| The following is an example of a Health
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| | If I had a reasonable chance of recovery,
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| Care Directive (many people still refer
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| | and were temporarily unable to decide or
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| to this as a Living Will). Â Â It is
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| | speakfor myself, I would want:
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| broken down into 3 basic parts. 1)
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| | Â
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| Appointment of the Health Care Agent.Â
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| | ________________________________________
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| 2) Health Care Instructions. 3) Making
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| | _________________________________________
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| the Document Legal.  Like most legal
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| | _________________________________________
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| documents, it can be a bit confusing and
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| | _____________________
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| overwhelming. The purpose for making
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| | Â
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| this easily available to the public is
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| | Â
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| simple. To help people know what to
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| | If I were dying and unable to decide or
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| expect before contacting a lawyer and
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| | speak for myself, I would want:
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| having him or her draft a directive for
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| | Â
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| them.  Nobody likes thinking about
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| | ________________________________________
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| their demise or incapacity. However,
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| | _________________________________________
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| dealing with such issues is a necessary
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| | _________________________________________
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| part of life.Â
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| | _____________________
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| Â
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| | Â
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| This example should not be used as a
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| | Â
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| substitute for getting solid legal advice
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| | If I were permanently unconscious and
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| from a licensed attorney. Every
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| | unable to decide or speak for myself, I
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| individual is different. Please
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| | would want:
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| consult a lawyer in your area to discuss
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| | Â
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| your specific estate planning needs.
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| | ________________________________________
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| Â
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| | _________________________________________
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| Â
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| | _________________________________________
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| HEALTH CARE DIRECTIVE
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| | _____________________
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| Â
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| | Â
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| I, ___________________________________,
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| | Â
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| understand this document allows me to do
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| | Â
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| One or both of the following:
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| | Â
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| Â
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| | If I were completely dependent on others
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| PART I: Name another person (called the
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| | for my care and unable to decide or speak
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| health care agent) to make health care
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| | formyself, I would want: .....
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| decisions for me if I am unable to decide
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| | Â
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| or speak for myself. My health care agent
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| | ________________________________________
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| must make health care decisions for me
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| | _________________________________________
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| based on the instructions I provide in
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| | _________________________________________
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| this document (Part II), if any, the
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| | _____________________
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| wishes I have made known to him or her,
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| | Â
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| or must act in my best interest if I have
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| | Â
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| not made my health care wishes known.
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| | In all circumstances, my doctors will try
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| Â
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| | to keep me comfortable and reduce my
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| And/or
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| | pain. This is how I feel about pain
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| Â
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| | relief if it would affect my alertness or
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| PART II: Give health care instructions to
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| | if it could shorten my life:
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| guide others making health care decisions
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| | Â
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| for me. If I have named a health care
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| | ________________________________________
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| agent, these instructions are to be used
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| | _________________________________________
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| by the agent. These instructions may also
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| | _________________________________________
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| be used by my health care providers,
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| | _____________________
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| others assisting with my health care and
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| | Â
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| my family, in the event I cannot make
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| | Â
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| decisions for myself.
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| | There are other things that I want or do
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| Â
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| | not want for my health care, if possible:
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| Â
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| | Â
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| PART I: APPOINTMENT OF HEALTH CARE AGENT
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| | Who I would like to be my doctor:
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| Â
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| | Â
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| This is who I want to make health care
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| | ________________________________________
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| decisions for me if I am unable to decide
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| | _________________________________________
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| or speak for myself (I know I can
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| | _________________________________________
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| change my agent or alternate agent at any
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| | _____________________
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| time and I know I do not have to appoint
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| | Â
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| an agent or an alternate agent)
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| | Â
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| Â
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| | Â
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| NOTE: If you appoint an agent, you should
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| | Â
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| discuss this health care directive with
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| | Where I would like to live to receive
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| your agent and give your agent a copy. If
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| | health care:
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| you do not wish to appoint an agent, you
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| | Â
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| may leave Part I blank and go to Part II.
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| | ________________________________________
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| Â
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| | _________________________________________
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| Â
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| | _________________________________________
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| When I am unable to decide or speak for
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| | _____________________
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| myself, I trust and appoint
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| | Â
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| ___________________ to make health care
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| | Â
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| decisions for me. This person is called
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| | Â
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| my health care agent. Relationship of
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| | Where I would like to die and other
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| my health care agent to me:
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| | wishes I have about dying:
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| ___________________
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| | Â
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| Telephone number of my health care agent:
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| | ________________________________________
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| _________________________
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| | _________________________________________
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| Address of my health care agent:
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| | _________________________________________
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| _________________________
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| | _____________________
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| Â
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| | Â
|
| (OPTIONAL) APPOINTMENT OF ALTERNATE
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| | My wishes about donating parts of my body
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| HEALTH CARE AGENT: If my health care
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| | when I die:
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| agent is not reasonably available, I
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| | Â
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| trust and appoint _________________ to be
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| | ________________________________________
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| my health care agent instead.Â
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| | _________________________________________
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| Relationship of my alternate health care
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| | _________________________________________
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| agent to me:
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| | _____________________
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| ___________________________Telephone
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| | My wishes about what happens to my body
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| number of my alternate health care agent:
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| | when I die (cremation, burial):
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| ___________________________ Address of my
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| | Â
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| alternate health care agent:
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| | ________________________________________
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| ___________________________
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| | _________________________________________
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| Â
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| | _________________________________________
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| THIS IS WHAT I WANT MY HEALTH CARE AGENT
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| | _____________________
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| TO BE ABLE TO
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| | Â
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| DO IF I AM UNABLE TO DECIDE OR SPEAK FOR
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| | Â
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| MYSELF (I know I can change these
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| | Any other things:
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| choices)
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| | Â
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| Â
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| | ________________________________________
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| My health care agent is automatically
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| | _________________________________________
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| given the powers listed below in (A)
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| | _________________________________________
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| through (D).
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| | _____________________
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| My health care agent must follow my
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| | Â
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| health care instructions in this document
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| | Â
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| or any other instructions I have given to
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| | PART III: MAKING THE DOCUMENT LEGAL
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| my agent. If I have not given health care
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| | Â
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| instructions, then my agent must act in
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| | This document must be signed by me. It
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| my best interest. Whenever I am unable to
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| | also must either be verified by a notary
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| decide or speak for myself, my health
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| | public
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| care agent has the power to:
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| | (Option 1) OR witnessed by two witnesses
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| Â
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| | (Option 2). It must be dated when it is
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| (A) Make any health care decision for me.
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| | verified or witnessed.I am thinking
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| This includes the power to give, refuse,
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| | clearly, I agree with everything that is
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| orwithdraw consent to any care,
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| | written in this document, and I have made
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| treatment, service, or procedures. This
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| | this document willingly.
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| includes deciding whether to stop or not
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| | Â
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| start health care that is keeping me or
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| | Â
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| might keep me alive, and deciding about
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| | ___________________________________
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| intrusive mental health treatment.
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| | My Signature
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| Â
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| | Â Â
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| (B) Choose my health care providers.
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| | ___________________________________
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| Â
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| | Date signed:
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| (C) Choose where I live and receive care
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| | Â
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| and support when those choices relate to
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| | ___________________________________Â
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| myhealth care needs.
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| | Date of birth:
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| Â
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| | Â
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| (D) Review my medical records and have
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| | ___________________________________Â
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| the same rights that I would have to give
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| | Address:
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| mymedical records to other people.
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| | Â
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| Â
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| | Â
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| If I DO NOT want my health care agent to
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| | If I cannot sign my name, I can ask
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| have a power listed above in (A) through
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| | someone to sign this document for me.
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| (D) OR if I want to LIMIT any power in
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| | Â
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| (A) through (D), I MUST say that here:
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| | Â
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| Â
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| | ________________________________________
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| ________________________________________
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| | ____________
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| _____________________________
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| | Signature of the person who I asked to
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| Â
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| | sign this document for me.
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| My health care agent is NOT automatically
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| | Â
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| given the powers listed below in (1) and
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| | ________________________________________
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| (2). If I WANT my agent to have any of
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| | _______________
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| the powers in (1) and (2), I must INITIAL
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| | Printed name of the person who I asked to
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| the line in front of the power; then my
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| | sign this document for me.
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| agent WILL HAVE that power.
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| | Â
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| Â
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| | Â
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| ______Â Â (1)Â To decide whether to
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| | Option 1: Notary Public
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| donate any parts of my body, including
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| | Â
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| organs, tissues, and eyes, when I die.
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| | In my presence
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| Â
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| | on___________________________________
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| ______ (2)Â To decide what will happen
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| | (date),
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| with my body when I die (burial,
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| | _________________________________________
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| cremation).
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| | _ (name) acknowledged his/hersignature on
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| Â
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| | this document or acknowledged that he/she
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| If I want to say anything more about my
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| | authorized the person signing this
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| health care agent's powers or limits on
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| | document to sign on his/her behalf. I am
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| the powers, I can say it here:Â
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| | not named as a health care agent or
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| _________________________________________
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| | alternate health care agent in this
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| _______________________________
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| | document.
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| Â
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| | Â
|
| Â
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| | ________________________________________
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| Â
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| | __Â
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| Â
| |
| | (Signature of Notary)
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| PART II: HEALTH CARE INSTRUCTIONS
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| | Â (Notary Stamp)
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| Â
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| | Â
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| NOTE: Complete this Part II if you wish
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| | Â
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| to give health care instructions. If you
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| | Option 2: Two Witnesses
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| appointed an agent in Part I, completing
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| | Â
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| this Part II is optional but would be
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| | Two witnesses must sign. Only one of the
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| very helpful to your agent. However, if
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| | two witnesses can be a health care
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| you chose not to appoint an agent in Part
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| | provider or an employee of a health care
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| I, you MUST complete some or all of this
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| | provider giving direct care to me on the
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| Part II if you wish to make a valid
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| | day I sign this document.
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| health care directive.
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| | Â
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| Â
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| | Witness One:
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| These are instructions for my health care
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| | (i) In my presence on
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| when I am unable to decide or speak for
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| | _______________________ (date),
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| myself.
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| | ________________ (name) acknowledged his
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| These instructions must be followed (so
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| | her signature on this document or
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| long as they address my needs).
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| | acknowledged that he/she authorized the
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| Â
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| | person signing this document to sign on
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| THESE ARE MY BELIEFS AND VALUES ABOUT MY
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| | his/her behalf.
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| HEALTH CARE
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| | (ii) I am at least 18 years of age.
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| (I know I can change these choices or
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| | (iii) I am not named as a health care
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| leave any of them blank)
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| | agent or an alternate health care agent
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| Â
| |
| | in this document.
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| I want you to know these things about me
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| | (iv) If I am a health care provider or an
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| to help you make decisions about my
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| | employee of a health care provider giving
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| health care:
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| | directcare to the person listed above in
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| Â
| |
| | (A), I must initial this box: [Â Â ]
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| My goals for my health care:
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| | I certify that the information in (i)
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| _________________________________________
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| | through (iv) is true and correct.
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| _________________________________________
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| | Â
|
| _________________________________________
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| | ______________________________________Â
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| _____________________
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| | (Signature of Witness One)
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| Â
| |
| | Â
|
| Â
| |
| | Address:Â
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| Â
| |
| | _________________________________________
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| My fears about my health care:
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| | _________________________________________
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| _________________________________________
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| | _________________________________________
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| _________________________________________
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| | _____________________
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| _________________________________________
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| | Â
|
| _____________________
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| | Â
|
| Â
| |
| | Witness Two:
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| Â
| |
| | (i) In my presence on
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| My spiritual or religious beliefs and
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| | ________________________ (date),
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| traditions:
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| | _________________ (name) acknowledged his
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| _________________________________________
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| | her signature on this document or
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| _________________________________________
| |
| | acknowledged that he/she authorized the
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| _________________________________________
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| | person signing this document to sign on
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| _____________________
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| | his/her behalf.
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| Â
| |
| | (ii) I am at least 18 years of age.
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| Â
| |
| | (iii) I am not named as a health care
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| Â
| |
| | agent or an alternate health care agent
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| My beliefs about when life would be no
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| | in this document.
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| longer worth living:
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| | (iv) If I am a health care provider or an
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| Â
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| | employee of a health care provider giving
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| ________________________________________
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| | directcare to the person listed above in
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| _________________________________________
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| | (A), I must initial this box: [Â Â ]
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| _________________________________________
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| | I certify that the information in (i)
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| _____________________
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| | through (iv) is true and correct.
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| Â
| |
| | Â
|
| My thoughts about how my medical
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| | ________________________________________
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| condition might affect my family:
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| | ‚
|
| Â
| |
| | (Signature of Witness Two)
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| ________________________________________
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| | Â
|
| _________________________________________
| |
| | Address:
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| _________________________________________
| |
| | ________________________________________
|
| _____________________
| |
| | _________________________________________
|
| Â
| |
| | _________________________________________
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| THIS IS WHAT I WANT AND DO NOT WANT FOR
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| | _____________________
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| MY HEALTH CARE
| |
| | Â
|
| Â
| |
| | REMINDER: Keep this document with your
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| (I know I can change these choices or
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| | personal papers in a safe place (not in a
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| leave any of them blank)Â Many medical
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| | safe deposit box). Give signed copies to
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| treatments may be used to try to improve
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| | your doctors, family, close friends,
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| my medical condition or to prolong my
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| | health care agent, and alternate health
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| life. Examples include artificial
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| | care agent. Make sure your doctor is
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| breathing by a machine connected to a
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| | willing to follow your wishes. This
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| tube in the lungs, artificial feeding or
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| | document should be part of your medical
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| fluids through tubes, attempts to start a
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| | record at your physician's office and at
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| stopped heart, surgeries, dialysis,
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| | the hospital, home care agency, hospice,
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| antibiotics, and blood transfusions. Most
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| | or nursing facility where you receive
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| medical treatments can be tried for a
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| | your care.
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| while and then stopped if they do not
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| | Â
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| help. I have these views about my
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| | Some of this information was taken from
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| health care in these situations:Â
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| | Minnesota statute section 145C.16.Â
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| (Note: You can discuss general feelings,
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| | This should not be considered legal
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| specific treatments, or leave any of them
| |
| | advice, it is provided as a public
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| blank)
| |
| | service.
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| Â
| |
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|
