This required section states the Declarant's (the person who the Advance Directive is created for) intention to make an Advance Directive. Press [Ctrl+F1] for more information.
This required section states the circumstances under which life-prolonging procedures will be withheld or withdrawn, and includes an optional "coma" provision. Press [Ctrl+F1] for more information.
This optional section states the Declarant's preferences on whether artificially administered nutrition and hydration should be withheld or withdrawn. Press [Ctrl+F1] for more information.
This optional section states what effect should be given to the Advance Directive if the Declarant is pregnant. Press [Ctrl+F1] for more information.
This optional section allows for additional specific instructions and requests. Press [Ctrl+F1] for more information.
This optional section designates an "Agent" to make health care decisions if the Declarant is unable to do so. Press [Ctrl+F1] for more information.
This optional section allows the Declarant to specify the powers of the Agent. Press [Ctrl+F1] for more information.
This recommended provision provides that the inclusion of an invalid request or instruction does not invalidate the other provisions. Press [Ctrl+F1] for more information.
This required section provides an opportunity for the Declarant to request that the provisions of this document be honored. Press [Ctrl+F1] for more information.
This required section provides the signature line for the Declarant who must sign in the presence of witnesses. Press [Ctrl+F1] for more information.
This required section provides signature lines for the witnesses in accordance with state law requirements. Press [Ctrl+F1] for more information.
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Advance Health Care Directive
ADDIVA
The Virginia 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 Declarant's name or edit the information as desired. Use the P.I. Manager to select and paste a record. The Declarant is the person who this Directive is being prepared for. The Declarant states his/her intentions regarding life-prolonging procedures if the Principal is in a terminal condition.
AVA01
! Declaration Section (1 of 11)
[Access Document Information for an explanation regarding this document.]
ADVANCE MEDICAL DIRECTIVE
Declaration made this _____ day of _______________, 19___. I, !, willfully and voluntarily make known my desire and do hereby declare:
Enter the Declarant's name or edit the information as desired. Use the P.I. Manager to select and paste a record. The Declarant is the person who this Directive is being prepared for. The Declarant states his/her intentions regarding life-prolonging procedures if the Principal is in a terminal condition.
AVA02
! Life Support Section (2 of 11)
If at any time my attending physician should determine that I have a terminal condition
! [Optional COMA provision] or a permanently unconscious condition (persistent vegetative state)
where the application of life-prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.
Enter an X if you want life-prolonging procedures withheld or withdrawn if you become permanently unconscious. This Directive authorizes the physician to withdraw/withhold life-prolonging procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
AVA03
! Optional Nutrition Section (3 of 11)
If I have a condition stated above, it is my preference
! TO RECEIVE artificially administered nutrition and hydration (food and fluids).
! NOT TO RECEIVE artificially administered nutrition and hydration (food and fluids), except as deemed necessary to provide me with comfort care or to alleviate pain.
Enter an X to include a paragraph that states whether you wish to receive or not to receive artificial nutrition and hydration if you are terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X if you WISH TO RECEIVE artificially administered nutrition and hydration, even though your physicians certify that you have a terminal or permanently unconscious condition.
Enter an X if you DO NOT WISH TO RECEIVE artificially administered nutrition and hydration if your physicians certify that you have a terminal or permanently unconscious condition.
AVA04
! Optional Pregnancy Section (4 of 11)
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 continued application of life-prolonging procedures, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-prolonging procedures 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. This provision states that the Advance Directive will not be enforced if you are pregnant. Certain exceptions to this statement are presented. Press [Ctrl+F1] for more information.
Enter an X to provide an exception to the invalidity of the Advance Directive if you are pregnant. This exception permits enforcement of the Advance Directive if the fetus could not develop to the point of live birth with the continued application of life-prolonging procedures.
Enter an X to provide an exception to the invalidity of the Advance Directive if you are pregnant. This exception requests that pain or physical harm to you be considered in determining whether life-prolonging procedures should be withheld or withdrawn.
AVA05
! Optional Other Section (5 of 11)
Other specific requests:
Enter an X to include a paragraph that allows you to state other specific requests or instructions.
Use this space to state any other specific requests or instructions.
AVA06
m ! Optional Agent Section (6 of 11)
Appointment of Agent.
I hereby appoint !, of
!, ! !,
! Country: !,
Phone: !,
as my Agent to make health care decisions on my behalf as authorized in this document.
If ! is not reasonably available or is unable or unwilling to act as my Agent, then I appoint
!, of
!, ! !,
! Country: !,
Phone: !,
to serve in that capacity.
I hereby grant to my Agent, named above, full power and authority to make health care decisions on my behalf as described below whenever I have been determined to be incapable of making an informed decision about providing, withholding or withdrawing medical treatment. The phrase "incapable of making an informed decision" means (i) unable to understand the nature, extent and probable consequences of a proposed medical decision or unable to make a rational evaluation of the risks and benefits of a proposed medical decision as compared with the risks and benefits of alternatives to that decision, or (ii) unable to communicate such understanding in any way. My agent's authority under this document is effective as long as I am incapable of making an informed decision.
The determination that I am incapable of making an informed decision shall be made by my attending physician and a second physician or licensed clinical psychologist after a personal examination of me and shall be certified in writing. Such certification shall be required before treatment is withheld or withdrawn, and before, or as soon as reasonably practicable after, treatment is provided, and every 180 days thereafter while the treatment continues.
In exercising the power to make health care decisions on my behalf, my agent shall follow my desires and preferences as stated in this document or as otherwise known to my agent. My agent shall be guided by my medical diagnosis and prognosis and any information provided by my physicians as to the intrusiveness, pain, risks, and side effects associated with treatment or non-treatment. My agent shall not authorize a course of treatment which he or she knows, or upon reasonable inquiry ought to know, is contrary to my religious beliefs or my basic values, whether expressed orally or in writing. If my agent cannot determine what treatment choice I would have made on my own behalf, then my agent shall make a choice for me based upon what he or she believes to be in my best interests.
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Enter an X to include a section that allows you to designate someone as a "Health Care Agent" to make health care decisions for you if you are unable to do so. Press [Ctrl+F1] for more information.
Enter the Agent's name or use the P.I. Manager to select and paste a record.
Enter the Agent's street address or edit the information as desired.
Enter the Agent's extended street address or edit the information as desired.
Enter the Agent's city or edit the information as desired.
Enter the Agent's state/province or edit the information as desired.
Enter the Agent's zip/postal code or edit the information as desired.
Enter an X to include the Agent's country, if outside the United States.
Enter the country or edit the information as desired.
Enter a phone number at which the Agent may be reached.
Enter the Alternate Agent's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Agent's street address or edit the information as desired.
Enter the Alternate Agent's extended street address or edit the information as desired.
Enter the Alternate Agent's city or edit the information as desired.
Enter the Alternate Agent's state/province or edit the information as desired.
Enter the Alternate Agent's zip/postal code or edit the information as desired.
Enter an X to include the Alternate Agent's country, if outside the United States.
Enter a phone number at which the Alternate Agent may be reached.
AVA07
! Optional Agent Authority Section (7 of 11)
Powers of My Agent. The powers of my agent shall include the following [choose one or more of the following]:
! To consent to or refuse or withdraw consent to any type of medical care, treatment, surgical procedure, diagnostic procedure, medication and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, artificially administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the power to consent to the administration of dosages of pain relieving medication in excess of standard dosages in an amount sufficient to relieve pain, even if such medication carries the risk of addiction or inadvertently hastens my death.
To request, receive, and review any information, verbal or written, regarding my physical or mental health, including but not limited to, medical and hospital records, and to consent to the disclosure of this information.
To employ and discharge my health care providers.
To authorize my admission to or discharge (including transfer to another facility) from any hospital, hospice, nursing home, adult home or other medical care facility.
To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers.
Further, my agent shall not be liable for the costs of treatment pursuant to this authorization, based solely on that authorization.
Enter an X to include a section which states the Agent's powers.
Enter an X if the Agent will have the power to make decisions regarding medical care, including artificial feeding and resuscitation.
Enter an X if the Agent will have the power to request, review and disclose any information regarding the physical or mental condition of the Declarant.
Enter an X if the Agent will have the power to employ and discharge any of the Declarant's health care providers.
Enter an X if the Agent will have the power to authorize the Declarant's admission to or discharge from health care facilities (including the power to authorize the Declarant's transfer to different facilities).
Enter an X if the Agent will have the power to take lawful action in order to carry out these desires of the Declarant.
AVA08
! Optional Severability Section (8 of 11)
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.
It is recommended that this severability provision be included to prevent one invalid provision from invalidating the entire document. However, if you do not want to include it, press the space bar to deselect the checkbox. Press [Ctrl+F1] for information regarding the reasons for including a severability paragraph.
AVA09
! Right of Refusal Section (9 of 11)
In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this advance directive shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal.
This advance directive shall not terminate in the event of my disability.
AVA10
! Declarant Signature Section (10 of 11)
By signing below, I indicate that I am emotionally and mentally competent to make this advance directive and that I understand the purpose and effect of this document.
Date Signed: _______________ _____, 19___.
______________________________________
Signature
Declarant Name: !
Declarant Address:
City: !
State: !
! Country: !
! SSN: !
! Birthdate: !
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's state/province or edit the information as desired.
Enter an X to include the Declarant's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By providing the SSN, the health care providers will be assisted in maintaining their Advance Directive files. Press [Ctrl+F1] for more information.
Enter the Declarant's social security number or edit the information as desired.
Enter an X to include the Declarant's date of birth. By providing the birthdate, the health care providers will be assisted in maintaining their Advance Directive files. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the Declarant's date of birth or edit the information as desired.
AVA11
! Witness Signature Section (11 of 11)
[If the document is not properly witnessed, it may not be enforceable.]
The Declarant signed the foregoing advance directive in my presence. I am not the spouse or blood relative of the Declarant.
Enter the name of the FIRST Witness or use the P.I. Manger to select and paste a record. The following information regarding the name and address of the Witness may be left blank and be completed when the document is signed. The Witness cannot be the Declarant's spouse or a blood relative.
Enter the First Witness' street address or edit the information as desired.
Enter the First Witness' extended street address or edit the information as desired.
Enter the First Witness' city or edit the information as desired.
Enter the First Witness' state/province or edit the information as desired.
Enter the First Witness' zip/postal code or edit the information as desired.
Enter an X to include the First 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 following information regarding the name and address of the Witness may be left blank and be completed when the document is signed. The Witness cannot be the Declarant's spouse or a blood relative.
Enter the Second Witness' street address or edit the information as desired.
Enter the Second Witness' extended street address or edit the information as desired.
Enter the Second Witness' city or edit the information as desired.
Enter the Second Witness' state/province or edit the information as desired.
Enter the Second Witness' zip/postal code or edit the information as desired.
Enter an X to include the Second Witness' country, if outside the United States.
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