appoint a representative to make health care decisions for you.
INITIAL ONE:
_____ I have previously signed a Health Care Power of Attorney. I want it to remain in effect unless I appointed a health care representative after signing the Health Care Power of Attorney.
_____ I have a Health Care Power of Attorney, and I revoke it.
_____ I do not have a Health Care Power of Attorney.
NOTE: One witness must not be a relative (by blood, marriage or adoption) of the person signing this advance directive. That witness must also not be entitled to any portion of the person's estate upon death. That witness must also not own, operate or be employed at a health care facility where the person is a patient or resident.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. The name of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed.
AOR14
! Acceptance Section (6 of 6)
[The Representative and Alternate Representative must sign the Advance Directive indicating their agreement to be a health care representative.]
PART E: ACCEPTANCE BY HEALTH CARE REPRESENTATIVE
I accept this appointment and agree to serve as health care representative. I understand I must act consistently with the desires of the person I represent, as expressed in this advance directive or otherwise made known to me. If I do not know the desires of the person I represent, I have a duty to act in what I believe in good faith to be that person's best interest. I understand that this document allows me to decide about that person's health care only while that person cannot do so. I understand that the person who appointed me may revoke this appointment. If I learn that this document has been suspended or revoked, I will inform the person's health care provider if known to me.
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