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Personal Documents and Forms - Living Will
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DESIGNATION OF HEALTH CARE SURROGATE

I, _________________________, of ____________________________, ______________________________, $state, being of sound mind, voluntarily create this Designation of Health Care Surrogate.

PRIOR DESIGNATIONS
I revoke any prior Designation of Health Care Surrogate.

APPOINTMENT OF HEALTH CARE SURROGATE
In the event that I have been determined to be incapable of providing informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care decisions:

_______________________
_______________________
_______________________, $state, _______________________
Telephone: _______________________
Relationship: _______________________

APPOINTMENT OF ALTERNATE HEALTH CARE SURROGATE
If I revoke _______________________'s authority or if _______________________ is not willing, able, or reasonably available to make a health care decision for me, I designate as my alternate surrogate:

_______________________
_______________________
_______________________, $state, _______________________
Telephone: _______________________
Relationship: _______________________

SURROGATE'S AUTHORITY
My surrogate is authorized to act for me in all matters relating to my health care. My surrogate's powers include, but are not limited to:

  • Full power to consent, refuse consent, or withdraw consent to all medical, surgical, hospital and related health care treatments and procedures on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my surrogate by me;
  • Full power to make decisions on whether to provide, withhold, or withdraw artificial nutrition and hydration on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my surrogate by me;
  • Full power to review and receive any information regarding my physical or mental health, including medical and hospital records, in accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), and theAmerican Recovery and Reinvestment Act of 2009 ("ARRA");
  • Full power to sign any releases in order to obtain this information;
  • Full power to sign any documents required to request, withdraw, or refuse treatment or to be released or transferred to another medical facility.

My surrogate does not have authority to act for me for any other purpose unrelated to my health care. All of my surrogate's actions under this power during any period when I am unable to make or communicate health care decisions have the same effect on my heirs, devisees and personal representatives as if I were competent and acting for myself.

WHEN SURROGATE'S AUTHORITY BECOMES EFFECTIVE
The designation of my surrogate will become effective as soon as this document is signed and will remain in effect until my death, or until I revoke it. This designation will not be affected by my subsequent disability or incompetence.

SURROGATE'S OBLIGATIONS
My surrogate will make health care decisions for me in accordance with this document, and in accordance with any instructions I give in a Living Will, Health Care Directive or other such document (either included in this document or as a separate document), and my other wishes to the extent known to my surrogate. To the extent my wishes are unknown, my surrogate will make health care decisions for me in accordance with what my surrogate determines to be in my best interest. In determining my best interest, my surrogate will consider my personal values to the extent known to my surrogate.

EFFECT OF COPY
A copy of this Designation of Health Care Surrogate has the same effect as the original.

SEVERABILITY
If any part or parts of this Designation of Health Care Surrogate is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of such part or parts shall not in any way affect the remaining parts, and this document shall be construed as though the invalid or illegal part or parts had never been included herein. But if the intent of this Designation of Health Care Surrogate would be defeated by such construction, then it shall not be so construed.

SIGNATURE
This Designation of Health Care Surrogate is made after careful reflection, while I am of sound mind. I am fully informed as to all contents of this document and understand the full import of this grant of powers to my surrogate. I fully understand that by signing this document, I will permit my surrogate to make health care decisions for me. I understand that my signature on this document gives my surrogate authority to provide, withhold, or withdraw consent to health care treatments or procedures on my behalf; to apply for public benefits to defray the cost of my health care; and to authorize my admission to or transfer from a health care facility. I further affirm that I am not signing this document as a condition of treatment or admission to a health care facility.

   

Signature:

_________________________

Name:

_________________________

Date:

$month $day, $year

Place:

____________________, $state


NOTIFICATION
I will notify and send a copy of this document to the following persons other than my surrogate, so they may know who my surrogate is.

Name: _____________________________
Address: __________________________________
Phone: _______________

Name: _____________________________
Address: __________________________________
Phone: _______________


STATEMENT OF WITNESSES
(Use if document is not notarized.)

I, the undersigned witness, declare that _________________________, the person who signed this document, is personally known to me and appears to be of sound mind and acting of his own free will and under no duress. He signed (or asked another to sign for him) this document in my presence. I further declare that I am at least 18 years of age, I am not entitled to any portion of _________________________'s estate, not financially responsible for _________________________'s health care, not named as _________________________'s health care Surrogate in this document, and that I am not married to _________________________ and not related to _________________________ by blood or adoption.


First witness

____________________________
(signature of witness)

____________________________
(print name)

_________________________________
(address)

________________________________
(city) (state)

___________________________
(date)


Second witness

____________________________
(signature of witness)

____________________________
(print name)

_________________________________
(address)

________________________________
(city) (state)

___________________________
(date)


NOTARY ACKNOWLEDGEMENT


STATE OF $state

COUNTY OF ____________________

The foregoing instrument was acknowledged before me this $day day of $month, $year, by _________________________, who is personally known to me or who has produced ____________________ as identification.



________________________________
Notary Public

________________________________
(print name)



RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________  Date: ____________________
2. ____________________________________  Date: ____________________
3. ____________________________________  Date: ____________________
4. ____________________________________  Date: ____________________
5. ____________________________________  Date: ____________________


LIVING WILL

If I, _________________________, become incapacitated and am unable to direct my health care providers as to my own health care, I direct that this statement be read as a true reflection of my health care wishes.

DEFINITIONS
For the purposes of this document, the following definitions apply:

  1. "Artificially administered food and water" (or artificial nutrition and hydration) means the provision of nutrients or fluids by a tube inserted in vein, under the skin in the subcutaneous tissues, or in the stomach (gastrointestinal tract).
  2. "Attending physician" means the physician licensed by the state board of medicine, selected by or assigned to the patient, and who has primary responsibility for the treatment and care of the patient.
  3. "Comfort care" means treatment, including prescription medication, provided to the patient for the sole purpose of alleviating pain. Artificially administered food and water is not included.
  4. "End stage condition" means an irreversible condition that is caused by injury, disease, or illness which has resulted in progressively severe and permanent deterioration, and which, to a reasonable degree of medical probability, treatment of the condition would be ineffective.
  5. "Health care provider" or "provider" means any person licensed, certified, or otherwise authorized by law to administer health care in the ordinary course of business or practice of a profession.
  6. "Incapacity" or "incompetent" means the patient is physically or mentally unable to communicate a willful and knowing health care decision. For the purposes of making an anatomical gift, the term also includes a patient who is deceased.
  7. "Life-prolonging procedure" (or "life-sustaining procedure") means any medical procedure, treatment, or intervention which sustains, restores, or supplants a spontaneous vital function. In this document the term does not include sustenance and hydration administration, or the provision of medication or the performance of medical procedure, when such medication or procedure is deemed necessary to provide comfort care or to alleviate pain.
  8. "Persistent vegetative state" means a permanent and irreversible condition in which there is:
          a. The absence of voluntary action or cognitive behavior of any kind.
          b. An inability to communicate or interact purposefully with the environment.
  9. "Terminal condition" means a condition caused by injury, disease, or illness from which there is no reasonable medical probability of recovery and which, without treatment, can be expected to cause death.

MEDICAL DIRECTIONS AND END-OF-LIFE DECISIONS
I direct that my health care providers and others involved in my care, provide, withhold, or withdraw treatment in accordance with my directions below:

  1. If I have an incurable and irreversible (terminal) condition that will result in my death within a relatively short time, I direct that:
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.
  2. If I am diagnosed as being in an end-state condition and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that:
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.
  3. If I am diagnosed as being in a persistent vegetative state and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that:
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.

ADDITIONAL INSTRUCTIONS
I have no additional instructions.

I understand that I may change the above-listed directives at any time by revoking this declaration and writing a new one.

EFFECT OF COPY
A copy of this Living Will has the same effect as the original.

SEVERABILITY
If any part or parts of this Living Will is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of such part or parts shall not in any way affect the remaining parts, and this document shall be construed as though the invalid or illegal part or parts had never been included herein. But if the intent of this Living Will would be defeated by such construction, then it shall not be so construed.

SIGNATURE
This document is made upon careful reflection. Options that I have considered and rejected are not printed above. I confirm that the health care directions contained herein were made after careful consideration and in full awareness of other options that may have been available to me. I declare that I am an adult in the State of $state, that I understand the full import of this declaration, and that I am emotionally and mentally competent to give these directions.

Signed at ____________________, in the State of $state, this $day day of $month, $year.

Signature:

_________________________

Name:

_________________________

Address:

____________________________

 

______________________________, $state


STATEMENT OF WITNESSES

  1. I declare under penalty of perjury under the laws of the State of $state that:
  2. The individual who signed or acknowledged this Living Will, _________________________, is personally known to me, or his identity was proven to me by convincing evidence;
  3. _________________________ appeared to be eighteen (18) years of age or older, or of the legal age in this state to create this type of document;
  4. I am of at least eighteen (18) years of age and _________________________ signed or acknowledged this Living Will in my presence;
  5. _________________________ appears to be of sound mind and under no duress, fraud, or undue influence;
  6. I am not a person appointed as _________________________'s health care surrogate;
  7. I am not _________________________'s health care provider, an employee of _________________________'s health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly; and
  8. I am not related to _________________________ by blood or marriage and I would not be entitled to any portion of _________________________'s estate on his death.

First witness

____________________________
(signature of witness)

_______________________
(print name)

____________________________
(address)

____________________________
(city) (state)

______________
(date)

Second witness

____________________________
(signature of witness)

_______________________
(print name)

____________________________
(address)

____________________________
(city) (state)

______________
(date)


NOTARY ACKNOWLEDGEMENT

STATE OF $state

COUNTY OF __________________
The foregoing instrument was acknowledged before me this _________ day of ____________, 20__, by _________________________.

___________________ (Signature of person taking acknowledgement)

___________________ (Name of Notary printed, typed or stamped)

___________________ (Title or rank)

_________ Personally known OR
Type of identification produced: ___________________

___________________ (Serial number, if any)


RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________  Date: ____________________
2. ____________________________________  Date: ____________________
3. ____________________________________  Date: ____________________
4. ____________________________________  Date: ____________________
5. ____________________________________  Date: ____________________

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