Chat Room
04-10-2009, 02:01 PM
below is a copy of the advance directive i executed on myself. take the time to do one, JUST IN CASE.
ymmv as to your state laws and the laws of countries other than the united states. i am under the belief, however, that these directives will be upheld in almost all states.
and, as always, this is not legal advice and i am not your lawyer.
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I, My Name, of Mycounty, Mystate, appoint the person named below to be my health care agent to make health and personal care decisions for me.
Effective immediately and continuously until my death or revocation by a writing signed by me or someone authorized to make health care treatment decisions for me, I authorize all health care providers or other covered entities to disclose to my health care agent, upon my agent's request, any information, oral or written, regarding my physical or mental health, including, but not limited to, medical and hospital records and what is otherwise private, privileged, protected or personal health information, such as health information as defined and described in the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat. 1936), the regulations promulgated thereunder and any other State or local laws and rules. Information disclosed by a health care provider or other covered entity may be redisclosed and may no longer be subject to the privacy rules provided by 45 C.F.R. ç 164.
The remainder of this document will take effect when and only when I lack the ability to understand, make or communicate a choice regarding a health or personal care decision as verified by my attending physician. My health care agent may not delegate the authority to make decisions.
MY HEALTH CARE AGENT HAS ALL OF THE FOLLOWING POWERS SUBJECT TO THE HEALTH CARE TREATMENT INSTRUCTIONS THAT FOLLOW:
1. To authorize, withhold or withdraw medical care and surgical procedures.
2. To authorize, withhold or withdraw nutrition (food) or hydration (water) medically supplied by tube through my nose, stomach, intestines, arteries or veins.
3. To authorize my admission to or discharge from a medical, nursing, residential or similar facility and to make agreements for my care and health insurance for my care, including hospice and/or palliative care.
4. To hire and fire medical, social service and other support personnel responsible for my care.
5. To take any legal action necessary to do what I have directed.
6. To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order, including an out-of-hospital DNR order, and sign any required documents and consents.
APPOINTMENT OF HEALTH CARE AGENT
I appoint the following health care agent:
Health Care Agent: Name of person
Address: Address of person
Telephone Number: Telephone of person
If my health care agent is not readily available or if my health care agent is my spouse and an action for divorce is filed by either of us after the date of this document, I appoint the person or persons named below in the order named.
First Alternative Health Care Agent:
Address:
Telephone Number:
E-MAIL:
NEW PAGE
Second Alternative Health Care Agent:
Address:
Telephone Number:
GUIDANCE FOR HEALTH CARE AGENT
GOALS
If I have an end-stage medical condition or other extreme irreversible medical condition, my goals in making medical decisions are as follows:
1. Comfort/care
2. Preservation of mental function
SEVERE BRAIN DAMAGE OR BRAIN DISEASE
If I should suffer from severe and irreversible brain damage or brain disease with no realistic hope of significant recovery, I would consider such a condition intolerable and the application of aggressive medical care to be burdensome.
I therefore request that my health care agent respond to any intervening (other and separate) life-threatening conditions in the same manner as directed for an end-stage medical condition or state of permanent unconsciousness as I have indicated below.
Initials________
HEALTH CARE TREATMENT INSTRUCTIONS IN THE EVENT OF END-STAGE MEDICAL CONDITION OR PERMANENT UNCONSCIOUSNESS (LIVING WILL)
The following health care treatment instructions exercise my right to make my own health care decisions. These instructions are intended to provide clear and convincing evidence of my wishes to be followed when I lack the capacity to understand, make, or communicate my treatment decisions:
If I have an end-stage medical condition (which will result in my death, despite the introduction or continuation of medical treatment) or am permanently unconscious such as in an irreversible coma or irreversible vegetative state and there is no realistic hope of significant recovery, all of the following apply:
1. I direct that I be given health care treatment to relieve pain or provide comfort even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit forming.
2. I direct that all life prolonging procedures be withheld or withdrawn.
3. I specifically do not want any of the following as life prolonging procedures:
a. Heart-lung resuscitation (CPR)
b. Mechanical ventilator (breathing machine)
c. Dialysis (kidney machine)
d. Surgery
e. Chemotherapy radiation treatment
f. Antibiotics
NEW PAGE
4. I do not want nutrition (food) or hydration (water) medically supplied by a tube into my nose, stomach, intestine, arteries, or veins if I have an end-stage medical condition or am permanently unconscious and there is no realistic hope of significant recovery.
HEALTH CARE AGENT'S USE OF INSTRUCTIONS
_____My health care agent must follow these instructions.
LEGAL PROTECTION
Mystate law protects my health care agent and health care providers from any legal liability for their good faith actions in following my wishes as expressed in this form or in complying with my health care agent's direction. On behalf of myself, my executors and heirs, I further hold my health care agent and my health care providers harmless and indemnify them against any claim for their good faith actions in recognizing my health care agent's authority or in following my treatment instructions.
ORGAN DONATION
_____ I consent to donate my organs and tissues at the time of my death for the purpose of transplant, medical study or education.
Having carefully read this document, I have signed it this ____ day of ______________, 20__, revoking all previous health care powers of attorney and health care treatment instructions.
SIGNED: ___________________________________________________
WITNESS: __________________________________________________
WITNESS: __________________________________________________
NEW PAGE
NOTARIZATION
On this _____day of _________________, 20____, before me personally appeared the aforesaid declarant and principal, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County of________________, State of______________________ the day and year first above written.
Notary Public
My commission expires ______________________
ymmv as to your state laws and the laws of countries other than the united states. i am under the belief, however, that these directives will be upheld in almost all states.
and, as always, this is not legal advice and i am not your lawyer.
*******************************************************************************************************
DURABLE HEALTH CARE POWER OF ATTORNEY
I, My Name, of Mycounty, Mystate, appoint the person named below to be my health care agent to make health and personal care decisions for me.
Effective immediately and continuously until my death or revocation by a writing signed by me or someone authorized to make health care treatment decisions for me, I authorize all health care providers or other covered entities to disclose to my health care agent, upon my agent's request, any information, oral or written, regarding my physical or mental health, including, but not limited to, medical and hospital records and what is otherwise private, privileged, protected or personal health information, such as health information as defined and described in the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat. 1936), the regulations promulgated thereunder and any other State or local laws and rules. Information disclosed by a health care provider or other covered entity may be redisclosed and may no longer be subject to the privacy rules provided by 45 C.F.R. ç 164.
The remainder of this document will take effect when and only when I lack the ability to understand, make or communicate a choice regarding a health or personal care decision as verified by my attending physician. My health care agent may not delegate the authority to make decisions.
MY HEALTH CARE AGENT HAS ALL OF THE FOLLOWING POWERS SUBJECT TO THE HEALTH CARE TREATMENT INSTRUCTIONS THAT FOLLOW:
1. To authorize, withhold or withdraw medical care and surgical procedures.
2. To authorize, withhold or withdraw nutrition (food) or hydration (water) medically supplied by tube through my nose, stomach, intestines, arteries or veins.
3. To authorize my admission to or discharge from a medical, nursing, residential or similar facility and to make agreements for my care and health insurance for my care, including hospice and/or palliative care.
4. To hire and fire medical, social service and other support personnel responsible for my care.
5. To take any legal action necessary to do what I have directed.
6. To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order, including an out-of-hospital DNR order, and sign any required documents and consents.
APPOINTMENT OF HEALTH CARE AGENT
I appoint the following health care agent:
Health Care Agent: Name of person
Address: Address of person
Telephone Number: Telephone of person
If my health care agent is not readily available or if my health care agent is my spouse and an action for divorce is filed by either of us after the date of this document, I appoint the person or persons named below in the order named.
First Alternative Health Care Agent:
Address:
Telephone Number:
E-MAIL:
NEW PAGE
Second Alternative Health Care Agent:
Address:
Telephone Number:
GUIDANCE FOR HEALTH CARE AGENT
GOALS
If I have an end-stage medical condition or other extreme irreversible medical condition, my goals in making medical decisions are as follows:
1. Comfort/care
2. Preservation of mental function
SEVERE BRAIN DAMAGE OR BRAIN DISEASE
If I should suffer from severe and irreversible brain damage or brain disease with no realistic hope of significant recovery, I would consider such a condition intolerable and the application of aggressive medical care to be burdensome.
I therefore request that my health care agent respond to any intervening (other and separate) life-threatening conditions in the same manner as directed for an end-stage medical condition or state of permanent unconsciousness as I have indicated below.
Initials________
HEALTH CARE TREATMENT INSTRUCTIONS IN THE EVENT OF END-STAGE MEDICAL CONDITION OR PERMANENT UNCONSCIOUSNESS (LIVING WILL)
The following health care treatment instructions exercise my right to make my own health care decisions. These instructions are intended to provide clear and convincing evidence of my wishes to be followed when I lack the capacity to understand, make, or communicate my treatment decisions:
If I have an end-stage medical condition (which will result in my death, despite the introduction or continuation of medical treatment) or am permanently unconscious such as in an irreversible coma or irreversible vegetative state and there is no realistic hope of significant recovery, all of the following apply:
1. I direct that I be given health care treatment to relieve pain or provide comfort even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit forming.
2. I direct that all life prolonging procedures be withheld or withdrawn.
3. I specifically do not want any of the following as life prolonging procedures:
a. Heart-lung resuscitation (CPR)
b. Mechanical ventilator (breathing machine)
c. Dialysis (kidney machine)
d. Surgery
e. Chemotherapy radiation treatment
f. Antibiotics
NEW PAGE
4. I do not want nutrition (food) or hydration (water) medically supplied by a tube into my nose, stomach, intestine, arteries, or veins if I have an end-stage medical condition or am permanently unconscious and there is no realistic hope of significant recovery.
HEALTH CARE AGENT'S USE OF INSTRUCTIONS
_____My health care agent must follow these instructions.
LEGAL PROTECTION
Mystate law protects my health care agent and health care providers from any legal liability for their good faith actions in following my wishes as expressed in this form or in complying with my health care agent's direction. On behalf of myself, my executors and heirs, I further hold my health care agent and my health care providers harmless and indemnify them against any claim for their good faith actions in recognizing my health care agent's authority or in following my treatment instructions.
ORGAN DONATION
_____ I consent to donate my organs and tissues at the time of my death for the purpose of transplant, medical study or education.
Having carefully read this document, I have signed it this ____ day of ______________, 20__, revoking all previous health care powers of attorney and health care treatment instructions.
SIGNED: ___________________________________________________
WITNESS: __________________________________________________
WITNESS: __________________________________________________
NEW PAGE
NOTARIZATION
On this _____day of _________________, 20____, before me personally appeared the aforesaid declarant and principal, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County of________________, State of______________________ the day and year first above written.
Notary Public
My commission expires ______________________