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Living Wills and Health Care Directives - What is Involved?

The following is an example of a Health CareÂ
Directive (many people still refer to this as
a Living Will). Â Â It is broken down____________________________________________
into 3 basic parts. 1) Appointment of_____________________________________________
the Health Care Agent. 2) Health Care_____________________________________________
Instructions. 3) Making the Document_________
Legal.  Like most legal documents,
it can be a bit confusing andÂ
overwhelming. The purpose for making
this easily available to the public isÂ
simple. To help people know what to
expect before contacting a lawyer and havingIf I were permanently unconscious and unable
him or her draft a directive for them.Âto  decide or speak for myself, I would want:
 Nobody likes thinking about their
demise or incapacity. However, dealingÂ
with such issues is a necessary part of
life.Â____________________________________________
_____________________________________________
Â_____________________________________________
_________
This example should not be used as a
substitute for getting solid legal adviceÂ
from a licensed attorney. Every
individual is different. Please consultÂ
a lawyer in your area to discuss your
specific  estate  planning  needs.Â
ÂÂ
ÂIf I were completely dependent on others for
my care and unable to decide or speak
HEALTH  CARE  DIRECTIVEformyself,  I  would  want:  .....
ÂÂ
I, ___________________________________,____________________________________________
understand this document allows me to do One_____________________________________________
or  both  of  the  following:_____________________________________________
_________
Â
Â
PART I: Name another person (called the
health care agent) to make health careÂ
decisions for me if I am unable to decide or
speak for myself. My health care agent mustIn all circumstances, my doctors will try to
make health care decisions for me based onkeep me comfortable and reduce my pain. This
the instructions I provide in this documentis how I feel about pain relief if it would
(Part II), if any, the wishes I have madeaffect my alertness or if it could shorten my
known to him or her, or must act in my bestlife:
interest if I have not made my health care
wishes  known.Â
Â____________________________________________
_____________________________________________
And/or_____________________________________________
_________
Â
Â
PART II: Give health care instructions to
guide others making health care decisions forÂ
me. If I have named a health care agent,
these instructions are to be used by theThere are other things that I want or do not
agent. These instructions may also be used bywant  for  my  health  care,  if  possible:
my health care providers, others assisting
with my health care and my family, in theÂ
event  I  cannot  make  decisions for myself.
Who  I  would  like  to  be  my  doctor:
Â
Â
Â
____________________________________________
PART  I:  APPOINTMENT  OF  HEALTH  CARE AGENT_____________________________________________
_____________________________________________
Â_________
This is who I want to make health careÂ
decisions for me if I am unable to decide or
speak for myself (I know I can changeÂ
my agent or alternate agent at any time and I
know I do not have to appoint an agent or anÂ
alternate  agent)
Â
Â
Where I would like to live to receive health
NOTE: If you appoint an agent, you shouldcare:
discuss this health care directive with your
agent and give your agent a copy. If you doÂ
not wish to appoint an agent, you may leave
Part  I  blank  and  go  to  Part  II.____________________________________________
_____________________________________________
Â_____________________________________________
_________
Â
Â
When I am unable to decide or speak for
myself, I trust and appointÂ
___________________ to make health care
decisions for me. This person is called myÂ
health care agent. Relationship of my
health  care agent to me: ___________________Where I would like to die and other wishes I
have  about  dying:
Telephone number of my health care agent:
_________________________Â
Address of my health care agent:____________________________________________
______________________________________________________________________
_____________________________________________
Â_________
(OPTIONAL) APPOINTMENT OF ALTERNATE HEALTHÂ
CARE AGENT: If my health care agent is not
reasonably available, I trust and appointMy wishes about donating parts of my body
_________________ to be my health care agentwhen  I  die:
instead. Relationship of my alternate
health care agent to me:Â
___________________________Telephone number
of my alternate health care agent:____________________________________________
___________________________ Address of my_____________________________________________
alternate health care agent:_____________________________________________
____________________________________
ÂMy wishes about what happens to my body when
I  die  (cremation,  burial):
THIS IS WHAT I WANT MY HEALTH CARE AGENT TO
BE  ABLE  TOÂ
DO IF I AM UNABLE TO DECIDE OR SPEAK FOR____________________________________________
MYSELF  (I  know  I can change these choices)_____________________________________________
_____________________________________________
Â_________
My health care agent is automatically givenÂ
the  powers  listed below in (A) through (D).
Â
My health care agent must follow my health
care instructions in this document or anyAny  other  things:
other instructions I have given to my agent.
If I have not given health care instructions,Â
then my agent must act in my best interest.
Whenever I am unable to decide or speak for____________________________________________
myself, my health care agent has the power_____________________________________________
to:_____________________________________________
_________
Â
Â
(A) Make any health care decision for me.
This includes the power to give, refuse,Â
orwithdraw consent to any care, treatment,
service, or procedures. This includesPART  III:  MAKING  THE  DOCUMENT  LEGAL
deciding whether to stop or not start health
care that is keeping me or might keep meÂ
alive, and deciding about intrusive mental
health  treatment.This document must be signed by me. It also
must  either  be  verified by a notary public
Â
(Option 1) OR witnessed by two witnesses
(B)  Choose  my  health  care  providers.(Option 2). It must be dated when it is
verified or witnessed.I am thinking clearly,
ÂI agree with everything that is written in
this document, and I have made this document
(C) Choose where I live and receive care andwillingly.
support when those choices relate to myhealth
care  needs.Â
ÂÂ
(D) Review my medical records and have the___________________________________
same rights that I would have to give
mymedical  records  to  other  people.My  Signature
  Ãƒâ€š
If I DO NOT want my health care agent to have___________________________________
a power listed above in (A) through (D) OR if
I want to LIMIT any power in (A) through (D),Date  signed:
I  MUST  say  that  here:
Â
Â
___________________________________Â
____________________________________________
_________________________Date  of  birth:
ÂÂ
My health care agent is NOT automatically___________________________________Â
given the powers listed below in (1) and (2).
If I WANT my agent to have any of the powersAddress:
in (1) and (2), I must INITIAL the line in
front of the power; then my agent WILL HAVEÂ
that  power.
Â
Â
If I cannot sign my name, I can ask someone
______Â Â (1)Â To decideto  sign  this  document  for  me.
whether to donate any parts of my body,
including organs, tissues, and eyes, when IÂ
die.
Â
Â
____________________________________________
______ (2)Â To decide what will happen________
with  my body when I die (burial, cremation).
Signature of the person who I asked to sign
Âthis  document  for  me.
If I want to say anything more about myÂ
health care agent's powers or limits on the
powers, I can say it here:Â____________________________________________
________________________________________________________
___________________________
Printed name of the person who I asked to
Âsign  this  document  for  me.
ÂÂ
ÂÂ
ÂOption  1:  Notary  Public
PART  II:  HEALTH  CARE  INSTRUCTIONSÂ
ÂIn my presence
on___________________________________ (date),
NOTE: Complete this Part II if you wish to__________________________________________
give health care instructions. If you(name) acknowledged his/hersignature on this
appointed an agent in Part I, completing thisdocument or acknowledged that he/she
Part II is optional but would be very helpfulauthorized the person signing this document
to your agent. However, if you chose not toto sign on his/her behalf. I am not named as
appoint an agent in Part I, you MUST completea health care agent or alternate health care
some or all of this Part II if you wish toagent  in  this  document.
make  a  valid  health  care  directive.
Â
Â
___________________________________________Ã
These are instructions for my health care‚
when I am unable to decide or speak for
myself.(Signature  of  Notary)
These instructions must be followed (so long  (Notary  Stamp)
as  they  address  my  needs).
Â
Â
Â
THESE ARE MY BELIEFS AND VALUES ABOUT MY
HEALTH  CAREOption  2:  Two  Witnesses
(I know I can change these choices or leaveÂ
any  of  them  blank)
Two witnesses must sign. Only one of the two
Âwitnesses can be a health care provider or an
employee of a health care provider giving
I want you to know these things about me todirect care to me on the day I sign this
help you make decisions about my health care:document.
ÂÂ
My goals for my health care:Witness  One:
_____________________________________________
_____________________________________________(i) In my presence on _______________________
_____________________________________________(date), ________________ (name) acknowledged
_________his/her signature on this document or
acknowledged that he/she authorized the
Âperson signing this document to sign on his
her  behalf.
Â
(ii)  I  am  at  least  18  years  of  age.
Â
(iii) I am not named as a health care agent
My fears about my health care:or an alternate health care agent in this
_____________________________________________document.
_____________________________________________
_____________________________________________(iv) If I am a health care provider or an
_________employee of a health care provider giving
directcare to the person listed above in (A),
ÂI  must  initial  this  box:  [Â Â ]
ÂI certify that the information in (i) through
(iv)  is  true  and  correct.
My spiritual or religious beliefs and
traditions:Â
_____________________________________________
___________________________________________________________________________________Â
_____________________________________________
_________(Signature  of  Witness  One)
ÂÂ
ÂAddress:Â
_____________________________________________
Â_____________________________________________
_____________________________________________
My beliefs about when life would be no longer_________
worth  living:
Â
Â
Â
____________________________________________
_____________________________________________Witness  Two:
_____________________________________________
_________(i) In my presence on
________________________ (date),
Â_________________ (name) acknowledged his/her
signature on this document or acknowledged
My thoughts about how my medical conditionthat he/she authorized the person signing
might  affect  my  family:this  document  to  sign  on  his/her behalf.
Â(ii)  I  am  at  least  18  years  of  age.
____________________________________________(iii) I am not named as a health care agent
_____________________________________________or an alternate health care agent in this
_____________________________________________document.
_________
(iv) If I am a health care provider or an
Âemployee of a health care provider giving
directcare to the person listed above in (A),
THIS IS WHAT I WANT AND DO NOT WANT FOR MYI  must  initial  this  box:  [Â Â ]
HEALTH  CARE
I certify that the information in (i) through
Â(iv)  is  true  and  correct.
(I know I can change these choices or leaveÂ
any of them blank)Â Many medical
treatments may be used to try to improve my________________________________________Â
medical condition or to prolong my life.
Examples include artificial breathing by a
machine connected to a tube in the lungs,(Signature  of  Witness  Two)
artificial feeding or fluids through tubes,
attempts to start a stopped heart, surgeries,Â
dialysis, antibiotics, and blood
transfusions. Most medical treatments can beAddress:
tried for a while and then stopped if they do
not help. I have these views about my____________________________________________
health care in these situations:Â (Note:_____________________________________________
You can discuss general feelings, specific_____________________________________________
treatments,  or  leave  any  of  them  blank)_________
ÂÂ
If I had a reasonable chance of recovery, andREMINDER: Keep this document with your
were temporarily unable to decide or speakforpersonal papers in a safe place (not in a
myself,  I  would  want:safe deposit box). Give signed copies to your
doctors, family, close friends, health care
Âagent, and alternate health care agent. Make
sure your doctor is willing to follow your
____________________________________________wishes. This document should be part of your
_____________________________________________medical record at your physician's office and
_____________________________________________at the hospital, home care agency, hospice,
_________or nursing facility where you receive your
care.
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Some of this information was taken from
If I were dying and unable to decide or speakMinnesota statute section 145C.16. This
for  myself,  I  would  want:should not be considered legal advice, it is
provided as a public service.



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