Advance Health Care Directive
I, [Your full name], born [Your date of birth], residing at [Your address], being of sound mind and at least eighteen years of age, make this Advance Health Care Directive (the “Directive”) voluntarily. This Directive does two things. In Part 1, I name a health care agent to make decisions about my medical care if I cannot make or communicate them myself. In Part 2, I state my own instructions about the care I do and do not want, which my agent and my health care providers are to follow. I may complete either part or both. I intend this Directive to be honoured in every state I may be in, and I revoke any earlier advance directive, health care proxy or living will to the extent it is inconsistent with this one.
Part 1. Designation of Health Care Agent
1.1 Agent. I designate [Health care agent: name], my [Agent: relationship to you], of [Agent: address], telephone [Agent: phone], as my health care agent (the “Agent”) to make health care decisions for me as authorised in this Directive.
1.2 Alternates. If my Agent is not willing, able or reasonably available to act, I designate [First alternate agent: name], telephone [First alternate: phone], as my first alternate agent. If my first alternate is also not willing, able or reasonably available, I designate [Second alternate agent: name (or “None”)], telephone [Second alternate: phone (or “None”)], as my second alternate agent. An alternate who acts has every power given to my Agent.
1.3 Authority. My Agent may make all decisions about my health care that I could make myself, including consenting to, refusing or withdrawing any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition; selecting and discharging physicians and other providers; admitting me to or discharging me from any hospital, nursing home, hospice or other facility; and consenting to, refusing or withdrawing artificial nutrition and hydration and all other forms of life-sustaining treatment. My Agent’s authority is subject only to these limits: [Limits on your agent’s authority (or “None”)].
1.4 When authority begins. My Agent’s authority becomes effective: [When your agent’s authority takes effect]. If it becomes effective on a determination of incapacity, that determination shall be made in writing by my attending physician and shall be entered in my medical record. While I am able to make my own decisions, my own decisions control, and my Agent shall consult me and defer to me.
1.5 Agent’s duty. My Agent shall make decisions in accordance with my instructions in Part 2 and my other wishes to the extent known to my Agent. Where my wishes are not known, my Agent shall decide in accordance with what my Agent determines in good faith to be in my best interest, taking my personal, religious and moral values into account. My Agent has no liability for a decision made in good faith under this Directive.
1.6 Authority after death. My Agent may make anatomical gifts consistent with Part 3, authorise an autopsy, and direct the disposition of my remains, unless I have provided otherwise in a will or other signed writing.
1.7 Nomination of guardian. If a court ever needs to appoint a guardian or conservator of my person, I nominate my Agent, and if my Agent cannot serve, my alternates in the order named.
Part 2. Instructions for Health Care
2.1 Terminal condition. If my attending physician and one other physician determine that I have an incurable and irreversible condition that will result in my death within a relatively short time, and I am unable to make my own decisions, my instruction is: [If you have an incurable condition that will cause death soon].
2.2 Permanent unconsciousness. If two physicians determine to a reasonable degree of medical certainty that I am permanently unconscious and will not regain awareness, my instruction is: [If you are permanently unconscious].
2.3 Artificial nutrition and hydration. In the situations described in 2.1 and 2.2, my instruction about food and water supplied by tube or intravenously is: [Artificial nutrition and hydration (feeding tube)]. I understand that withholding or withdrawing it may result in my death from dehydration or malnutrition, and that the choice is mine to make.
2.4 Relief from pain. Whatever else I have chosen, I direct that treatment to relieve pain and discomfort be provided at all times, including medication that may hasten my death if that is the only way to keep me comfortable, subject to this choice: [Relief from pain]. I want to be kept clean, warm and free of pain, and to receive the kindness that any person deserves.
2.5 Other wishes. I add the following wishes, which are to be read together with the choices above and control over them where they are more specific: [Other wishes (or “None”)].
2.6 Interpretation. If any part of these instructions is unclear or does not fit the circumstances, my Agent shall interpret them in light of my known values, and my health care providers shall follow my Agent’s interpretation.
Part 3. Organ and Tissue Donation
On my death, my instruction about donation of my organs, tissues, eyes or parts is: [Organ and tissue donation]. Limits on the gift, or the purposes for which it may be used (transplantation, therapy, research or education): [Donation: limits or purposes (or “None”)]. If I have not limited the purposes, the gift may be used for any of them. If I have chosen to donate, my health care providers may maintain me on life support long enough to preserve the gift, and that period is not a prolongation of life for the purposes of Part 2.
Part 4. Primary Physician
I designate [Primary physician: name], telephone [Primary physician: phone], as my primary physician. If that physician is not willing, able or reasonably available to act, my Agent may designate another physician in consultation with my other health care providers.
Part 5. General Provisions
5.1 Release of medical information. I authorise every health care provider to disclose my protected health information, including my diagnosis, prognosis and treatment options, to my Agent and alternates for the purpose of carrying out this Directive, and I intend my Agent to be treated as my personal representative under the Health Insurance Portability and Accountability Act of 1996 and its regulations at 45 CFR §164.502(g). This authority is effective immediately, so that my Agent can determine whether my incapacity has arisen.
5.2 Revocation. I may revoke this Directive at any time while I am able to do so, in whole or in part, by a signed writing, by executing a new directive, or by telling my attending physician in person. If I have designated my spouse as Agent and our marriage is dissolved or annulled, the designation is revoked and my first alternate becomes my Agent unless I provide otherwise in writing.
5.3 Reliance and copies. A health care provider who acts in good faith reliance on this Directive, or on the decision of my Agent under it, is released from liability to me and my estate to the same extent as if I had made the decision myself. A photocopy, scan or electronically signed copy of this Directive has the same effect as the original.
5.4 Governing law; severability. This Directive is made under the laws of the State of [Governing law (state)]. I intend it to be honoured in any state as a directive validly executed under that state’s law or under the law of my domicile. If any provision is held invalid, the remaining provisions shall be given full effect.
5.5 Electronic signature. This Directive may be signed electronically, and the electronic execution record, timestamps and document fingerprints kept by the signing platform are evidence of execution. Where the law of my state requires a written signature, wet-ink witness signatures or a notarial acknowledgment, I intend to complete those formalities on a printed copy, and the printed copy so completed shall be my Directive.
Part 6. Signature and Statement of Witnesses
6.1 Signature of principal. I sign this Directive on the date shown in the execution record, having read it and understood it, freely and without duress or undue influence.
6.2 Statement of witnesses. Each witness, by signing below, declares that: (1) the person who signed this Directive is personally known to me or proved their identity to me by satisfactory evidence; (2) that person signed or acknowledged this Directive in my presence; (3) that person appears to be of sound mind and under no duress, fraud or undue influence; (4) I am at least eighteen years of age; (5) I am not the person appointed as Agent or alternate agent by this Directive; (6) I am not the principal’s attending physician, a health care provider who is treating the principal, or an employee or operator of a health care facility or residential care facility where the principal is a patient or resident; and (7) I signed this statement in the presence of the principal.
6.3 Additional statement. At least one of the witnesses further declares that I am not related to the principal by blood, marriage or adoption, and that to the best of my knowledge I am not entitled to any part of the principal’s estate on the principal’s death under a will now existing or by operation of law.
First witness: [First witness: name], of [First witness: address]. Second witness: [Second witness: name], of [Second witness: address].
Signatures
Principal (the person this directive is for) · First witness · Second witness