In most jurisdictions you must be at least 18 years of age to create a valid health care document. Please ensure that this document will be valid for you where you reside.
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Do you wish to create a Living Will, Medical Power of Attorney, or both?
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Living Will
Complete the following sentences by choosing the phrases that represent your wishes.
If I have a terminal condition, I would like the following
done:
If I am in a persistent vegetative state, I would like the
following done:
If I am in a permanent coma, I would like the following done:
Pregnancy
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Is there a possibility that you currently are or may become pregnant
in the near future?
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If you are pregnant do you want your directive to be ignored until after the pregnancy ends?
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Section 1. Living Will
These directions will only be used if you become unable to speak for yourself.
Other Directions
| Are there any other things you want done or not done? |
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| Number of other things you want listed: |
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Section 2. If I need someone to speak for me
This form may be used in the state of Alabama to name a person you would like
to make medical or other decisions for you if you become too sick to speak for
yourself. This person is called a health care proxy.
Your health care proxy must be an adult. Your health care proxy should
not be any of the following:
- a treating health care provider,
- a non-relative employee of your treating health care provider,
- an operator of a community care facility,
- or a non-relative employee of an operator of a community care facility
Please name the person you want to be your health care proxy.
Information of first choice for Proxy
Please name a second choice for health care proxy to cover the possibility
that your first choice may be unable, unwilling or unavailable to be your
health care proxy by the time you need a proxy.
Information of second choice for Proxy
Instructions for proxy
Choose the statement below that most accurately reflects your wishes:
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Do you want your health care proxy to make decisions about whether you are given
food and water through a tube or an IV?
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Do you want your health care proxy to be able to see your medical
records?
Section 3. What I Want
| Please list the people you would want your doctor to speak
with if the time comes for you to stop receiving life sustaining treatment or food or water
through a tube or an IV (if that is what you have chosen in this Advance Directive for Health Care).
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Number of people you want to list:
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Living Will
- This document may be used in the State of Idaho to make your wishes known about what
medical treatment or other care you would or would not want if you become too sick to
speak for yourself.
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You are not required to have a Living Will.
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If you do have a Living Will, be sure that your doctor, family, and friends
know you have one and know where it is located.
- You can change your mind about any directions you give by tearing up the
Living Will and writing a new one.
2. If at any time you should become unable to communicate your instructions about your medical
treatment and care, what would you want done?
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Where the application of artificial life-sustaining procedures
Life sustaining procedures includes drugs,
machines, or medical procedures that would
keep you alive but would not cure you. Even
if you choose not to have life sustaining
treatment, you will still get medicines and
treatments that ease your pain and keep you
comfortable unless otherwise directed.
shall serve only to prolong my life artificially, I direct such procedures be withheld or withdrawn except
for the artificial administration of nutrition and hydration
Artificial nutrition and hydration means the
provision of nutrients and fluids (food
and water) by a tube inserted in a vein, under
the skin in the subcutaneous tissues, or in
the stomach (gastrointestinal tract).
(food and water).
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I direct that all medical treatment, care, and nutrition and hydration necessary
to restore my health, sustain my life, and to abolish or alleviate pain or distress
be provided to me. Artificial nutrition and hydration shall not be withheld or withdrawn
from me if I would die from malnutrition or dehydration rather than from my injury, disease,
illness or condition.
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Where the application of artificial life-sustaining procedures shall serve only to prolong my
life artificially, I direct such procedures be withheld or withdrawn, including the artificial
administration of nutrition and hydration (food and water).
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Pregnancy
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Is there a possibility that you currently are or may become pregnant in the future?
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If you are pregnant do you want your Living Will to be ignored until after the pregnancy ends?
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In order to ensure that the directions you have expressed are
implemented, you may appoint any adult person and authorize him or
her to make health care decisions on your behalf in accordance with
your living will. This person is called your health care agent. The
document used to appoint a health care agent is your "Durable Power of
Attorney for Health Care".
In order to ensure that the directions you have expressed are implemented, you may appoint
any adult person and authorize him or her to make health care decisions on your behalf
in accordance with your living will. This person is called your health care agent.
Your agent's authority only becomes effective after you have become
incapable of directing your own health care. To appoint a health
care agent, you must create another document called a "Durable Power
of Attorney for Health Care".
Would you like to make a durable power of attorney for health care to appoint a health care agent?
Declaration Relating to Use of
Life-Prolonging Treatment
- Life-prolonging treatment means any medical procedure, treatment, or intervention
that, when administered to me, will serve only to prolong the process of my dying and where
in the judgment of my attending physician, death will occur whether or not the treatment is used.
The term does not include the provision of appropriate nutrition and hydration or the performance
of any medical treatment necessary to provide comfort care or alleviate pain; or medical procedures,
treatment, or intervention performed in an emergency, pre-hospital situation.
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Artificially provided food and hydration means being given nutrients (food) and water
through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone
helping me.
Please check the statements that most accurately reflect your wishes in the following circumstances:
If I am in a terminal condition, I would like the following done:
If I am permanently unconscious, I would like the following done:
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Is there a possiblity that you are, or may in the future
become pregnant?
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Do you want the directions you give in this declaration to be ignored
if you are pregnant?
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Living Will Declaration
Please make yourself familiar with the following definitions. You will need to refer to them in the next sections.
- Cardiopulmonary resuscitation or CPR
means treatment
to try to restart breathing or heartbeat. CPR may be done by breathing into the mouth,
pushing on the chest, putting a tube through the mouth or the nose into the throat,
administering medication, giving electric shock to the chest, or by other means.
- Health Care means any medical
(including dental, nursing, psychological, and surgical) procedure, treatment, intervention
or other measure used to maintain, diagnose or treat any physical or mental condition.
- My living will declaration or my living will means this document.
- Life-sustaining treatment
means any health care, with the exception of artificially or technologically supplied nutrition or
hydration and CPR, that will serve only to prolong the dying process.
- Artificially or technologically supplied nutrition or hydration
means the providing of food and fluids through intravenous or tube "feedings".
- Do Not Resuscitate or DNR Order means a medical order given by a physician and written in my medical records that
Cardiopulmonary resuscitation or CPR is not to be administered to me.
- Terminal condition or terminal illness means an irreversible, incurable and untreatable condition caused
by disease, illness or injury. My physician and one other physician will have examined me and
believe that I cannot recover and that death is likely to occur within a relatively short time
if I do not receive life-sustaining treatment.
- Permanently unconscious state
means an irreversible condition in which I am permanently unaware of myself and my surroundings.
My physician and one other physician must examine me and agree that a total loss of higher brain function
has left me unable to feel pain or suffering.
Please check the statements that most accurately reflect your wishes in the following circumstances.
Terminal Condition
If I am in a terminal condition, I would like the following done:
Permanent Unconsciousness
If I am permanently unconscious, I would like the
following done:
Pregnancy
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Is there a possibility that you are, or may in the future become pregnant?
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Do you want the directions you give in this declaration to be ignored if you are pregnant?
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Witnesses
Your Living Will Declaration will not be valid unless you and 2 adult witnesses sign the
document in each others' presence, or unless you acknowledge the document before a notary public.
Your witnesses may NOT be any of the following:
- Your health care agent or alternate health care agent, designated in a Health Care Power of Attorney;
- Your attending physician;
- An administrator of a health care facility in which you are receiving care; or
- Your relative by blood, adoption or marriage.
| Living Will |
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Please note: the U.S. Constitution allows people to determine the kind of health care they will receive.
However, many states limit the types of health care decisions that can be made, and the instructions that
you provide below may go beyond what is allowed in your state. This will not invalidate your instructions,
but they may be limited to what is legally allowable. LawDepot does not limit your choice of instructions
because this area of law is still developing. Some choices that are not now approved by legislation may be
approved by the time your document is in effect. Moreover, the constitution gives you the right to make
your own choices.
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Make sure you understand the following definitions:
"Life Support" means a medical procedure or intervention which keeps you alive,
but does not cure you, and serves only to prolong the dying process. Life-support does
not include comfort care or tube feeding.
"Comfort care" means treatment, including prescription medication, provided to me
for the sole purpose of alleviating pain, and does not include tube feeding.
"Tube feeding" means nutrition and hydration provided by means of a nasogastric
tube or tube into the stomach, intestines or veins.
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In this section, you will be answering the following questions:
When your body is no longer able to perform certain life sustaining functions and
you are being kept alive only by the assistance of life prolonging procedures or
machines, and it has been established to a reasonable degree of medical certainty
that there is no possibility of recovery, do you wish to still receive life-prolonging
procedures?
When you are no longer able to chew food or swallow liquids on your own and you have a terminal
condition with no hope of recovery, do you wish to still receive food and water artificially
(ie. by tube feeding)?
Even if life support is discontinued your physicians will still want to give you medication
and perform other procedures to reduce any pain you may feel and to ensure your comfort.
These procedures may have the effect of extending your life. If you have a terminal condition
with no hope of recovery, do you wish to receive procedures and medications to reduce your pain
and to provide you comfort even if the procedures may extend your life?
If my condition is determined to be terminal and with no hope of recovery, I would like the following done:
| Life Support:
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| Tube Feeding: |
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| Comfort Care: |
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If I become permanently unconscious with no hope of recovery, I would like the following done:
| Life Support: |
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| Food and Water: |
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| Comfort Care: |
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Pregnancy
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Is there a possibility that you currently are or may become pregnant
in the near future?
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If you are pregnant do you want your directive to be ignored until after the pregnancy ends?
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You can change or cancel your Living Will at any time, as long as you have mental capacity.
Once you have become incapable, however, you will not be able to change your Living Will.
In the next section (your Medical Power of Attorney) you will be choosing someone to be your
health care representative (agent). That person will make health care decisions for you if
you become incapable of making or communicating your own decisions. If you do not want your
living will to be cast in stone at the moment you cease to be capable, you may give your
agent the power to revoke it on your behalf.
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Would you like your agent to have this power?
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A Medical Power of Attorney gives your agent the power and authority to make health care decisions
for you, but does not give him or her the power to enforce the decisions you have already made for
yourself (in your Living Will). If you want to, you can give your agent the power to enforce your
Living Will.
| Would you like your agent to have this power?
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You can change or cancel your Living Will at any time, as long as you have mental capacity.
Once you have become incapable, however, you will not be able to change your Living Will.
If you do not want your Living Will to be cast in stone at the moment you cease to be capable,
you may decide to choose a person (called your agent) who will have the power to revoke it on your behalf.
| Do you want to have an agent who can revoke this Living Will
on your behalf? |
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Agent Details
Please type in the information of your (revoking) agent:
Do you want to name a successor for this agent?
A successor agent takes the
place of your first choice for agent, if your first choice
is unable or unwilling to act as your agent.
Successor Agent Details
Please type in the information of your (revoking) agent:
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