ADVANCE HEALTH CARE DIRECTIVE

This page is designed to make you aware of the importance of making your wishes known and to make it easier for you to put those wishes in writting.
Once you have read and completed the following form, check with your attorney to verify that it meets your state's requirements.

The states of CALIFORNIA, RHODE ISLAND, AND WISCONSIN require the use of their respective state-specific forms; these forms are offered as the "Living Will" and "Health Care Power of Attorney" documents.  In addition, the states of NEVADA, NEW HAMPSHIRE, OHIO, SOUTH CAROLINA, TENNESSEE, TEXAS, and VERMONT have unique statutory requirements regarding the form of "Living Will" and "Health Care Power of Attorney" documents.  The NORTH DAKOTA statute provides that the form provided in its statute is the "preferred form".  

DELAWARE
, KENTUCKY, MAINE, OKLAHOMA, OREGON, and VIRGINIA have adopted specific advance directive forms which are separate documents in the state selection menu.  KENTUCKY, OKLAHOMA, and OREGON require that their state-specific forms be used for an Advance Health Care Directive.
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ADVANCE HEALTH CARE DIRECTIVE

If I, ____________, of _______________., Miami, Florida 33100, am not able to make an informed decision regarding my health care, I direct that my instructions and wishes as stated in this document be followed.

 

1.  DESIGNATION OF AGENT.  I recognize that if I am unable to make an informed decision regarding my health care, it may become necessary for some other person to act on my behalf.  I designate:

 

Agent Name:                            _________________

Agent Address:                         _________________

                                                _________________

Phone:                                      _________________

Phone 2:                                   _________________

Relation, if any:                         _________________

 

as my Agent to make health care decisions for me, if I am not able to make an informed decision for myself, except to the extent that I state otherwise in this document.

By the use of the term "health care decision" I mean an informed decision to accept, maintain, discontinue or refuse any care, treatment, intervention, service or procedure to maintain, diagnose or treat my physical or mental condition, subject to any statement of my desires and any limitations included in this document.  

By the use of the term "health care" I mean all medical treatment, the provision, withholding or withdrawal of any health care or medical procedure, or service to maintain, diagnose, treat or provide for a patient's physical or mental health or personal care, unless such authority is otherwise limited by this document.
 

By the use of the term "Agent" I mean any health care decision-maker such as a Patient Advocate, Health Care Representative, Health Care Proxy, Power of Attorney for Health Care, or Health Care Surrogate.
 

2.  AUTHORITY OF AGENT.
  My Agent is authorized to make any and all health care decisions for me that may be deemed appropriate by my Agent, subject to my wishes and the limitations (if any) as stated in this document.  My Agent shall request and evaluate information concerning my medical diagnosis, the prognosis, the benefits and risks of the proposed health care, and alternatives to the proposed health care.  My Agent shall consider the decision that I would have made if I had the ability to do so.  If my Agent does not know my wishes regarding a specific health care decision, my Agent shall make a decision for me in accordance with what my Agent determines to be in my best interest.  In determining my best interest, my Agent shall consider my personal beliefs and basic values to the extent known to my Agent.  

My Agent must try to discuss health care decisions with me.  However, if I am unable to communicate, my Agent may make such decisions for me.
 

I authorize my Agent to:

a.     Request, receive and review any information, verbal or written, regarding my physical or mental health including medical and hospital records, and to consent to the disclosure of such records to others.

b.    Execute on my behalf any releases or other documents that may be required in order to obtain any information, verbal or written, regarding my physical or mental health.

c.     Make all necessary arrangements for health care services on my behalf, including the authority to select, employ and discharge health care providers.

d.    Make decisions regarding admission to or discharge from, even against medical advice, any health care facility or service.

e.     Sign any documents titled or purporting to be "Consent to Permit Treatment" or "Refusal to Permit Treatment", necessary waivers or releases from liability required by a hospital, physician, or other health care provider.

 
3.  EFFECTIVITY.  This document shall become effective immediately.  

4.  TERMINAL CONDITION.
  If I have a "terminal condition", I direct that my life not be extended by life-sustaining procedures; such procedures shall be withheld or withdrawn.  

By the use of the term "terminal condition", I mean that my death from an incurable or irreversible condition is imminent, and even if life-sustaining procedures are used there is no reasonable expectation of my recovery.
 

5.  COMA.
  If I am in a "permanent coma", I direct that my life not be extended by life-sustaining procedures; such procedures shall be withheld or withdrawn.  

By the use of the term "permanent coma", I mean that I am not conscious and am not aware of my environment, I show no behavioral response to the environment, I am not able to interact with others, and there is no reasonable expectation of my recovery within a medically appropriate period.
 

6.  
LIFE-SUSTAINING PROCEDURES.  By the use of the term "life-sustaining procedures", I mean any procedure, treatment, intervention, or other measure that has the primary effect of prolonging my life and is not necessary to provide for my comfort or freedom from pain.  

7.  ARTIFICIAL NUTRITION/HYDRATION. 
I DO NOT WANT to receive artificial nutrition or hydration if I have a terminal condition, except to the extent necessary to provide comfort for me and freedom from pain.  

By the use of the term "artificial nutrition or hydration", I mean food and fluids that are provided to me by artificial means such as a nasogastric tube or tube into the stomach, intestines or veins.
 

8. SPECIFIC MEDICAL PROCEDURES.
  Notwithstanding any other provision of this document, it is my general desire (i) to RECEIVE the following procedures or treatment that are so marked, if such procedures are deemed appropriate by my attending physician and any Agent that I may have designated to make health care decisions for me, and (ii) NOT TO RECEIVE the following procedures or treatment that are so marked, although such procedures are deemed appropriate by my attending physician.

 

RECEIVE

NOT TO RECEIVE

Artificial or mechanical respiration

 

 

Cardiopulmonary resuscitation

 

 

Any form of surgery or invasive diagnostic procedures

 

 

Kidney dialysis

 

 

Chemotherapy  


 

For any item that I have marked "RECEIVE", I do not wish to receive such procedure or treatment if I have a terminal condition, except to the extent necessary to provide comfort for me and freedom from pain.

9.  DONATION OF ORGANS.  I desire that no anatomical gifts be made from my body.   

10.  AUTOPSY. 
I do not consent to an autopsy.  

11.  NOMINATION OF GUARDIAN/CONSERVATOR.
  If it becomes necessary for a court to appoint a guardian or conservator of my person ("Conservator"), I designate ________________________________________________,
be appointed as the guardian or conservator of my person.  

If the person designated is unwilling or unable to serve as my Guardian/Conservator, I designate _________________________________________________________

No bond shall be required of my Guardian/Conservator in any jurisdiction.  Any decisions concerning my health care to be made by my Guardian or Conservator of my person shall be made in accordance with my directions as stated in this document.

By the use of the term "Guardian" or "Conservator of my person", I mean a person or entity appointed by a court to provide for my care and physical well-being.  Such term does NOT include the appointment of a person or entity to manage my financial affairs.  

12.  HOLD HARMLESS.
  All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, or my heirs for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them, except for willful misconduct or gross negligence.  

13.  SEVERABILITY.
  If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and thus the directions in this document are severable.  

If any provision is not legally enforceable, it is my intent that this document be taken as a formal statement of my wishes and desires concerning health care decisions, and the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
 

I hope that my health care providers and other persons responsible for my care will regard themselves as morally bound by these provisions.
 

I have read and understand the contents of this document.  I am emotionally and mentally competent to make this declaration.  It is my intention that this document be honored by my family and health care providers as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences from such refusal. 
 

Date:___________________

Signature
________________

Declarant Name: ________________________________     
 

Declarant Address: ______________________________     
                                                         

SSN
: ______________        

Birthdate: __________         

Under the penalty of perjury I declare that the Declarant and each witness signed this document in each other's presence.  Based upon my personal observation, the Declarant appears to be a competent individual, and is aware of the nature of this document.  The Declarant is personally known to me or has satisfactorily proven to be the person who voluntarily signed this document, and did not appear to be under or subject to any duress, fraud, constraint or undue influence.  To the best of my knowledge, I am not 

(1)     related to the Declarant by blood, marriage, or adoption,

(2)     designated as Agent or alternate Agent under this document,

(3)     entitled to any portion of the Declarant's estate according to the laws of intestate succession or under any will or codicil of the Declarant,

(4)     the attending physician of the Declarant or an employee of the attending physician or an owner, operator, officer, director, or employee of a hospital or care or residential facility in which the Declarant is a patient or resident,

(5)     an employee of the Declarant's life or health insurance provider,

(6)     directly financially responsible for the Declarant's medical care,

(7)     entitled to a present claim against any portion of the Declarant's estate, or

(8)     entitled to any financial benefit by reason of the death of the Declarant.

 

I am at least 19 years of age, and did not sign this document for the Declarant.

Witness Signature:                         ________________________________________

Witness Name:                              _________________________

Witness Address:                          ___________________________________

                                                     ___________________________________

                                                     ___________________________________

 

Date:                                             ________________________________________

 

Witness Signature:                         ________________________________________

Witness Name:                              _________________________

Witness Address:                          ___________________________________

                                                     ___________________________________

                                                     ___________________________________

 

Date:                                             ________________________________________