This required section includes the Declarant's name and address. The Declarant is the person who the Advance Health Care Directive is prepared for. Press [Ctrl+F1] for more information.
This optional section provides for the designation of an "Agent" to make medical and health care decisions on behalf of the Declarant, if the Declarant is unable to do so. Press [Ctrl+F1] for more information.
This optional section should be selected if a health care Agent has been designated. This section describes the Agent's authority, and provides direction to the Agent. Press [Ctrl+F1] for more information.
This required section indicates when the document becomes effective, and provides for the document's continued validity during Declarant's incapacity. Press [Ctrl+F1] for more information.
This required section states the Declarant's preferences regarding life sustaining procedures if the Declarant is in a terminal condition. Press [Ctrl+F1] for more information.
This required section states the Declarant's preferences regarding life sustaining procedures if the Declarant is in a permanent coma (and a definition of this term). Press [Ctrl+F1] for more information.
This required section defines life sustaining procedures which may be withdrawn or withheld if the Declarant has an irreversible condition as specified in prior sections. Press [Ctrl+F1] for more information.
This required section describes the Declarant's preferences regarding the provision of artificially administered nutrition and fluids. Press [Ctrl+F1] for more information.
This optional section lists certain procedures the Declarant wishes to receive or not receive. Circumstances at the time such a procedure may be prescribed are also considered. Press [Ctrl+F1] for more information.
This optional section allows the Declarant 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 permits the Declarant to make anatomical gifts and state that life sustaining procedures may be used until organ donations can be made. Press [Ctrl+F1] for more information.
This optional section states whether or not the Declarant authorizes an autopsy, or authorizes the Declarant's Agent to consent to an autopsy. Press [Ctrl+F1] for more information.
This optional section permits the Declarant to specify other requests, instructions, or values, such as religious beliefs, philosophy of life or preferences such as location of care. Press [Ctrl+F1] for more information.
This optional section states the name and address of the person to be appointed as Guardian for the Declarant if one needs to be appointed by a court proceeding. Press [Ctrl+F1] for more information.
This required section states that any person or Agent who carries out the instructions in this document shall not be held liable for any damage or claims as a result of such action. Press [Ctrl+F1] for more information.
This required section provides some protection that the Declarant's wishes and desires will be followed, even though the Declarant's state laws may be somewhat restrictive. Press [Ctrl+F1] for more information.
This required section provides general statements regarding the Declarant's intentions and provides for the signatures of the Declarant, the witnesses, and/or a Notary Public. Press [Ctrl+F1] for more information.
This required section provides information regarding the suggested distribution of copies of the Advance Health Care Directive. Press [Ctrl+F1] for more information.
Times New Roman
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Advance Health Care Directive
GENADD
The Advance Health Care Directive document combines the best features of the Living Will and Health Care Powers of Attorney, by allowing 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.
!!!!! !!!!
The Declarant is the person that the document is being prepared for. The program assumes that you are the Declarant. Enter the state where you reside. The selected state will control some of the language in the document. If unsure what state to enter, an Attorney should be consulted.
Enter the Declarant's name or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the Declarant's city or edit the information as desired.
The program completes the state by transferring the information from a previous field. You may modify the information only by returning to that field.
Enter an X to include the Declarant's country, if outside of the United States.
Enter the country or edit the information as desired.
Enter the Agent's name or use the P.I. Manager to select and paste a record. CERTAIN INDIVIDUALS SHOULD NOT BE DESIGNATED AS A HEALTH CARE AGENT. PRESS [CTRL+F1] TO REVIEW THE LIMITATIONS ON WHO MAY SERVE AS A HEALTH CARE AGENT.
Enter the Alternate Agent's name or use the P.I. Manager to select and paste a record.
Enter the Second Alternate Agent's name or use the P.I. Manager to select and paste a record.
GAD01
! Name of Declarant Section (1 of 18)
ADVANCE HEALTH CARE DIRECTIVE
[THIS DOCUMENT ALLOWS THE DECLARANT TO PROVIDE INSTRUCTIONS AND WISHES REGARDING HEALTH CARE IF THE DECLARANT IS UNABLE TO MAKE SUCH DECISIONS. THIS DOCUMENT DOES NOT USE THE WORD-FOR-WORD TERMINOLOGY OF STATE LAWS PERTAINING TO THE FORM OF ADVANCE MEDICAL DIRECTIVES SUCH AS A LIVING WILL OR A HEALTH CARE POWER OF ATTORNEY. HOWEVER, IT IS DESIGNED TO COMPLY WITH U.S. SUPREME COURT REQUIREMENTS.
The states of CALIFORNIA, RHODE ISLAND AND WISCONSIN require the use of their respective state specific forms; these forms are offered as part of the "Living Will" and "Health Care Power of Attorney" documents. In addition, the states of NEVADA, NEW HAMPSHIRE, OHIO, SOUTH CAROLINA, TENNESSEE, TEXAS, and VERMONT have unique statutory requirements regarding the form of advance directives. The NORTH DAKOTA statute provides that the form provided in its statute is the "preferred form".
KENTUCKY, OKLAHOMA, OREGON, and VIRGINIA have adopted specific advance directive forms which are separate documents in the state selection menu. KENTUCKY, OKLAHOMA, and OREGON require that their state specific forms be used for an Advance Health Care Directive.
PRESS [CTRL+F1] FOR MORE INFORMATION REGARDING THE ADVANCE HEALTH CARE DIRECTIVE.
The Declarant currently resides in: !.]
If I,
!, of
!, ! !,
! Country: !,
am not able to make an informed decision regarding my health care, I direct that my instructions and wishes as stated in this document be followed.
The Declarant is the person that the document is being prepared for. The program assumes that you are the Declarant. Enter the state where you reside. The selected state will control some of the language in the document. If unsure what state to enter, an Attorney should be consulted.
Enter the Declarant's name or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the Declarant's street address or edit the information as desired.
Enter the Declarant's extended street address or edit the information as desired.
Enter the Declarant's city or edit the information as desired.
The program completes the state by transferring the information from a previous field. You may modify the information only by returning to that field.
Enter the Declarant's zip/postal code or edit the information as desired.
Enter an X to include the Declarant's country, if outside of the United States.
Enter the country or edit the information as desired.
(GAD02
! Optional Designation of Agent Section (2 of 18)
!. DESIGNATION OF AGENT. I recognize that if I am unable to make an informed decision regarding my health care, it may become necessary for some other person to act on my behalf. I designate
Agent Name: !
Agent Address:
Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
as my Agent to
! make health care decisions for me,
! make health care decisions for me, if I am not able to make an informed decision for myself,
except to the extent that I state otherwise in this document.
If I revoke my Agent's authority, or if my Agent is not willing, able, or reasonably available to make a health care decision for me, I designate the following person as my alternate Agent:
Agent Name: !
Agent Address:
Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
If I revoke my alternate Agent's authority, or if my alternate Agent is not willing, able, or reasonably available to make a health care decision for me, I designate the following person as my second alternate Agent:
Agent Name: !
Agent Address:
Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
If the person that I designate as Agent or an alternate Agent is or ever becomes my spouse, he or she shall be ineligible to serve as my Agent if
! we are separated, or if
our marriage is annulled or we are divorced.
By the use of the term "health care decision" I mean an informed decision to accept, maintain, discontinue or refuse any care, treatment, intervention, service or procedure to maintain, diagnose or treat my physical or mental condition, subject to any statement of my desires and any limitations included in this document.
By the use of the term "health care" I mean all medical treatment, the provision, withholding or withdrawal of any health care or medical procedure, or service to maintain, diagnose, treat or provide for a patient's physical or mental health or personal care, unless such authority is otherwise limited by this document.
By the use of term "Agent" I mean any health care decision-maker such as a Patient Advocate, Health Care Representative, Health Care Proxy, Power of Attorney for Health Care, or Health Care Surrogate.
Enter an X to include a section that provides for the designation of an "Agent". An agent (surrogate, patient advocate, health care proxy, etc.) is a person who is authorized by the Declarant to make medical and health care decisions on behalf of the Declarant if the Declarant is 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. CERTAIN INDIVIDUALS SHOULD NOT BE DESIGNATED AS A HEALTH CARE AGENT. PRESS [CTRL+F1] TO REVIEW THE LIMITATIONS ON WHO MAY SERVE AS A HEALTH CARE AGENT.
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 the Agent's phone number or edit the information as desired.
Enter a phone number at which the Agent may be reached during business hours, if different from the home phone number.
Enter a description of the Agent's relation to the Declarant.
Enter an X if the Agent will be authorized to make health care decisions for the Declarant, independent of the Declarant's ability to make decisions. This selection is most appropriate if the Declarant desires that the Agent's authority be effective immediately.
Enter an X if the Agent will be authorized to make health care decisions for the Declarant only if the Declarant is unable to make such decisions.
Enter an X to designate an alternate agent to act on behalf of the Declarant if the first choice is unable or unwilling to do so (or if the Agent's authority is revoked).
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 the Alternate Agent's phone number or edit the information as desired.
Enter a phone number at which the Alternate Agent may be reached during business hours, if different from the home phone number.
Enter a description of the Alternate Agent's relation to the Declarant.
Enter an X to designate a Second Alternate Agent to act on behalf of the Declarant if the Alternate Agent is unable or unwilling to do so (or if the Alternate Agent's authority is revoked).
Enter the Second Alternate Agent's name or use the P.I. Manager to select and paste a record.
Enter a description of the Second Alternate Agent's relation to the Declarant.
Enter an X if the person named as agent is or ever becomes the Declarant's spouse, and the Declarant desires that his or her spouse not serve as agent if they are divorced or their marriage is annulled.
Enter an X if the Declarant desires that the Declarant's spouse not serve as agent if the Declarant is separated from such spouse.
GAD03
! Optional Authority of Agent Section (3 of 18)
!. AUTHORITY OF AGENT. My Agent is authorized to
! make any and all health care decisions for me that may be deemed appropriate by my Agent, subject to my wishes and the limitations (if any) as stated in this document. My Agent shall request and evaluate information concerning my medical diagnosis, the prognosis, the benefits and risks of the proposed health care, and alternatives to the proposed health care. My Agent shall consider the decision that I would have made if I had the ability to do so. If my Agent does not know my wishes regarding a specific health care decision, my Agent shall make a decision for me in accordance with what my Agent determines to be in my best interest. In determining my best interest, my Agent shall consider my personal beliefs and basic values to the extent known to my Agent.
My Agent must try to discuss health care decisions with me. However, if I am unable to communicate, my Agent may make such decisions for me.
To the extent deemed appropriate by my Agent, my Agent may discuss health care decisions with my family and others, to the extent they are available.
I authorize my Agent 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 any information, verbal or written, regarding my physical or mental health.
! !. 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 from, even against medical advice, 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.
! !. !
[Indiana version] STATEMENT OF DESIRES CONCERNING WITHDRAWAL OR WITHHOLDING OF HEALTH CARE: I authorize my health care representative to make decisions in my best interest concerning withdrawal or withholding of health care. If at any time, based on my previously expressed preferences and the diagnosis and prognosis, my health care representative is satisfied that certain health care is not or would not be beneficial, or that such health care is or would be excessively burdensome, then my health care representative may express my will that such health care be withheld or withdrawn and may consent on my behalf that any or all health care be discontinued or not instituted, even if death may result.
My health care representative must try to discuss this decision with me. However, if I am unable to communicate, my health care representative may make such a decision for me, after consultation with my physician or physicians and other relevant health care givers. To the extent appropriate, my health care representative may also discuss this decision with my family and others, to the extent they are available.
Enter an X to include a section that specifies the authority of the Agent to act on behalf of the Declarant. This section should be included if an agent is designated. Press [Ctrl+F1] for more information.
Enter an X to give the Agent full authority to make any medical or health care decision on behalf of the Declarant (subject to any limitations stated in this document).
Enter an X to state the Agent's authority in other terms. For example, this option may be used to state a more restricted scope of authority for the Agent.
Enter a description of the Agent's authority by completing the sentence; My agent is authorized to "make any health care decisions for me that may be deemed appropriate by my Agent, subject to my wishes and the limitations (if any) as stated in this document".
Enter an X to include an optional sentence that requires the Agent to discuss health care decisions with the Declarant before making a final decision.
Enter an X to include an optional sentence that allows the Agent to discuss health care decisions with the Declarant's family before making a final decision.
Enter an X to include a provision which enables the Agent to request and review health care information, sign releases, and make arrangements for health care.
Enter an X to authorize the Agent to review the Declarant's medical records, and consent to the disclosure of records to others.
Enter an X to authorize the Agent to sign release forms which may be required to obtain health care information.
Enter an X to authorize the Agent to select, employ and discharge health care providers, and to make all arrangements necessary for the Declarant's health care.
Enter an X to authorize the Agent to make decisions regarding the admission or discharge of the Declarant from any health care facility, including discharge against medical advice.
Enter an X to authorize the Agent to sign consent or refusal of consent documents for any proposed health care, including waivers of liability.
Enter an X to state the Agent's authority in other terms.
Enter a description of the Agent's authority.
Enter an X if the Declarant resides in Indiana and wants to authorize the Agent to make decisions regarding the withdrawal or withholding of health care. Indiana requires that this exact language be included. Later options permit the Declarant to specify his or her desires and wishes regarding such decisions.
GAD04
! Effectivity Section (4 of 18)
!. EFFECTIVITY. This document shall become effective
! immediately.
! upon a determination by appropriate medical personnel that I am unable to make and communicate informed decisions regarding my own health care.
The authority conveyed by this document shall not be affected by my subsequent disability or incapacity. I expect to be fully informed about and allowed to participate in any health care decision for me, to the extent that I am able.
I am to be considered incapable of making or communicating health care decisions if
! one physician has
! two physicians have
! !, of
!, ! !,
! Country: !,
(my preferred physician) or another physician has
personally examined me and signed a written opinion that I have a condition that means that I am unable to receive and evaluate information concerning my medical diagnosis, the prognosis, the benefits and risks of the proposed health care, and alternatives to the proposed health care, or I am unable to communicate decisions to such an extent that I lack the capacity to make my own health care decisions. This power exists only when I am unable, in the opinion of such physician(s), to make health care decisions for myself.
A copy of this statement must be attached to this document.
! A copy of this written determination shall be made a part of my medical record, and shall be reviewed
! not less than annually.
! not less than every 180 days.
All the powers conferred to my Agent shall be suspended if I regain the ability to make or communicate health care decisions. The powers granted to my Agent shall become effective again if I am later determined unable to participate in health care decisions in the manner described above.
Enter an X if this document shall become effective immediately. The Declarant will continue to be informed and participate in health care decisions to the extent possible. Press [Ctrl+F1] for more information regarding the "durability" of this document.
Enter an X if this document will not become effective until the Declarant's physician(s) have determined that the Declarant is unable to make and communicate health care decisions.
Enter an X to select a provision describing the method of determining that the Declarant is incapable of making or communicating health care decisions.
Enter an X if the Declarant desires that one physician make the determination that the Declarant is unable to make or communicate health care decisions.
Enter an X if the Declarant desires that two physicians make the determination that the Declarant is unable to make or communicate health care decisions.
Enter an X to specify the name of a particular physician to make the determination that the Declarant is unable to make or communicate health care decisions.
Enter the name of the physician designated to make the determination that Declarant is unable to make or communicate health care decisions. Use the P.I. Manager to select and paste a record.
Enter the physician's street address or edit the information as desired.
Enter the physician's extended street address or edit the information as desired.
Enter the physician's city or edit the information as desired.
Enter the physician's state/province or edit the information as desired.
Enter the physician's zip/postal code or edit the information as desired.
Enter an X to include the country where the physician's office is located, if outside the United States.
Enter the country where the physician's office is located or edit the information as desired.
Enter an X to require that the physician's written statement be attached to this document.
Enter an X to require that the physician's written statement be made a part of the Declarant's medical record.
Enter an X if the Declarant desires that the physician's determination be reviewed at least once a year.
Enter an X if the Declarant desires that the physician's determination be reviewed at least every six months.
Enter an X to specify another time frame in which the physician's written statement must be reviewed.
Enter the time frame in which the physician's written statement must be reviewed.
Enter an X to include a provision that the Agent's authority will cease if the Declarant regains the ability to make or communicate health care decisions. The Agent's authority will become effective again if the Declarant later becomes unable to make or communicate health care decisions.
GAD05
! Terminal Condition Section (5 of 18)
!. TERMINAL CONDITION. If I have a "terminal condition", I direct that
! my life not be extended by life sustaining procedures; such procedures shall be withheld or withdrawn.
! my life be prolonged to the greatest extent possible, within the standards of accepted medical practice, without regard to my condition, the chances I have for recovery, or the cost of the procedures.
! my Agent make decisions concerning withdrawal or withholding of health care. If based on my previously expressed preferences, the diagnosis and prognosis, and my Agent is satisfied that certain health care is not or would not be beneficial, or that such health care is or would be excessively burdensome, then my Agent may express my will that such health care be withheld or withdrawn, even if death may result.
If my physician believes that any life sustaining procedure may lead to a significant recovery, I direct my physician to implement the treatment for a reasonable period of time. If it does not improve my condition, I direct that the treatment 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.
By the use of the term "terminal condition", I mean
! that my death from an incurable or irreversible condition is imminent, and even if life sustaining procedures are used there is no reasonable expectation of my recovery.
! [Ohio version] AN IRREVERSIBLE, INCURABLE, AND UNTREATABLE CONDITION CAUSED BY DISEASE, ILLNESS, OR INJURY TO WHICH, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AS DETERMINED IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS BY MY ATTENDING PHYSICIAN AND ONE OTHER PHYSICIAN WHO HAS EXAMINED ME, BOTH OF THE FOLLOWING APPLY: (1) THERE CAN BE NO RECOVERY, AND (2) DEATH IS LIKELY TO OCCUR WITHIN A RELATIVELY SHORT TIME IF LIFE-SUSTAINING TREATMENT IS NOT ADMINISTERED.
! [User to compose own statement.]
Enter an X if life-sustaining procedures should be withheld or withdrawn if the Declarant has a terminal condition. Press [Ctrl+F1] for more information regarding "life-sustaining procedures".
Enter an X if all available medical treatment should be provided for the Declarant if the Declarant has a terminal condition.
Enter an X if the Declarant authorizes the Agent to determine whether or not life-sustaining procedures should be withheld or withdrawn if the Declarant has a terminal condition.
Enter an X to include an optional sentence which provides for a "trial period" of a particular treatment. If such life-sustaining procedure does not improve the Declarant's condition, the treatment should then be withdrawn.
Enter an X to include an optional sentence that states the meaning of the term "terminal condition". It is recommended that this sentence be included. Press [Ctrl+F1] for more information regarding a "terminal condition".
Enter an X to include a definition of "terminal condition" which reflects a common definition used by many states.
Enter an X to include a specific definition that is part of the Ohio Modified Uniform Rights of the Terminally Ill Act.
Enter an X to compose a definition of "terminal condition". The above definitions may be modified. You may wish to refer to the "Living Will" or "Health Care Power of Attorney" document for your state to see a state-specific definition of "terminal condition".
Use this space to compose the Declarant's definition of "terminal condition".
GAD06
! Permanent Coma Section (6 of 18)
!. COMA. If I am in a "permanent coma", I direct that
! my life not be extended by life-sustaining procedures; such procedures shall be withheld or withdrawn.
! my life be prolonged to the greatest extent possible, within the standards of accepted medical practice, without regard to my condition, the chances I have for recovery, or the cost of the procedures.
! my agent make decisions concerning withdrawal or withholding of health care. If based on my previously expressed preferences, the diagnosis and prognosis, and my agent is satisfied that certain health care is not or would not be beneficial, or that such health care is or would be excessively burdensome, then my agent may express my will that such health care be withheld or withdrawn, even if death may result.
If my physician believes that any life sustaining procedure may lead to a significant recovery, I direct my physician to implement the treatment for a reasonable period of time. If it does not improve my condition, I direct that the treatment 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.
By the use of the term "permanent coma", I mean
! that I am not conscious and am not aware of my environment, I show no behavioral response to the environment, I am not able to interact with others, and there is no reasonable expectation of my recovery within a medically appropriate period.
! [Ohio version] A STATE OF PERMANENT UNCONSCIOUSNESS THAT, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AS DETERMINED IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS BY MY ATTENDING PHYSICIAN AND ONE OTHER PHYSICIAN WHO HAS EXAMINED ME, IS CHARACTERIZED BY BOTH OF THE FOLLOWING: (1) I AM IRREVERSIBLY UNAWARE OF MYSELF AND MY ENVIRONMENT, AND (2) THERE IS A TOTAL LOSS OF CEREBRAL CORTICAL FUNCTIONING, RESULTING IN MY HAVING NO CAPACITY TO EXPERIENCE PAIN OR SUFFERING.
! [User-composed statement]
Enter an X if life-sustaining procedures should be withheld or withdrawn if the Declarant is in a permanent coma. Press [Ctrl+F1] for more information regarding "permanent coma" or "life-sustaining procedures".
Enter an X all available medical treatment should be provided for the Declarant if the Declarant is in a permanent coma.
Enter an X if the Declarant authorizes the Agent to determine whether or not life-sustaining procedures should be withheld or withdrawn if the Declarant is in a permanent coma.
Enter an X to include an optional sentence which provides for a "trial period" of a particular treatment. If such life-sustaining procedure does not improve the Declarant's condition, the treatment should then be withdrawn.
Enter an X to include an optional sentence that states the meaning of the term "permanent coma". It is recommended that this sentence be included. Press [Ctrl+F1] for more information regarding a "permanent coma".
Enter an X to include a definition of "permanent coma" that reflects a common definition used by many states.
Enter an X to include a specific definition that is part of the Ohio Modified Uniform Rights of the Terminally Ill Act.
Enter an X to compose a definition of "permanent coma". The above definitions may be modified. You may wish to refer to the It's Legal "Living Will" or "Health Care Power of Attorney" document for your state to see a state-specific definition of "permanent coma".
Enter the Declarant's definition of "permanent coma" by completing the sentence; By the use the term permanent coma, I mean "that I am not able to respond to the environment, and there is no reasonable expectation to my recovery within a medically appropriate period."
GAD07
! Life Sustaining Procedures Section (7 of 18)
!. LIFE SUSTAINING PROCEDURES. By the use of the term "life sustaining procedures", I mean
! any procedure, treatment, intervention, or other measure that has the primary effect of prolonging my life and is not necessary to provide for my comfort or freedom from pain.
! forms of medical care that only serve to artificially prolong the dying process and include forms of medical treatment which sustain, restore or supplant vital bodily functions. Life sustaining procedures do not include care directed to my comfort or to alleviate pain.
Enter an X to define life-sustaining procedures as those procedures which only prolong the dying process. Such procedures are withheld or withdrawn only if the Declarant is in an irreversible condition with no hope of recovery. However, any care which provides pain relief shall be provided. Press [Ctrl+F1] for more information.
Enter an X to define life-sustaining procedures as those procedures which artificially prolong the process of dying by taking the place of a vital bodily function. However, any care which provides pain relief shall be provided. Press [Ctrl+F1] for more information regarding "life-sustaining procedures".
GAD08
! Nutrition/Hydration Section (8 of 18)
!. ARTIFICIAL NUTRITION/HYDRATION.
! I authorize my agent to determine whether artificial nutrition or hydration should be withheld or withdrawn.
! I WANT to receive artificial nutrition or hydration, if I have a terminal condition or am in a permanent coma.
! I DO NOT WANT to receive artificial nutrition or hydration, if
! I have a terminal condition,
! I am in a permanent coma,
! I have a terminal condition or am in a permanent coma,
except to the extent necessary to provide comfort for me and freedom from pain.
By the use of the term "artificial nutrition or hydration", I mean food and fluids that are provided to me by artificial means such as a nasogastric tube or tube into the stomach, intestines or veins.
Enter an X if the Declarant gives the health care Agent the authority to determine whether or not artificially administered nutrition and/or hydration should be withheld or withdrawn. The Agent can base this decision on information available at the time a decision is required. Press [Ctrl+F1] for more information.
Enter an X if the Declarant wishes to receive artificially administered nutrition and/or hydration.
Enter an X if the Declarant does not wish to receive artificially administered nutrition and/or hydration.
Enter an X if the Declarant does not wish to receive artificially administered nutrition and/or hydration if the Declarant has a "terminal condition".
Enter an X if the Declarant does not wish to receive artificially administered nutrition and/or hydration if the Declarant is in a "permanent coma".
Enter an X if the Declarant does not wish to receive artificially administered nutrition and/or hydration if the Declarant has a "terminal condition" or is in a "permanent coma".
Enter an X to include an optional sentence that explains the meaning of the term "artificially administered nutrition or hydration". Press [Ctrl+F1] for more information.
%GAD09
! Optional Specific Medical Procedures Section (9 of 18)
!. SPECIFIC MEDICAL PROCEDURES. 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 agent 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 agent 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 in a permanent coma,
! have a terminal condition or am in a permanent coma,
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 Declarant wishes to receive or not to 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 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 Declarant desires that his or her Health Care Agent consider the circumstances at the particular time any of the above procedures are prescribed, and the Agent determine whether the procedure or treatment should be provided.
Enter an X if the Declarant does not wish to receive the above procedures if the Declarant has a terminal condition or is in a permanent coma.
Enter an X if the Declarant does not wish to receive the above procedures if the Declarant has a "terminal condition".
Enter an X if the Declarant does not wish to receive the above procedures if the Declarant is in a "permanent coma".
Enter an X if the Declarant does not wish to receive the above procedures if the Declarant has a "terminal condition" or is in a "permanent coma".
GAD10
! Optional Pregnancy Section (10 of 18)
!. 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 with respect to the withholding or withdrawal of life sustaining procedures and/or the withholding or withdrawal of artificially administered nutrition and hydration.
! [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 sustaining procedures, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life sustaining 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 Advance Directive shall be effective during any period that I am pregnant.
Enter an X to include a pregnancy paragraph that allows the Declarant to state her preference regarding how much effect should be given to this document if she is pregnant. Press [Ctrl+F1] for more information.
Enter an X to request that life-sustaining procedures 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-sustaining procedures.
Enter an X to request that consideration be given to the impact of physical harm or pain to the Declarant in determining whether life-sustaining procedures should be withheld or withdrawn if the Declarant is pregnant.
GAD11
! Optional Donation of Organs Section (11 of 18)
!. 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
! in another document I have specified and agreed to donate 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 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 if the Declarant desires that no anatomical gifts be made upon death.
Enter an X if the Declarant desires that anatomical gifts be made upon his or her death, and directs that artificial support procedures be used to maintain the Declarant's body until organ donation wishes can be met.
Enter an X if the Declarant's organ donation has been provided for in another document or designation, such as a uniform donor card or a driver's license designation. This program also offers an organ donation document.
Enter an X if the Declarant has not signed an organ donation in another document. The next option permits the Declarant 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 Declarant authorizes the donation of any needed organs, tissues, or body parts.
Enter an X if the Declarant 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 Declarant's death.
Enter an X if the above anatomical gift may be made for any purpose permitted by law.
Enter an X if the above anatomical gift 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.
GAD12
! Optional Autopsy Section (12 of 18)
!. AUTOPSY.
! I do not consent to an autopsy.
! I consent to any autopsy.
! My Agent may give consent to or refuse an autopsy.
Enter an X to include a provision regarding an autopsy after the Declarant'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 regarding autopsy.
Enter an X if the Declarant does not consent to an autopsy.
Enter an X if the Declarant consents to an autopsy.
Enter an X if the Declarant authorizes his or her agent to consent or refuse to consent to an autopsy of the Declarant's body after death.
GAD13
! Optional Other Requests Section (13 of 18)
!. OTHER SPECIFIC REQUESTS.
Enter an X to state other specific requests or instructions of the Declarant. 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 Agent's authority. Press [Ctrl+F1] for more information.
Use this space to state any other specific requests or instructions of the Declarant.
GAD14
! Optional Guardian Section (14 of 18)
!. NOMINATION OF GUARDIAN/CONSERVATOR. If it becomes necessary for a court to appoint a guardian or conservator of my person ("Conservator"), I designate
! my Agent (or alternate Agent)
! Name: !,
Street 1: !,
Street 2: !,
City: !,
State: !
Zip Code: !
! , Country: !
be appointed as the guardian or conservator of my person.
If the person designated is unwilling or unable to serve as my Guardian/Conservator, I designate
Name: !,
Street 1: !,
Street 2: !,
City: !,
State: !
Zip Code: !
! , Country: !
No bond shall be required of my Guardian/Conservator in any jurisdiction. Any decisions concerning my health care to be made by my Guardian or Conservator of my person, shall be made in accordance with my directions as stated in this document.
By the use of the term "Guardian" or "Conservator of my person", I mean a person or entity appointed by a court to provide for my care and physical well-being. Such term does NOT include the appointment of a person or entity to manage my financial affairs.
Enter an X to include a section that nominates a particular person to serve as the Declarant's Guardian (Conservator) if one is required by a legal proceeding. The person nominated will be appointed if the Court determines that such appointment is in the Declarant's best interests. Press [Ctrl+F1] for more information.
Enter an X if the Declarant desires that the person(s) appointed as agent or alternate agent also serve as Guardian ("Conservator").
Enter an X to nominate someone other than the Agent or Alternate Agent to serve as Guardian ("Conservator").
Enter the name of the person nominated as Guardian or use the P.I. Manager to select and paste a record.
Enter the person's street address or edit the information as desired.
Enter the person's extended street address or edit the information as desired.
Enter the person's city or edit the information as desired.
Enter the person's state/province or edit the information as desired.
Enter the person's zip/postal code or edit the information as desired.
Enter an X to include the person's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to enter the name of the person nominated to serve as the Declarant's Guardian if the first choice is unwilling or unable to do so.
Enter the name of the person nominated as Alternate Guardian or use the P.I. Manager to select and paste a record.
GAD15
! Hold Harmless Section (15 of 18)
!. 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, or my heirs 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.
GAD16
! Severability Section (16 of 18)
!. 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 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 Declarant's wishes be interpreted broadly. It is important to include this provision if there is any possibility that the Declarant would need to use the document in another state.
Enter an X to include a provision that asks health care providers and other persons to enforce the document as much as possible.
Enter an X to include a sentence which encourages health care providers and other decision makers to follow the Declarant's instructions and wishes as stated in this document.
4 | 2
GAD17
! Signature Section - Declarant Section (17 of 18)
I have read and understand the contents of this document. I am emotionally and mentally competent to make this declaration.
! It is my intention that this document be honored by my family and health care providers as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences from such refusal.
! I do not intend any direct taking of my life; but only that my dying not be unreasonably prolonged. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life, rather, only to permit the natural process of dying.
Enter an X to include a statement regarding the Declarant's legal right to make medical decisions.
Enter an X to include a statement that explains that the Declarant's making of an Advance Health Care Directive is not intended as authorizing the taking of the Declarant's life. Rather, it is the Declarant's exercise of the right to refuse medical treatment.
Enter an X to include any other statement the Declarant wishes to make.
Enter any other statement the Declarant wishes to make.
Enter the county or parish or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By including the social security number, 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.
Enter the Declarant's social security number.
Enter an X to include the Declarant'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 Declarant's date of birth.
Arizona
Idaho
Kansas
Kentucky
Minnesota
Mississippi
Nebraska
Nevada
New Jersey
Wyoming
GAD18
! Continuation of Signature Section - Witness Section (17 of 18)
[UNIQUE WITNESS REQUIREMENTS MAY APPLY IF THE DECLARANT RESIDES IN OR HAS APPLIED FOR ADMISSION TO A RESIDENTIAL CARE FACILITY SUCH AS A MENTAL HEALTH FACILITY OR NURSING HOME. PLEASE REVIEW THE STATE SPECIFIC FORMS TO DETERMINE WHETHER UNIQUE WITNESS REQUIREMENTS APPLY IN THE DECLARANT'S STATE. THE STATES OF CALIFORNIA, DELAWARE, GEORGIA, NEW YORK, NORTH DAKOTA, OREGON, SOUTH CAROLINA AND VERMONT HAVE SUCH REQUIREMENTS.]
Under the penalty of perjury I declare that the Declarant and each witness signed this document in each other's presence. Based upon my personal observation, the Declarant appears to be a competent individual, and is aware of the nature of this document. The Declarant is personally known to me or has satisfactorily proven to be the person who voluntarily signed this document, and did not appear to be under or subject to any duress, fraud, constraint or undue influence. To the best of my knowledge, I am not
(1) related to the Declarant by blood, marriage, or adoption,
(2) designated as Agent or alternate Agent under this document,
(3) entitled to any portion of the Declarant's estate according to the laws of intestate succession or under any will or codicil of the Declarant,
(4) the attending physician of the Declarant or an employee of the attending physician or an owner, operator, officer, director, or employee of a hospital or care or residential facility in which the Declarant is a patient or resident,
(5) an employee of the Declarant's life or health insurance provider,
(6) directly financially responsible for the Declarant's medical care,
(7) entitled to a present claim against any portion of the Declarant's estate, or
(8) entitled to any financial benefit by reason of the death of the Declarant.
I am at least 19 years of age, and did not sign this document for the Declarant.
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 witness information may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
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 country in which the witness resides.
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.
Alabama
Alaska
American Samoa
Colorado
Hawaii
Indiana
Louisiana
Mariana Islands
Missouri
Montana
New Hampshire
New Mexico
North Carolina
Pennsylvania
Puerto Rico
South Dakota
Tennessee
Virgin Islands(US)
Washington
West Virginia
Michigan
GAD19
! Continuation of Signatures - Witness or Notary Section (17 of 18)
[The Declarant's signature of this document must be witnessed by a Notary Public or by two witnesses. Select either option.]
[Notary Public]
NOTARY BLOCK
State of _________________________,
County of _________________________ ss:
On this _____ day of _______________, 19___, !, known to me (or satisfactorily proven) to be the person named in the foregoing instrument, personally appeared before me, a Notary Public, within and for the said State and County, and acknowledged that he/she freely and voluntarily executed the same for the purposes stated in the document.
[UNIQUE WITNESS REQUIREMENTS MAY APPLY IF THE DECLARANT RESIDES IN OR HAS APPLIED FOR ADMISSION TO A RESIDENTIAL CARE FACILITY SUCH AS A MENTAL HEALTH FACILITY OR NURSING HOME. PLEASE REVIEW THE STATE SPECIFIC FORMS TO DETERMINE WHETHER UNIQUE WITNESS REQUIREMENTS APPLY IN THE DECLARANT'S STATE. THE STATES OF CALIFORNIA, DELAWARE, GEORGIA, NEW YORK, NORTH DAKOTA, OREGON, SOUTH CAROLINA AND VERMONT HAVE SUCH REQUIREMENTS.]
Under the penalty of perjury I declare that the Declarant and each witness signed this document in each other's presence. Based upon my personal observation, the Declarant appears to be a competent individual, and is aware of the nature of this document. The Declarant is personally known to me or has satisfactorily proven to be the person who voluntarily signed this document, and did not appear to be under or subject to any duress, fraud, constraint or undue influence. To the best of my knowledge, I am not
(1) related to the Declarant by blood, marriage, or adoption,
(2) designated as Agent or alternate Agent under this document,
(3) entitled to any portion of the Declarant's estate according to the laws of intestate succession or under any will or codicil of the Declarant,
(4) the attending physician of the Declarant or an employee of the attending physician or an owner, operator, officer, director, or employee of a hospital or care or residential facility in which the Declarant is a patient or resident,
(5) employee of the Declarant's life or health insurance provider,
(6) directly financially responsible for the Declarant's medical care,
(7) entitled to a present claim against any portion of the Declarant's estate, or
(8) entitled to any financial benefit by reason of the death of the Declarant.
I am at least 19 years of age, and did not sign this document for the Declarant.
Enter an X if a Notary Public will acknowledge the Declarant's signature.
The program transfers the Declarant's name from a previous section. This field can be modified only by returning to that section.
Enter an X if two witnesses will acknowledge the Declarant's signature.
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 witness information may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
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 country in which the witness resides.
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.
Mississippi
GAD20
! Continuation of Signature Section - Notary Section (17 of 18)
[This document must be signed in the presence of a Notary Public.]
NOTARY BLOCK
State of _________________________,
County of _________________________ ss:
On this _____ day of _______________, 19___, !, known to me (or satisfactorily proven) to be the person named in the foregoing instrument, personally appeared before me, a Notary Public, within and for the said State and County, and acknowledged that he/she freely and voluntarily executed the same for the purposes stated in the document.
The program transfers the Declarant's name from a previous section. This field can be modified only by returning to that section.
GAD21
! Patient Advocate Acceptance Section - Michigan
[This document must also be signed by the Patient Advocate and Alternate Patient Advocate.]
PATIENT ADVOCATE ACCEPTANCE OF DESIGNATION
The Patient Advocate/Successor Patient Advocate(s) accept(s) the Patient's designation as stated in this document and agree(s) that:
a. This designation shall not become effective unless the Patient is unable to participate in medical treatment decisions.
b. A Patient Advocate ("Agent") shall not exercise powers concerning the Patient's care, custody, and medical treatment that the Patient, if the Patient were able to participate in the decision, could not have exercised on his or her own behalf.
c. This designation cannot be used to make a medical treatment to withhold or withdraw treatment from a Patient who is pregnant that would result in the pregnant Patient's death.
d. A Patient Advocate may make a decision to withhold or withdraw treatment which would allow a patient to die only if the Patient has expressed in a clear and convincing manner that the Patient Advocate is authorized to make such a decision, and that the Patient acknowledges that such a decision could or would allow the Patient's death.
e. A Patient Advocate shall not receive compensation for the performance of his or her authority, rights, and responsibilities, but a Patient Advocate may be reimbursed for actual and necessary expenses incurred in the performance of his or her authority, rights, and responsibilities.
f. A Patient Advocate shall act in accordance with the standards of care applicable to fiduciaries when acting for the Patient and shall act consistent with the Patient's best interest. The known desires of the Patient expressed or evidenced while the Patient is able to participate in medical treatment decisions are presumed to be in the Patient's best interests.
g. A Patient may revoke his or her designation at any time and in any manner sufficient to communicate an intent to revoke.
h. A Patient Advocate may revoke his or her acceptance to the designation at any time and in any manner sufficient to communicate an intent to revoke.
i. A Patient admitted to a health facility or agency has the rights enumerated in Section 20201 of the Public Health Code, Act No. 368 of Public Acts of 1978, being Section 333.20201 of the Michigan Compiled Laws.
NOTICE TO PERSON EXECUTING THIS DOCUMENT ("DECLARANT")
This is an important legal document. Before executing this document, you should know these important facts:
This document gives the person you designate as the Attorney-in-Fact (your Agent) the power to make health care decisions for you. This power exists only as to those health care decisions to which you are unable to give informed consent. The Attorney-in-Fact must act consistently with your desires as stated in this document or otherwise made known.
Except as you otherwise specify in this document, this document gives your Agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.
Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped or withheld if you object at the time.
The document gives your Agent authority to consent, to refuse to consent or to withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition. This power is subject to any statement of your desires and any limitations that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your Agent to make health care decisions for you if your Agent (a) authorizes anything that is illegal, (b) acts contrary to your known desires, or (c) where your desires are not known, does anything that is clearly contrary to your best interests.
You have the right to revoke the authority of your Agent by notifying your Agent or your treating doctor, hospital or other health care provider in writing of the revocation.
Your Agent has the right to examine your medical records and to consent to this disclosure unless you limit this right in this document.
Unless you otherwise specify in this document, this document gives your Agent the power after you die to (a) authorize an autopsy, (b) donate your body or parts thereof for transplant or for educational, therapeutic or scientific purposes, and (c) direct the disposition of your remains.
If there is anything in this document that you do not understand, you should ask your lawyer to explain it to you.
This Advance Health Care Directive will not be valid for making health care decisions unless it is either (a) signed by two (2) qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature or (b) acknowledged before a Notary Public in the state.
GAD23
! Health Care Document Information Section (18 of 18)
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent, if one is appointed in this document. If you are in a health care facility, a copy of this document should be included in your medical record.
The Advance Health Care Directive should be reviewed:
- if the appointed Agent or the alternate Agent is no longer able to serve;
- if the appointed Agent is your spouse and you become separated or divorced;
- if you wish to revise your desires as stated in the document.
It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate.
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