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Health Care Directive

Create Your Living Will


Create Your Living Will

Do you want to appoint someone to make your health care decisions if you are unable to?


Frequently Asked Questions
What is a Living Will?A Living Will allows you to have a say in the type of health care treatment you receive should you find yourself unable to act for yourself. A Living Will is also commonly known as a Health Care Directive.What is a Medical Power of Attorney?A Medical Power of Attorney allows you to appoint someone to make health care decisions on your behalf should you find yourself unable to act for yourself.What is the difference between a Living Will and a Last Will and Testament?A Living Will deals with the type of health care treatment you will receive while alive. In contrast, a Last Will determines how your estate will be dispersed after you pass. Both documents are part of a strong estate plan.


Your Health Care Directive

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DURABLE HEALTH CARE POWER OF ATTORNEY

NOTE: YOU SHOULD USE THIS DOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE AGENT IF YOU ARE COMFORTABLE GIVING THAT PERSON BROAD AND SWEEPING POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU. THERE IS NO LEGAL REQUIREMENT THAT ANYONE EXECUTE A HEALTH CARE POWER OF ATTORNEY.

EXPLANATION: You have the right to name someone to make health care decisions for you when you cannot make or communicate those decisions. This form may be used to create a health care power of attorney. If you prepare your own health care power of attorney, you should be very careful to make sure it is consistent with North Carolina law.

This document gives the person you designate as your health care agent broad powers to make health care decisions for you when you cannot make the decision yourself or cannot communicate your decision to other people. You should discuss your wishes concerning life-prolonging measures, mental health treatment, and other health care decisions with your health care agent. Except to the extent that you express specific limitations or restrictions in this form, your health care agent may make any health care decision you could make yourself.

This form does not impose a duty on your health care agent to exercise granted powers, but when a power is exercised, your health care agent will be obligated to use due care to act in your best interests and in accordance with this document.

This Health Care Power of Attorney is intended to be valid in any jurisdiction in which it is presented, but places outside North Carolina may impose requirements that this form does not meet.
If you want to use this form, you must complete it, sign it, and have your signature witnessed by two qualified witnesses and proved by a notary public. Do not sign this form until two witnesses and a notary public are present to watch you sign it. You then should give a copy to your health care agent and to any alternates you name. You should consider filing it with the Advance Health Care Directive Registry maintained by the North Carolina Secretary of State.

I, _________________________, of ____________________________, ______________________________, North Carolina, being of sound mind, voluntarily create this Durable Health Care Power of Attorney.

PRIOR DESIGNATIONS
I revoke any prior Durable Health Care Power of Attorney.

APPOINTMENT OF HEALTH CARE AGENT
In the event that I have been determined to be incapable of providing informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my agent for health care decisions:

_______________________
_______________________
_______________________, North Carolina, __________
Telephone: ______________________________
Relationship: _______________________

AGENT'S AUTHORITY
My agent is authorized to act for me in all matters relating to my health care. My agent's powers include, but are not limited to:

  • Full power to consent, refuse consent, or withdraw consent to all medical, surgical, hospital and related health care treatments and procedures on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my agent by me;
  • Full power to make decisions on whether to provide, withhold, or withdraw artificial nutrition and hydration on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my agent by me;
  • Full power to review and receive any information regarding my physical or mental health, including medical and hospital records, in accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), and the American Recovery and Reinvestment Act of 2009 ("ARRA");
  • Full power to sign any releases in order to obtain this information;
  • Full power to sign any documents required to request, withdraw, or refuse treatment or to be released or transferred to another medical facility.

My agent does not have authority to act for me for any other purpose unrelated to my health care. All of my agent's actions under this power during any period when I am unable to make or communicate health care decisions have the same effect on my heirs, devisees and personal representatives as if I were competent and acting for myself.

WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE
The designation of my health care agent will become effective on my inability to make or communicate health care decisions as determined by my attending physician and will remain in effect until my death, or until I regain competence and revoke it.

AGENT'S OBLIGATIONS
My agent will make health care decisions for me in accordance with this document, and in accordance with any instructions I give in a Living Will, Health Care Directive or other such document (either included in this document or as a separate document), and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent will make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent will consider my personal values to the extent known to my agent.

NOMINATION OF CONSERVATOR OR GUARDIAN
If a conservator or guardian of my person needs to be appointed for me by a court, I nominate _______________________, the agent designated in this form. My nominated conservator or guardian is not required to post bond or security.

EFFECT OF COPY
A copy of this Durable Health Care Power of Attorney has the same effect as the original.

SEVERABILITY
If any part or parts of this Durable Health Care Power of Attorney is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of such part or parts shall not in any way affect the remaining parts, and this document shall be construed as though the invalid or illegal part or parts had never been included herein. But if the intent of this Durable Health Care Power of Attorney would be defeated by such construction, then it shall not be so construed.

SIGNATURE
This Durable Health Care Power of Attorney is made after careful reflection, while I am of sound mind. I am fully informed as to all contents of this document and understand the full import of this grant of powers to my agent. I fully understand that by signing this document, I will permit my agent to make health care decisions for me. I understand that my signature on this document gives my agent authority to provide, withhold, or withdraw consent to health care treatments or procedures on my behalf; to apply for public benefits to defray the cost of my health care; and to authorize my admission to or transfer from a health care facility. I further affirm that I am not signing this document as a condition of treatment or admission to a health care facility.

   

Signature:

_________________________

Name:

_________________________

Date:

____________________

Place:

____________________, North Carolina


STATEMENT OF WITNESSES

I hereby state that the principal, _________________________, being of sound mind, signed the foregoing health care power of attorney in my presence, and that I am not related to _________________________ by blood or marriage, and that I do not know or have a reasonable expectation that I would not be entitled to any portion of the estate of _________________________ under any existing will or codicil of _________________________ or as an heir under the Intestate Succession Act, if _________________________ died on this date without a will. I also state that I am not _________________________'s attending physician or mental health treatment provider, nor a licensed health care provider who is a paid employee of _________________________'s attending physician or mental health treatment provider, nor a paid employee of the health facility in which _________________________ is a patient, nor a paid employee of a nursing home or any adult care home where _________________________ resides. I further state that I do not have any claim against _________________________.


First witness

____________________________
(signature of witness)

____________________________
(print name)

_________________________________
(address)

________________________________
(city) (state)

___________________________
(date)


Second witness

____________________________
(signature of witness)

____________________________
(print name)

_________________________________
(address)

________________________________
(city) (state)

___________________________
(date)


STATE OF NORTH CAROLINA
COUNTY OF ___________________

CERTIFICATE

I, ______________________, a Notary Public for ___________ County, North Carolina, hereby certify that _________________________ appeared before me and swore to me and to the witnesses in my presence that this instrument is a health care power of attorney, and that her free act and deed for the purposes expressed in it.

I further certify that ____________________ and __________________, witnesses, appeared before me and swore that they witnessed _________________________ sign the attached health care power of attorney, believing her to be of sound mind; and also swore that at the time they witnessed the signing:

  1. they were not related within the third degree to _________________________ or her spouse;
  2. they did not know nor have a reasonable expectation that they would be entitled to any portion of her estate upon her death under any will or codicil thereto then existing or under the Intestate Succession Act as it provided at that time;
  3. they were not a physician or mental health treatment provider attending her, nor a licensed health care provider who is a paid employee of _________________________'s attending physician or mental health treatment provider, nor a paid employee of a health facility in which _________________________ was a patient, nor a paid employee of a nursing home or any adult care home in which _________________________ resided; and
  4. they did not have a claim against her.

I further certify that I am satisfied as to the genuineness and due execution of the instrument. This the ________ day of ________________, ________.

__________________________
Notary Public
My Commission Expires: ___________________



RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________  Date: ____________________
2. ____________________________________  Date: ____________________
3. ____________________________________  Date: ____________________
4. ____________________________________  Date: ____________________
5. ____________________________________  Date: ____________________


LIVING WILL DECLARATION

NOTE: YOU SHOULD USE THIS DOCUMENT TO GIVE YOUR HEALTH CARE PROVIDERS INSTRUCTIONS TO WITHOLD OR WITHDRAW LIFE-PROLONGING MEASURES IN CERTAIN SITUATIONS. THERE IS NO LEGAL REQUIREMENT THAT ANYONE EXECUTE A LIVING WILL

GENERAL INSTRUCTIONS: You can use this Living Will to give instructions for the future if you want your health care providers to withhold or withdraw life-prolonging measures in certain situations. You should talk to your doctor about what these terms mean. The Living Will states what choices you would have made for yourself if you were able to communicate. Talk to your family members, friends, and others you trust about your choices. Also, it is a good idea to talk with professionals such as your doctors, clergypersons, and lawyers before you complete and sign this Living Will.

If you create your own Living Will you need to be very careful to ensure that it is consistent with North Carolina law.

This Living Will is intended to be valid in any jurisdiction in which it is presented, but places outside North Carolina may impose requirements that this form does not meet.

If you want to use this form, you must complete it, sign it, and have your signature witnessed by two qualified witnesses and proved before a clerk or assistant clerk of superior court or by a notary public. Do not sign this form until two witnesses and a clerk or assistant clerk of superior court or a notary public are present to watch you sign it. You then should consider giving a copy to your primary physician and/or a trusted relative, and should consider filing it with the Advanced Health Care Directive Registry maintained by the North Carolina Secretary of State.

If I, _________________________, become incapacitated and am unable to direct my health care providers as to my own health care, I direct that this statement be read as a true reflection of my health care wishes.

DEFINITIONS
For the purposes of this document, the following definitions apply:

  1. "Artificially administered food and water" (or artificial nutrition and hydration) means the provision of nutrients or fluids by a tube inserted in vein, under the skin in the subcutaneous tissues, or in the stomach (gastrointestinal tract).
  2. "Attending physician" means the physician licensed by the state board of medicine, selected by or assigned to the patient, and who has primary responsibility for the treatment and care of the patient.
  3. "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 included.
  4. "Health care provider" or "provider" means any person licensed, certified, or otherwise authorized by law to administer health care in the ordinary course of business or practice of a profession.
  5. "Irreversible (Permanent) Coma" 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.
  6. "Life-prolonging procedure" (or "life-sustaining procedure") means any medical procedure, treatment, or intervention which sustains, restores, or supplants a spontaneous vital function. In this document 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.
  7. "Persistent vegetative state" means a permanent and irreversible condition in which there is:
          a. The absence of voluntary action or cognitive behavior of any kind.
          b. An inability to communicate or interact purposefully with the environment.
  8. "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.

MEDICAL DIRECTIONS AND END-OF-LIFE DECISIONS
I direct that my health care providers and others involved in my care, provide, withhold, or withdraw treatment in accordance with my directions below:

  1. If I have an incurable and irreversible (terminal) condition that will result in my death within a relatively short time, I direct that:
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.
  2. If I am diagnosed as being in an irreversible coma and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.
  3. If I am diagnosed as being in a persistent vegetative state and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that:
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.

PREGNANCY
Notwithstanding my other directions, if I am known to be pregnant, I do not want life-sustaining treatment, artificially provided nourishment or fluids and comfort care treatment, to be withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth with their continued application.


ADDITIONAL INSTRUCTIONS
I have no additional instructions. I understand that I may change the above-listed directives at any time by revoking this declaration and writing a new one.

EFFECT OF COPY
A copy of this Living Will Declaration has the same effect as the original.

SEVERABILITY
If any part or parts of this Living Will Declaration is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of such part or parts shall not in any way affect the remaining parts, and this document shall be construed as though the invalid or illegal part or parts had never been included herein. But if the intent of this Living Will Declaration would be defeated by such construction, then it shall not be so construed.

SIGNATURE
This document is made upon careful reflection. Options that I have considered and rejected are not printed above. I confirm that the health care directions contained herein were made after careful consideration and in full awareness of other options that may have been available to me. I declare that I am an adult in the State of North Carolina, that I understand the full import of this declaration, and that I am emotionally and mentally competent to give these directions.

Signed at ____________________, in the State of North Carolina, this ________ day of ________________, ________.

Signature:

_________________________

Name:

_________________________

Address:

____________________________

 

______________________________, North Carolina


STATEMENT OF WITNESSES

I hereby state that the declarant, _________________________, being of sound mind signed the above declaration in my presence and that I am not related to _________________________ by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of _________________________ under any existing will or codicil of _________________________ or as an heir under the Intestate Succession Act if _________________________ died on this date without a will. I also state that I am not _________________________'s attending physician or mental health treatment provider, nor a licensed health care provider who is a paid employee of _________________________'s attending physician or mental health treatment provider, nor a paid employee of a health facility in which _________________________ is a patient, nor a paid employee of a nursing home or any adult care home where _________________________ resides. I further state that I do not now have any claim against _________________________.

First witness

____________________________
(signature of witness)

_______________________
(print name)

____________________________
(address)

____________________________
(city) (state)

______________
(date)

Second witness

____________________________
(signature of witness)

_______________________
(print name)

____________________________
(address)

____________________________
(city) (state)

______________
(date)


CERTIFICATE

STATE OF NORTH CAROLINA
COUNTY OF ___________________

I, ________________________, Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for ______________ County hereby certify that _________________________ the declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is her Declaration of a Desire for a Natural Death, and that she had willingly and voluntarily made and executed it as her free act and deed for the purposes expressed in it.

I further certify that ______________________ and ________________________, witnesses, appeared before me and swore that they witnessed _________________________, declarant, sign the attached declaration, believing her to be of sound mind; and also swore that at the time they witnessed the declaration:

  1. they were not related within the third degree to _________________________ or to _________________________'s spouse;
  2. they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of _________________________ upon _________________________'s death under any will of _________________________ or codicil thereto then existing or under the Intestate Succession Act as it provides at that time;
  3. they were not a physician or mental health treatment provider attending _________________________, nor a licensed health care provider who is an employee of _________________________'s attending physician or mental health treatment provider, nor a paid employee of a health facility in which _________________________ was a patient, nor a paid employee of a nursing home or any adult care home in which _________________________ resided; and
  4. they did not have a claim against _________________________.

I further certify that I am satisfied as to the genuineness and due execution of the declaration.

This the ________ day of ________________, ________.

________________________________
Clerk (Assistant Clerk) of Superior Court
or Notary Public (circle one as appropriate)
for the County of __________________

My Commission Expires: _________________________________________


RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________  Date: ____________________
2. ____________________________________  Date: ____________________
3. ____________________________________  Date: ____________________
4. ____________________________________  Date: ____________________
5. ____________________________________  Date: ____________________

Health Care Directive

What is a Health Care Directive?

A directive allows you to plan your medical treatment in advance should there ever come a time when you are unable to express your personal health care wishes.

A Health Care Directive is also known as:

  • Advance Directive
  • Living Will Form
  • Advance Health Care Directive
  • Advance Medical Directive
  • Living Will
  • Advance Decision Form

What is a Medical Power of Attorney?

A Medical Power of Attorney is a document used to appoint someone to make medical decisions on your behalf.

A Medical Power of Attorney is also known as:

  • Health Care Power of Attorney
  • Health Care Proxy
  • Durable Power of Attorney for Health Care
  • Power of Attorney Medical

What is a Living Will?

A Living Will is a document that you use to indicate your medical wishes in the event you are incapacitated or cannot consent to your health care treatment.

Is a Living Will the same as a Health Care Directive?

Some states use the terms Living Will and Health Care Directive interchangeably, and some states use one term but not the other. Generally, a Living Will and a Health Care Directive both dictate your health care preferences in the event of a medical emergency or incapacitation.

A Health Care Directive may also be used to refer to a document that contains a Living Will and a Medical Power of Attorney. In addition, different states have varying requirements in what constitutes a Living Will or Health Care Directive.

It's important to check your state's laws regarding these documents to determine exactly which documents you need to express your wishes.

What is the difference between a Living Will and a Last Will and Testament?

If you are unable to express your health care wishes in the future, hospitals and family can reference your Living Will as a statement of your medical wishes.

Alternatively, a Last Will and Testament is a document used to indicate how you would like your assets divided or children cared for after your death. You cannot specify medical treatment preferences with a Last Will.

Why should I create a Health Care Directive?

Without a Health Care Directive, the burden of making your medical decisions falls on your family members. Creating a personal directive not only gives you control of your medical wishes but it saves your family from making tough treatment choices on your behalf.

Additionally, implementing a Medical Power of Attorney allows you to discuss your treatment wishes with someone you trust prior to any unforeseen medical circumstance so they can make health care decisions in your best interest.

What medical decisions can I make with a Living Will?

Every state has its own limits as to what you are legally permitted to include in your directive. While you may specify instructions for a variety of medical situations and describe your feelings towards quality of life, keep in mind that health care providers can only carry out certain procedures according to your state laws.

With LawDepot's Living Will template, you can make decisions regarding the following medical situations:

Terminal Illness or Injury

If you are terminally ill or injured, you can document which, if any, treatment options you would like to pursue.

Terminally ill or injured means that medical professionals have concluded that you have a condition that cannot be cured and that is expected to result in limited life expectancy.

Life Support

You can specify whether you would like to receive any form of life support in the event of a medical emergency.

Life support means any life-sustaining procedures done to a patient to restore function to an organ through medical intervention.

Common forms of life support include CPR (Cardiopulmonary Resuscitation), defibrillators, assisted breathing, dialysis, and artificially administered food and water.

DNR stands for "Do Not Resuscitate", which means you do not wish to receive life support or resuscitation if an organ fails.

Permanent Unconsciousness

You can address which, if any, treatments you would like to receive in the event of permanent unconsciousness, such as a coma or persistent vegetative state.

Permanent unconsciousness is when there is a reasonable degree of medical certainty that the patient can no longer think, feel, knowingly move, or be aware that they are alive, and there is no hope for improvement.

When does my Health Care Directive come into effect?

The terms of your directive are binding once you sign the document. It comes into use when you have been found to be incapable of making your own medical decisions. Typically, this may be when you are incapacitated, in a coma, or in a vegetative state.

Can I make changes to my Health Care Directive?

You can make changes to your personal directive if you destroy your current one, notify your health care representative or hospital of your changes, and create and distribute a new directive. It's important to let everyone in your family know where you keep your advance directive so they can easily find it during an emergency.

Related Documents:

  • Power of Attorney: a document used to grant someone the authority to act on your behalf, such as tending to your finances or maintaining property
  • Last Will and Testament: a document specifying how you would like your estate divided upon your death
  • Child Medical Consent: a form granting a guardian the authorization to make medical decisions on behalf of your child
  • Medical Records Release: a form requesting your medical records be released to you or a third party
  • End-of-Life Plan: a document used to outline your wishes regarding memorial services or how you want your remains to be taken care of

Related Articles:

Frequently Asked Questions:

Health Care Directive FAQ
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