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.
Deciding on Treatment 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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Deciding on Treatment
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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Selecting a Representative
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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Deciding on Treatment
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?
Deciding on Treatment
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 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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Deciding on Treatment
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
Deciding on Treatment
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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:
If you want, you can choose a person (called your agent) who will have the power to enforce
your Living Will.
| Do you want to have an agent who can enforce this Living Will
on your behalf? |
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Note: If you chose to have an agent with the power to revoke, you should probably choose the same
person as your enforcing agent.
Choose one of the following:
Agent Details
Please type in the information of your (enforcing) 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 (enforcing) agent:
Deciding on Treatment
Living Will
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LIFE-PROLONGING PROCEDURES
"Life-prolonging procedure" means any medical procedure
, treatment, or intervention which sustains, restores, or
supplants a spontaneous vital function. The term does not
include sustenance and hydration administration or the
provision of medication or the performance of medical procedure,
when such medication or procedure is deemed necessary
to provide comfort care or to alleviate pain.
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In this section, you will choose whether or not you want to have life prolonging procedures
performed if you are in a
terminal condition
"Terminal condition" means a condition caused
by injury, disease, or illness from which there
is no reasonable medical probability of recovery
and which, without treatment, can be expected
to cause death.
, or a permanent coma or a
persistent vegetative state
"Persistent vegetative state" means a permanent
and irreversible condition of unconsciousness
in which there is 1) The absence of voluntary
action or cognitive behavior of any kind.
and 2) An inability to communicate or interact
purposefully with the environment.
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Choose one of the choices below to complete this sentence:
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If at any time my attending physician certifies in writing that I have a terminal condition, or
that I am in a permanent coma or a persistent vegetative state...
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I request the use of life-prolonging procedures that would extend my life.
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I DO NOT authorize the use of life prolonging procedures that would extend my life other than
as stated elsewhere in this declaration.
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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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| Living Will Directive
Deciding on Treatment
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Definitions
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Please become familiar with the following definitions.
You will need to refer to them in the following sections.
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Health care decision
means consenting to, or withdrawing consent for, any medical procedure, treatment or intervention.
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Artificially provided nutrition and hydration
means sustenance or fluids that are artificially or technologically administered.
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Comfort Care means the performance of any medical procedure, including the
administration of medication, deemed necessary to alleviate pain. Comfort care does not
include artificially provided nutrition and hydration.
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Life-prolonging treatment
means any medical procedure, treatment or intervention which:
- Utilizes mechanical or other artificial means to sustain, prolong, restore, or
supplant a vital function; and
- When administered to a patient would serve only to prolong the dying
process. Life prolonging procedure does not include comfort care or artificially
provided nutrition and hydration.
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| Appointment of Surrogate |
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A health care surrogate is an adult person, chosen by you, who is authorized to make health care
decisions for you if you are unable to make or communicate your own health care decisions.
You do not have to have health care surrogate. If you appoint a surrogate, he or she will be
obligated to make decisions in accordance with your wishes as expressed in this document.
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| Do you want to designate a health care surrogate? |
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Surrogate Details
| Do you want to designate an alternate health care surrogate? (recommended) |
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Alternate Surrogate Details
Directives
In this section, you will be answering the following questions:
When your body is no longer able to perform certain life sustaining functions, 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 you will recover, do you wish to still receive life-prolonging
procedures, or not?
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, or not?
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
would extend your life, or not?
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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Organ and Tissue Donation
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In the event of your death, do you want to be an organ or tissue donor?
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Note: Choosing "Yes" will make the following
provision appear in your document: "I authorize the giving of all or part of my body upon death
for any purpose specified in KRS 311.185."
Witnesses
This document will not be valid unless
it is signed in the presence of (2) witnesses OR
acknowledged by you before a Notary Public (not both).
Your witnesses or your notary public MUST NOT BE any of the following:
- related to you by blood, marriage or adoption
- your beneficiary, either under your will or by operation of law
- an employee of a health care facility in which you are a patient (unless the employee serves as a notary public)
- your attending physician
- any person who is directly financially responsible for your health care
Deciding on Treatment
Living Will
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,
or not?
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, or not?
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, or not?
Complete the following sentences by choosing the phrases that represent your wishes.
If I have a terminal condition:
If I am in a persistent vegetative state:
If I am in a permanent coma:
Deciding on Treatment
Living Will
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If at any time you should have an incurable injury, disease, illness or condition verified to be
a terminal condition by two (2) medical doctors who have examined you, and where the application of
life-sustaining treatment of any kind would serve only to prolong your life, and where a medical
doctor determines that you will die within six months, whether or not life-sustaining treatment is
used, or you have been diagnosed as being persistently unconscious, which of the following
statements below most accurately reflects your wishes?
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Terminal Condition
"Terminal condition" means an incurable and irreversible
condition that, even with the administration of life-sustaining
treatment, will, in the opinion of the attending physician and
another physician, result in death within six (6) months.
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| If my condition is determined to be terminal and with no hope of recovery, I would like
the following done:
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| Other Directives |
If you have other concerns about the kind of treatment you will be given when you can no longer
direct your own health care, you may add directives in your own words below. This is entirely optional.
You do not have to add more directives if you do not want to.
(Note: If you choose to add more directives, begin your sentences with "I direct that...")
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Advance Directive for
Health Care
The Oregon Advance Directive for Health Care allows you to appoint a representative (proxy/agent) and to give
instructions about the kind of health care you want to receive if you become unable to direct your own health care
(living will). You do not have to appoint a representative if you do not want to, and you do not have to give health
care instructions if you do not want to.
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Do you want this Advance Directive to be valid for the rest of your
life, or for a period of years only?
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Please enter the number of years for which you want your Advance Directive to
continue:
| Living Will
Deciding on Treatment
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You will need to complete the health care questions below about the care you wish
to receive if you are ever suffering from the following conditions:
- Terminal Condition
Terminal Condition means a condition caused by injury,
disease, or illness from which there is no reasonable
medical probability of recovery and which, without
treatment, can be expected to cause death.
- End Stage Condition
End Stage Condition means an irreversible condition that
is caused by injury, disease, or illness which has resulted
in progressively severe and permanent deterioration, and
which, to a reasonable degree of medical probability,
treatment of the condition would be ineffective.
- Persistent Vegetative State
Persistent Vegetative State means a permanent and
irreversible condition in which a person makes no
voluntary actions and demonstrates no evidence of
having thoughts, is unable to communicate and is
unaware of his or her own existence.
For these conditions you will be asked whether you wish to receive:
- artificial life support,
Artificial Life Support, also known as "life-prolonging procedures"
or "life-sustaining procedures" means any medical procedure,
treatment, or intervention which sustains, restores, or supplants
a spontaneous vital bodily function. In this document, Artificial
Life Support does not include artificially administered food and
water, or procedures that are necessary to provide comfort or
alleviate pain (including pain-relief medications).
- artificially administered food and water,
Artificially Administered Food and Water, also known
as tube feeding, involves putting a tube into a person's
stomach (through the nose, or through a small hole in
the abdomen). This is done for people who are too ill
to chew or swallow by themselves or with someone else
helping them. Without a feeding tube, such a person who
cannot eat will die within days or weeks. With a feeding
tube, the chance that a person will live depends on the
person's overall condition.
- and comfort care.
Comfort care means treatment, including prescription medication,
provided to the patient for the sole purpose of alleviating pain.
Artificially administered food and water is not comfort care. The
provision of comfort care may result in extending or shortening
a person's life.
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. |
Terminal Condition
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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| Food and Water: |
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| Comfort Care: |
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Permanent Coma
If I am in a permanent coma
with no hope of recovery, I would like the following done:
Irreversible Condition
If, in the judgment of my physician, I am suffering with an irreversible condition so that I cannot care for myself or make decisions for myself and am expected to die without life-sustaining treatment provided in accordance with prevailing standards of care, I would like the following done:
Permanent Unconsciousness
Permanent unconsciousness is when my doctor and another doctor agree that I can no longer think, feel, move or be aware of being alive. If I become permanently unconscious with no hope of recovery, I would like the following done:
End Stage Condition
If, in the judgment of my physician, I am suffering with an irreversible condition, caused by injury, disease, or illness which has resulted in progressively severe and permanent deterioration, so that I cannot care for myself or make decisions for myself and am expected to die without life-sustaining treatment provided in accordance with prevailing standards of care, 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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Persistent Vegetative State
If I am in a persistent vegetative state 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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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 directive to be ignored until after the pregnancy ends?
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Health Care Agent
You may designate a person of your choice to make treatment decisions for you if you are
comatose or otherwise unable to make your own decisions. This person must be at least
the age of majority for your jurisdiction and 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.
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Please enter the information of the person you wish to
designate below:
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Additional Instructions
Do you want to give additional instructions in your own
words?
Write a sentence (or more) beginning with "I direct that..."
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Powers and Authority of Your Designated Agent
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Your agent:
- will have the same power to make health care decisions for you as you would have yourself;
- must exercise his or her authority in accordance with your wishes (as expressed in this document, or
in a Living Will, or as you have otherwise instructed him or her);
- will have the authority to make decisions about the provision, withdrawal or refusal of life-prolonging care, treatment, services or procedures;
- will have the authority to:
- request, review and receive any information regarding your physical or mental health, including medical and hospital records;
- execute any releases or other documents that may be required in order to obtain the information referred to in i) above; and
- consent to the disclosure of the information referred to in i) above; and
- will have the authority to sign any document, form or release from liability that is necessary for the implementation of health care decisions.
Statement of Desires, Special Provisions and Limitations
If there are any special instructions you want to give to your health care agent, or any
limitations you want to put on the authority of your health care agent, type them in here:
Begin your sentence(s) with "My agent shall.." or "My agent is not authorized to.."
Organ and Tissue Donation
Please choose the statement below that most accurately reflects your wishes:
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Designation of Alternate Agents
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In the event that your first choice for agent is not available or becomes ineligible to be
your health care agent, do you want to designate an alternate health care agent?
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Please provide the name and contact information of the person you want as your alternate health care agent.
| Do you want to designate a second alternate? |
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Selecting a Representative
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Medical Power of Attorney
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YOU DO NOT HAVE TO APPOINT A HEALTH CARE REPRESENTATIVE.
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Do you want to appoint a health care representative?
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NOTE: You may not appoint your doctor, an employee of your doctor, or an owner, operator
or employee of your health care facility, unless that person is related to you by blood,
marriage or adoption or that person was appointed before your admission into the health
care facility.
Your Health Care Representative (also called Health Care Agent or Health Care Proxy) will make health care decisions
for you when you are no longer capable of making them for yourself, or if
you are unable to communicate your decisions to others.
Your representative must be at least of the age of majority for your jurisdiction, and should be someone you have spoken to about your wishes.
Your Health Care Representative 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
- a non-relative employee of an operator of a community care facility.
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Please type in the name, address and telephone number of the person you want to be your health care agent:
Representative's Information
Alternative Representative's Information
Except to the extent you state otherwise, this document gives
the person you name as your agent the authority to make any and all
health care decisions for you in accordance with your wishes,
including your religious and moral beliefs, when you are no longer
capable of making them yourself. Because "health care" means any
treatment, service, or procedure to maintain, diagnose, or treat
your physical or mental condition, your agent has the power to make
a broad range of health care decisions for you. Your agent may
consent, refuse to consent, or withdraw consent to medical
treatment and may make decisions about withdrawing or withholding
life-sustaining treatment. Your agent may not consent to voluntary
inpatient mental health services, convulsive treatment,
psychosurgery, or abortion.
Do you want to put any other limitations on the authority of your agent?
Type in your limitations in the box below.
Hint: Start your sentence(s) with "My agent may not..." or "My agent
shall..."
Powers of Agent
Your Health Care Agent has the following powers:
- power to consent, refuse consent, or withdraw consent to all medical, surgical,
hospital and related health care treatments and procedures according to your wishes
as stated in this document, or another document;
- power to make decisions about the provision to you of artificial nutrition and
hydration according to your wishes as stated in this document, or another document;
- power to obtain and review your medical records of all kinds;
- power to sign any releases in order to obtain your medical records; and
- power to sign any documents required to request, withdraw, or refuse treatment or to be released or transferred to another medical facility.
Other Instructions for Agent
If you would like to restrict the authority of your Agent, or if you have special instructions
for your Agent please type your restrictions or instructions here:
Hint: Start your sentences with "My Agent may not..." or
"My Agent must..." or "I direct that my Agent..."
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A durable power of attorney for health care does not have an expiration date under Ohio law.
However, if you want to specify an expiration date you may do so. Do you want to specify an
expiration date?
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Your agent will have the power to consent or refuse consent to treatment of any
physical or mental condition, to make arrangements for your admission to any treatment
facility, employ or discharge health care personnel, and to access your medical records.
Your agent will be instructed to consider your personal values when exercising the
authority given. Do you want to insert any special instructions for your health care
agent, or make a general statement about your desires to be followed by your agent?
What do you want to provide?
Finish the following sentence: "My agent shall...."
Type your general statement about your desires respecting health
care treatment here:
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Is there a particular treatment(s) you do NOT authorize your agent to
consent to?
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Please list the treatment(s) your agent may NOT consent to:
Are there any other limitations you want to put on your agent?
(e.g., "Before making a life or death
decision, my agent shall discuss the decision with my spouse")
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Please type, in sentence form, the further limitations you want to
put on your agent:
Special Provisions and Limitations
Your attorney-in-fact is not permitted to consent to any of the following: commitment to
or placement in a mental health treatment facility, convulsive treatment, psychosurgery,
sterilization or abortion. If there are any other types of treatments or placements that you do not want your attorney-in-fact to consent to, or other restrictions you wish to place on your attorney-in-fact, you should list them here. If you do not list
any limitations, your attorney-in-fact will have broad powers.
Begin your sentence with the words "My attorney-in-fact...".
(e.g., My attorney-in-fact may
not consent to chiropractic treatments for me.)
Duration
For how long will your representative's authority last?
Enter date:
(e.g. 2004)
Do you want your health care representative to be able to see your medical
records?
On the printed document, the section containing instructions for your health care representative looks
like the sample below:
Life Support
"Life support" refers to any medical means for maintaining life, including procedures, devices and
medications. If you refuse life support, you will still get routine measures to keep you clean and
comfortable.
INITIAL IF THIS APPLIES:
_____ My representative MAY decide about life support for me. (If you do not initial this space, then
your representative MAY NOT decide about life support.)
Tube Feeding
One sort of life support is food and water supplied artificially by medical device, known as tube feeding.
INITIAL IF THIS APPLIES:
_____ My representative MAY decide about tube feeding for me. (If you do not initial this space, then your
representative MAY NOT decide about tube feeding.)
If you want to add other authorizations, or instructions, or limitations for your health care representative,
please type them in the appropriate boxes below:
Authorizations:
Instructions:
Limitations:
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Authority of Health Care Proxy
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If at any time you should have an incurable injury, disease, illness or condition verified
to be a terminal condition by two (2) medical doctors who have examined you, and where the
application of life-sustaining treatment of any kind would serve only to prolong your life,
and where a medical doctor determines that you will die within six months, whether or not
life-sustaining treatment is used, or you have been diagnosed as being persistently
unconscious, what authority do you want your health care
proxy to have?
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Terminal Condition
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| If I have a terminal condition, |
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Do you want to authorize your health care proxy to do other things on your behalf if you are
in a terminal condition?
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By law, your health care proxy can act on your behalf for the purpose of making health care
decisions only. DO NOT authorize your health care proxy to act for any other purpose.
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How many further authorizations do you wish to give to your proxy?
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(Note: Begin each of your authorizations with "I authorize my health care proxy to...")
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Persistently Unconscious
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| If I am persistently unconscious, |
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Do you want to authorize your health care proxy to do other things on your behalf if you are persistently
unconscious?
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By law, your health care proxy can act on your behalf for the purpose of making health care
decisions only. DO NOT authorize your health care proxy to act for any other purpose.
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How many further authorizations do you wish to give to your proxy?
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(Note: Begin each of your authorizations with "I authorize my health care proxy to...")
Admission to Nursing Homes or Community-Based Residential Facilities
Your agent is authorized to admit you to a nursing home or community-based residential facility
for short-term stays for recuperative care or respite care. If you want to authorize your agent
to admit you to a nursing home or community-based residential facility for purposes other than
recuperative care or respite care, check yes to the questions below. If you do NOT want to
authorize your agent to admit you to a nursing home or community-based residential facility
for purposes other than recuperative care or respite care, choose "No" to the questions below.
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Do you want to authorize your agent to admit you to a nursing home for a purpose
other than recuperative care or respite care?
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Do you want to authorize your agent to admit you to a community-based residential
facility for a purpose other than recuperative care or respite care?
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Provision of a Feeding Tube
Check "Yes" below to authorize your health care agent to have a feeding tube withheld or withdrawn
from you, unless your physician has advised that, in his or her professional judgment, this will cause
you pain or will reduce your comfort.
Check "No" below if you do NOT want to give your agent authority to have a feeding tube withheld or
withdrawn from you, unless the provision of the nutrition or hydration is medically contraindicated.
Yes
No
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Are you now or is there a possibility that you may become pregnant?
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Do you want to authorize your health care agent to make health care decisions
for you even if you are pregnant?
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Statement of Desires, Special Provisions or Limitations
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Do you have any other desires or concerns regarding your health care that
you want your health care agent to take notice of?
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Please type your further desires, concerns or limitations in the text box below:
Anatomical Gifts
Please check the statement that reflects your wishes regarding the donation of organs or parts
upon death.
Note: If this choice revokes a prior commitment that you have made to make an anatomical gift
to a designated donee, you must agree to attempt to notify the donee to which or to whom you
agreed to donate. (This note is not applicable if you choose not to make a statement about
anatomical gifts.)
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Please list the organs or parts you are willing to donate.
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Do you want to give your agent the power to make a Health Care Directive
on your behalf after you have become too ill to direct your own care?
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Do you want to authorize your agent to consent to the donation of all or any of your tissue
or organs for purposes of transplantation?
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Agent's Authority
Your agent's authority begins when you become incapable of directing your own health care.
During your incapacity your agent will be given access to your health records and will be authorized
to sign releases or other necessary documents on your behalf. At any time you are capable of making
your own decisions, you may do so. Your agent will not have authority to act for you in matters
unrelated to your health care.
Please make sure you have read the entire document (including the disclosure statement located at
the top of the document) before signing, to make sure your wishes are expressed the way you want them to be.
Deciding on Treatment
Health Care Instructions
There are two ways to give health care instructions in this document. You can make the following general statement:
I do not want my life to be prolonged by life support. I also do not want tube feeding as life support.
I want my doctors to allow me to die naturally if my doctor and another knowledgeable doctor confirm I am
[fatally ill];
OR
you can choose from a list of options that describe the kind of care you might want (or not want) in particular
circumstances. To make your choice, you place your initials beside the option that reflects your wishes.
The printed document will look like the sample below:
Here are my desires about my health care if my doctor and another knowledgeable doctor confirm that I am
in a medical condition described below:
1. Close to Death
If I am close to death and life support would only postpone the moment of my death:
A. INITIAL ONE:
____ I want to receive tube feeding.
____ I want tube feeding only as my physician recommends.
____ I DO NOT WANT tube feeding.
B. INITIAL ONE:
____ I want any other life support that may apply.
____ I want life support only as my physician recommends.
____ I want NO life support.
2. Permanently Unconscious
If I am unconscious and it is very unlikely that I will ever become conscious again:
A. INITIAL ONE:
____ I want to receive tube feeding.
____ I want tube feeding only as my physician recommends.
____ I DO NOT WANT tube feeding.
B. INITIAL ONE:
____ I want any other life support that may apply.
____ I want life support only as my physician recommends.
____ I want NO life support.
3. Advanced Progressive Illness
If I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and
permanently unable to communicate by any means, swallow food and water safely, care for myself and recognize
my family and other people, and it is very unlikely that my condition will substantially improve:
A. INITIAL ONE:
____ I want to receive tube feeding.
____ I want tube feeding only as my physician recommends.
____ I DO NOT WANT tube feeding.
B. INITIAL ONE:
____ I want any other life support that may apply.
____ I want life support only as my physician recommends.
____ I want NO life support.
4. Extraordinary Suffering
If life support would not help my medical condition and would make me suffer permanent and severe pain:
A. INITIAL ONE:
____ I want to receive tube feeding.
____ I want tube feeding only as my physician recommends.
____ I DO NOT WANT tube feeding.
B. INITIAL ONE:
____ I want any other life support that may apply.
____ I want life support only as my physician recommends.
____ I want NO life support.
5. General Instruction
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I do not want my life to be prolonged by life support. I also do not want tube feeding as life support.
I want my doctors to allow me to die naturally if my doctor and another knowledgeable doctor confirm I am in
any of the medical conditions listed in Items 1 to 4 above.
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If the form in the above sample does not suit your needs, you can list
extra conditions or instructions in the textbox below. Your words will
appear on the printed document in a separate section called Additional
Conditions or Instructions.
Pregnancy
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Is there a possibility that you are currently or may become pregnant in the 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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Anatomical Gifts
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Do you want to donate all or part of your body for research, education or transplantation after
your death?
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Do you want to donate your entire body after death?
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Please check the parts you wish to donate:
Please list the other parts you wish to donate:
| Is there a specific part or parts you do NOT want to donate? |
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Please list the parts you do NOT want to donate below:
Pregnancy
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Is there a possibility that you are currently or may become pregnant in the 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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Statement of Desires, Special Provisions, and Limitations Regarding Health Care Decisions
Terminal Condition
If you are in a terminal condition and are unable to direct your own health care, do you want
your agent to be able to direct your health care providers to discontinue life-support?
Permanent Unconsciousness
If you become permanently unconscious, do you want your agent to be able to direct your
health care providers to discontinue life-support?
Artificial Feeding
Situations can arise in which the only way to allow a patient to die would be to discontinue
artificial feeding (artificial nutrition and hydration). If you become terminally ill
and are unable to direct your own health care, do you want your agent to be able to direct
your health care providers to discontinue artificial feeding?
Note: If you choose not to indicate a preference, your agent will not be authorized to
have artificial feeding withdrawn from you.
Special Provisions
If you have any special instructions for your agent, or if you wish to impose certain restrictions,
please type them in the text box below:
Note: Start your sentences with "My agent shall ..." or
"I authorize my agent to ..." or "I do NOT authorize my agent to ..."
Please make sure you have read the disclosure statement located at the top of the document before signing.
Witnesses
In order for this document to be valid, you must sign it in the presence of 2 witnesses.
(If you are physically unable to sign, the
declaration
Declaration means a written, witnessed document
voluntarily executed by an adult person of sound
mind under Wisconsin Statutes, s. 154.03 (1), but is
not limited in form or substance to that provided in
s. 154.03 (2).
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must be signed in your name by one
of the witnesses or some other person at your express direction and in your presence; such
a proxy signing must either take place in the presence of 2 witnesses, or be acknowledged by
you in the presence of 2 witnesses.)
Your witnesses must NOT include any of the following people:
- Someone related to you by blood, marriage or adoption;
- A person with knowledge of being entitled to or having a claim on any portion of your estate;
- Someone who is directly financially responsible for your health care;
- A health care provider who is serving you;
- An employee, other than a chaplain or a social worker, of the health care provider; or
- An employee, other than a chaplain or a social worker, of an inpatient health care facility in which you are a patient.
NOTE: You are responsible for notifying your attending physician of the existence
of this declaration.
Definitions
Make sure you understand the following definitions:
"Terminal condition" means a condition from which there is no hope of
recovery, and is certified as terminal by two physicians, one of whom is your
attending physician, who have personally examined you and have determined that,
without the use of life-sustaining procedures, your death would likely occur within
a relatively short period of time.
"Permanent unconsciousness" means a profound state of unconsciousness caused by
disease, injury, poison, or other means and for which it has been determined that there
exists no reasonable expectation of regaining consciousness, and includes a permanent
and irreversible condition in which there is: (a) The absence of voluntary action or
cognitive behavior of any kind; and (b) an inability to communicate or interact purposefully
with the environment."
"Life Sustaining Treatment" 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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Statement of Desires
In this section you may indicate your desires regarding life-sustaining treatment, tube
feeding and the provision of comfort care if you are in a terminal
condition or are permanently unconscious.
Statement of Desires Regarding Life-sustaining Treatment
With respect to the use of life sustaining treatment, please choose
one of the following:
Type your directive in your own words below:
Statement of Desires Regarding Tube Feeding
With respect to the use of tube feeding (Nutrition and Hydration provided by means
of a nasogastric tube or tube into the stomach, intestines or veins), please choose
one of the following:
Statement of Desires Regarding Comfort Care
With respect to the provision of comfort care (pain relief), please choose
one of the following:
Translation Statement
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If English is not your language and you will be asking someone to
translate this document for you, choose Yes.
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Do not sign your document until you are satisfied that it has been
accurately translated and you fully understand its meaning.
Anatomical Gifts
| Do you want your agent to decide whether to donate parts of your body when you die? |
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Access to Records
Do you want your health care agent to be able to see your medical records?
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