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Living Wills and Health Care Directives - What is Involved?

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




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