Advanced health care directive living will and health care proxy

This Advanced Health Care Directive (Living Will and Health Care Proxy) is intended to

be used by an individual to express his or her intentions regarding whether or not life-

sustaining procedures are to be utilized in the event he or she becomes incapacitated.

The document provides for the appointment of a Health Care Proxy in case the

individual is unable to speak for himself/herself either because he/she is terminally ill,

injured, or comatose. It contains numerous standard clauses as well as optional

provisions to fit the specific wishes of the individual. This is a useful estate planning tool

that can determine what actions will be taken when an individual becomes

incapacitated.

© Copyright 2012 Docstoc Inc. 2

ADVANCED HEALTH CARE DIRECTIVE

(Living Will and Health Care Proxy)

1. LIVING WILL

I, ________________ [Instruction: Insert the name of person making the direction], being of

sound mind, would like to make and express the following wishes known. I direct that my family, my

doctors and health care workers, and all others follow such directions I am writing down in this

document. I know that at any time I can change my mind about these directions by tearing up this

form and writing a new one. I can also do away with these directions by tearing them up and by

telling some adult person of my wishes and asking him/ her to write them down as per my

instructions.

I understand that these directions will only be used in case I am not being able to speak for myself.

a. If I become terminally ill or injured

Terminally ill or injured is when my doctor and another doctor decide that I have a condition that

cannot be cured and that I will likely die in the near future from this condition.

i. Life sustaining treatment

Life sustaining treatment includes drugs, machines, or medical procedures that would keep

me alive, but would not cure me. I know that even if I choose not to have life sustaining

treatment, I will still get medicines and treatments that ease my pain and keep me

comfortable.

[Instruction: Insert your initial by either “Yes” or “No” in the appropriate box]

I want to have life sustaining treatment if I am terminally ill or injured.

____ Yes

____ No

ii. Artificially provided Food and Hydration (food and water through a tube). I understand

that if I am terminally ill or injured I may need to be given food and water through a tube to

keep me alive if I can no longer chew or swallow on my own or with someone helping me.


I want to have food and water provided through a tube if I am terminally ill or injured.


____ Yes

____ No

b. If I Become Permanently Unconscious.

Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable

degree of medical certainty, I can no longer think, feel anything, knowingly move, or be aware of

being alive. They believe this condition will last indefinitely without hope for improvement and

have watched me long enough to make that decision. I understand that at least one of these

doctors must be qualified to make such a diagnosis.

i. Life sustaining treatment. Life sustaining treatment includes drugs, machines, or other

medical procedures that would keep me alive, but would not cure me. I know that even if I

choose not to have life sustaining treatment, I will still get medicines and treatments that ease

my pain and keep me comfortable.


I want to have life-sustaining treatment if I am permanently unconscious.

____ Yes

____ No

ii. Artificially provided Food and Hydration (Food and water through a tube). I understand

that if I become permanently unconscious, I may need to be given food and water through a

tube to keep me alive if I can no longer chew or swallow on my own or with someone helping

me.


I want to have food and water provided through a tube if I am permanently unconscious.

____ Yes

____ No


Other Directions: [Instruction: Choose any one clause as applicable]

In addition to the directions I have listed on this form, I also want the following:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________

[Instruction: Choose this clause if you want to insert any other things you want done or not

done]

OR

If you do not have other directions, place your initials here:

____ No, I do not have any other directions. [Instruction: Choose this clause by placing your initial

if you do not have other directions]

2. IF I NEED SOMEONE TO SPEAK FOR ME.

This form can be used in the State of ________________ to name a person you would like to make

medical or other decisions for you if you become too sick to speak for yourself. This person is called

a Health Care Proxy. You do not have to name a Health Care Proxy. The directions in this form will

be followed even if you do not name a Health Care Proxy.

[Instruction: Insert your initials by giving only one answer as per applicable]

_____ I do not want to name a health care proxy.

[Instruction: If you check this answer, refer to Section 3]

_____ I want the person listed below to be my Health Care Proxy. I have talked with this person

about my wishes.

First choice for Health Care Proxy: _______________________________

[Instruction: Insert the name of first choice for health care proxy]


Relationship to me: ___________________________________

[Instruction: Insert the relationship of the health care proxy with the person making this

instrument]

Address: ___________________________________________________________________

[Instruction: Insert the address of first choice of health care proxy]

Phone number: ___________________________

[Instruction: Insert the contact number of first choice for health care proxy]

If this person is not able, not willing, or not available to be my Health Care Proxy, this is my next

choice:

Second choice for Health Care Proxy: _______________________________

[Instruction: Insert the name of second choice for health care proxy]

Relationship to me: ___________________________________

[Instruction: Insert the relationship of the second health care proxy with the person making this

instrument]

Address: ___________________________________________________________________

[Instruction: Insert the address of second choice of health care proxy]

Phone number: ___________________________

[Instruction: Insert the contact number of second choice for health care proxy]

Instructions for Health Care Proxy:



I want my Health Care Proxy to make decisions about whether to give me food and water through a

tube.

____ Yes

____ No

[Instruction: Insert your initials by giving only one answer as per applicable]

____ I want my Health Care Proxy to follow only the directions as listed on this form.

____ I want my Health Care Proxy to follow my directions as listed on this form and to make any

decisions about things I have not covered in the form.

____ I want my Health Care Proxy to make the final decision, even though it could mean doing

something different from what I have listed on this form.

3. THE THINGS LISTED ON THIS FORM ARE WHAT I WANT.

I understand the following:

a. If my doctor or hospital does not want to follow the directions I have listed, they must see that I

get to a doctor or hospital that will follow my directions.

b. If I am pregnant, or if I become pregnant, the choices I have made on this form will not be

followed until after the birth of the baby.

c. If the time comes for me to stop receiving life sustaining treatment or food and water through a

tube, I direct that my doctor talk about the good and bad points of doing this, along with my

wishes, with my Health Care Proxy, if I have one, and with the following people:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

__________________________________________________________________


4. MY SIGNATURE

Your name: _____________________ [Instruction: Insert your name]

The month, day, and year of your birth: ____ [Month] ____ [Date] ____ [Year]

Your signature: _____________________ [Instruction: Insert your signature]

Date signed: ____ [Month] ____ [Date] ____ [Year]


5. WITNESSES:

I am witnessing this form because I believe this person to be of sound mind. I did not sign the

person’s signature, and I am not the Health Care Proxy. I am not related to the person by blood,

adoption, or marriage and not entitled to any part of his or her estate. I am not directly responsible for

paying for his or her medical care.

____________________________________

[Instruction: Insert signature of Witness#1]

_______________________________________________

[Instruction: Insert printed/typed name of Witness#1]

____ [Month] ____ [Date], 20____

____________________________________

[Instruction: Insert signature of Witness#2]

_______________________________________________

[Instruction: Insert printed/typed name of Witness#2]

____ [Month] ____ [Date], 20____

6. SIGNATURE OF HEALTH CARE PROXY

I, ____________________________ [Instruction: Insert the name of health care proxy], am

willing to serve as the Health Care Proxy.


______________________________________________

[Instruction: Insert the signature of health care proxy]

____ [Month] ____ [Date], 20____


Signature of Second Choice for Health Care Proxy:

I, ____________________________ [Instruction: Insert the name of second choice for health

care proxy], am willing to serve as the Health Care Proxy if the first choice cannot serve.

_____________________________________________________________

[Instruction: Insert the signature of second choice for health care proxy]

____ [Month] ____ [Date], 20____


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Advanced health care directive living will and health care proxy