Living Wills and Health Care Directives - What is Involved?

The following is an example of a Health Carefeeding or fluids through tubes, attempts to start a
Directive (many people still refer to this as a Livingstopped heart, surgeries, dialysis, antibiotics, and
Will). Â Â It is broken down into 3blood transfusions. Most medical treatments can be
basic parts. 1) Appointment of the Healthtried for a while and then stopped if they do not
Care Agent. 2) Health Carehelp. I have these views about my health
Instructions. 3) Making the Documentcare in these situations: (Note: You can
Legal.  Like most legal documents, itdiscuss general feelings, specific treatments, or leave
can be a bit confusing and overwhelming.Âany of them blank)
The purpose for making this easily available to theÂ
public is simple. To help people know whatIf I had a reasonable chance of recovery, and were
to expect before contacting a lawyer and having himtemporarily unable to decide or speakfor myself, I
or her draft a directive for them. Âwould want:
Nobody likes thinking about their demise orÂ
incapacity. However, dealing with such issues_________________________________
is a necessary part of life.ÂÂ
ÂÂ
This example should not be used as a substitute forIf I were dying and unable to decide or speak for
getting solid legal advice from a licensedmyself, I would want:
attorney. Every individual isÂ
different. Please consult a lawyer in your_________________________________
area to discuss your specific estate planning needs.Â
ÂÂ
ÂIf I were permanently unconscious and unable to
HEALTH CARE DIRECTIVEdecide or speak for myself, I would want:
ÂÂ
I,_________________________________
___________________________________,Â
understand this document allows me to do One orÂ
both of the following:Â
ÂÂ
PART I: Name another person (called the health careIf I were completely dependent on others for my
agent) to make health care decisions for me if I amcare and unable to decide or speak formyself, I
unable to decide or speak for myself. My health carewould want: .....
agent must make health care decisions for me basedÂ
on the instructions I provide in this document (Part_________________________________
II), if any, the wishes I have made known to him orÂ
her, or must act in my best interest if I have notÂ
made my health care wishes known.In all circumstances, my doctors will try to keep me
Âcomfortable and reduce my pain. This is how I feel
And/orabout pain relief if it would affect my alertness or if it
Âcould shorten my life:
PART II: Give health care instructions to guide othersÂ
making health care decisions for me. If I have named_________________________________
a health care agent, these instructions are to be usedÂ
by the agent. These instructions may also be usedÂ
by my health care providers, others assisting with myThere are other things that I want or do not want
health care and my family, in the event I cannotfor my health care, if possible:
make decisions for myself.Â
ÂWho I would like to be my doctor:
ÂÂ
PART I: APPOINTMENT OF HEALTH CARE AGENT_________________________________
ÂÂ
This is who I want to make health care decisions forÂ
me if I am unable to decide or speak forÂ
myself (I know I can change my agent orÂ
alternate agent at any time and I know I do notWhere I would like to live to receive health care:
have to appoint an agent or an alternate agent)Â
Â_________________________________
NOTE: If you appoint an agent, you should discussÂ
this health care directive with your agent and giveÂ
your agent a copy. If you do not wish to appoint anÂ
agent, you may leave Part I blank and go to Part II.Where I would like to die and other wishes I have
Âabout dying:
ÂÂ
When I am unable to decide or speak for myself, I_________________________________
trust and appoint ___________________ toÂ
make health care decisions for me. This person isMy wishes about donating parts of my body when I
called my health care agent. Relationship ofdie:
my health care agent to me:Â
____________________________________________________
Telephone number of my health care agent:My wishes about what happens to my body when I
_________________________die (cremation, burial):
Address of my health care agent:Â
__________________________________________________________
ÂÂ
(OPTIONAL) APPOINTMENT OF ALTERNATEÂ
HEALTH CARE AGENT: If my health care agent isAny other things:
not reasonably available, I trust and appointÂ
_________________ to be my health care agent_________________________________
instead. Relationship of my alternate healthÂ
care agent to me:Â
___________________________TelephonePART III: MAKING THE DOCUMENT LEGAL
number of my alternate health care agent:Â
___________________________ Address ofThis document must be signed by me. It also must
my alternate health care agent:either be verified by a notary public
___________________________(Option 1) OR witnessed by two witnesses (Option
Â2). It must be dated when it is verified or witnessed.I
THIS IS WHAT I WANT MY HEALTH CARE AGENTam thinking clearly, I agree with everything that is
TO BE ABLE TOwritten in this document, and I have made this
DO IF I AM UNABLE TO DECIDE OR SPEAK FORdocument willingly.
MYSELF (I know I can change these choices)Â
ÂÂ
My health care agent is automatically given the___________________________________
powers listed below in (A) through (D).My Signature
My health care agent must follow my health care Â
instructions in this document or any other instructions___________________________________
I have given to my agent. If I have not given healthDate signed:
care instructions, then my agent must act in my bestÂ
interest. Whenever I am unable to decide or speak‚
for myself, my health care agent has the power to:Date of birth:
ÂÂ
(A) Make any health care decision for me. This‚
includes the power to give, refuse, orwithdrawAddress:
consent to any care, treatment, service, orÂ
procedures. This includes deciding whether to stop orÂ
not start health care that is keeping me or mightIf I cannot sign my name, I can ask someone to sign
keep me alive, and deciding about intrusive mentalthis document for me.
health treatment.Â
ÂÂ
(B) Choose my health care providers.________________
ÂSignature of the person who I asked to sign this
(C) Choose where I live and receive care anddocument for me.
support when those choices relate to myhealth careÂ
needs.___________________
ÂPrinted name of the person who I asked to sign this
(D) Review my medical records and have the samedocument for me.
rights that I would have to give mymedical recordsÂ
to other people.Â
ÂOption 1: Notary Public
If I DO NOT want my health care agent to have aÂ
power listed above in (A) through (D) OR if I wantIn my presence
to LIMIT any power in (A) through (D), I MUST say(date),
that here:_____ (name) acknowledged his/hersignature on this
Âdocument or acknowledged that he/she authorized
_________________________________the person signing this document to sign on his/her
Âbehalf. I am not named as a health care agent or
My health care agent is NOT automatically given thealternate health care agent in this document.
powers listed below in (1) and (2). If I WANT myÂ
agent to have any of the powers in (1) and (2), I______Â
must INITIAL the line in front of the power; then my(Signature of Notary)
agent WILL HAVE that power. (Notary Stamp)
ÂÂ
______Â Â (1)Â To decideÂ
whether to donate any parts of my body, includingOption 2: Two Witnesses
organs, tissues, and eyes, when I die.Â
ÂTwo witnesses must sign. Only one of the two
______ (2)Â To decide what will happenwitnesses can be a health care provider or an
with my body when I die (burial, cremation).employee of a health care provider giving direct care
Âto me on the day I sign this document.
If I want to say anything more about my health careÂ
agent's powers or limits on the powers, I can say itWitness One:
here:Â(i) In my presence on
__________________________________________________________ (date),
Â________________ (name) acknowledged his/her
Âsignature on this document or acknowledged that he
Âshe authorized the person signing this document to
Âsign on his/her behalf.
PART II: HEALTH CARE INSTRUCTIONS(ii) I am at least 18 years of age.
Â(iii) I am not named as a health care agent or an
NOTE: Complete this Part II if you wish to givealternate health care agent in this document.
health care instructions. If you appointed an agent in(iv) If I am a health care provider or an employee of
Part I, completing this Part II is optional but would bea health care provider giving directcare to the person
very helpful to your agent. However, if you choselisted above in (A), I must initial this box: [Â
not to appoint an agent in Part I, you MUSTÂ ]
complete some or all of this Part II if you wish toI certify that the information in (i) through (iv) is true
make a valid health care directive.and correct.
ÂÂ
These are instructions for my health care when I am_Â
unable to decide or speak for myself.(Signature of Witness One)
These instructions must be followed (so long as theyÂ
address my needs).Address:Â
Â_________________________________
THESE ARE MY BELIEFS AND VALUES ABOUT MYÂ
HEALTH CAREÂ
(I know I can change these choices or leave any ofWitness Two:
them blank)(i) In my presence on
Â________________________ (date),
I want you to know these things about me to help_________________ (name) acknowledged his
you make decisions about my health care:her signature on this document or acknowledged that
Âhe/she authorized the person signing this document
My goals for my health care:to sign on his/her behalf.
_________________________________(ii) I am at least 18 years of age.
Â(iii) I am not named as a health care agent or an
Âalternate health care agent in this document.
Â(iv) If I am a health care provider or an employee of
My fears about my health care:a health care provider giving directcare to the person
_________________________________listed above in (A), I must initial this box: [Â
ÂÂ ]
ÂI certify that the information in (i) through (iv) is true
My spiritual or religious beliefs and traditions:and correct.
_________________________________Â
Â___Â
Â(Signature of Witness Two)
ÂÂ
My beliefs about when life would be no longer worthAddress:
living:_________________________________
ÂÂ
_________________________________REMINDER: Keep this document with your personal
Âpapers in a safe place (not in a safe deposit box).
My thoughts about how my medical condition mightGive signed copies to your doctors, family, close
affect my family:friends, health care agent, and alternate health care
Âagent. Make sure your doctor is willing to follow your
_________________________________wishes. This document should be part of your medical
Ârecord at your physician's office and at the hospital,
THIS IS WHAT I WANT AND DO NOT WANT FORhome care agency, hospice, or nursing facility where
MY HEALTH CAREyou receive your care.
ÂÂ
(I know I can change these choices or leave any ofSome of this information was taken from Minnesota
them blank) Many medical treatments maystatute section 145C.16. This should not be
be used to try to improve my medical condition or toconsidered legal advice, it is provided as a public
prolong my life. Examples include artificial breathing byservice.
a machine connected to a tube in the lungs, artificial