Advance Directive. including Power of Attorney for Health Care. Dardaaranka. kana mid ah Awoodda Mattalaadda Daryeelka Caafimaadka

Transcription

1 Patient Medical Record Number: Advance Directive including Power of Attorney for Health Care Or Label Overview Kor ka eegidda Dardaaranka kana mid ah Awoodda Mattalaadda Daryeelka Caafimaadka This legal document meets the requirements for Wisconsin, Minnesota and Iowa.* It lets you Name another person to make your health care decisions if you cannot make them for yourself. Write down your goals and preferences for future medical care in specific situations. Warqadaan sharciga waxay la kullantaa sharuudaha Wisconsin, Minnesota iyo Iowa.* Waxay kuu ogolaataa in aad Magacaawdid qof kale oo kuu gaara go aanada caafimaadka haddii aadan adiga naftaada gaari karin. Qor ujeedooyinkaada iyo waxyaabaha aad ka dooneysid daryeelka caafimaadka mustaqbalka marka aad ku sugan tahay xaaladaha qaar. The person you name is called your health care agent. You can also name alternate health care agents who can make decisions if the person you named first or second cannot or is not willing to make those decisions. This document gives your agent authority to make health care decisions on your behalf only after doctors have determined you are incapable of making health care decisions for yourself. Qofka aad magacaawday waxaa lagu magacaabaa wakiilkaada daryeelka caafimaadka. Waxaad kaloo magacaabi kartaa wakiilo kale oo lagu baddalo wakiilada daryeelka caafimaadka, kuwaasoo kuu gaari kara go aano haddii qofka aad adiga magacaawday marka kowaad ama marka labaad uusan awoodin ama uusan rabin in uu gaaro go aanada. Warqadaan waxay wakiilkaada siisaa awoodda uu ku gaaro go aanada daryeelka caafimaadka oo keliya kaddib marka takhaatiirta go aan ku gaarto in aadan awood u lahayn in aad naftaada gaartid go aanada daryeelka caafimaadka. *As of June 1, 2017 *Laga bilaabo Juun 1, 2017 The name Honoring Choices Wisconsin is used under license from the Twin Cities Medical Foundation. waxaa la isticmaalaa magaca Honoring Choices Wisconsin sida hoos timaado shattiga Twin Cities Medical Foundation. Cover page. Not part of document. Do not scan. Bogga kore. Qeyb kama aha warqadda. Ha ku samaynin skan.

2 This document does not give your agent authority to: Warqadaam ma siiso wakiilkaada awoodda uu ku: Make financial or other business decisions. Gaaro go aanada ganacsiga ama maaliyadda. Make certain decisions about your mental health treatment. Gaaro go aanada qaar ee ku saabsan daweynta caafimaadka madaxa. Read this advance directive carefully before you complete and sign it. You should discuss your goals, values, and this advance directive with your health care agent(s). Unless you talk with your health care agent(s), they may not know your goals and be able to follow your instructions. Si taxadir leh u akhri dardaarankaan ka hor inta aadan buuxinin, kaddibna saxiixin. Waa in aad ujeedooyinkaada, waxyaabaha aad qiimeysid, iyo dardaarankaan kala hadashid wakiilka (wakiilada) daryeelka caafimaadkaada. Haddii aadan kala hadlin wakiilkaada (wakiiladaada) daryeelka caafimaadka, waxaa dhici karto in iyaga aysan ogaanin ujeedooyinkaada iyo in aysan raacin tilmaamaha aad siisid. Recommendation: make an appointment with an advance care planning facilitator for help. If this advance directive does not meet your needs, ask your health organization or attorney about other options. Tallada: ballan ka qabso fududeyaha daryeelka si aad u heshid kaalmo. Haddii dardaarankaan uusan la kulmin baahidaada, weydii ururka caafimaadkaada ama qareen talooyinka kuu banaan. Cover page. Not part of document. Do not scan. Bogga kore. Qeyb kama aha warqadda. Ha ku samaynin skan.

3 To complete this advance directive Si aad u dhamaystirtid dardaarankaan This advance directive is divided into four parts: Dardaarankaan waxaa loo qeybiyay afar qeyb: Part 1 My health care agent Qeybta 1aad - Wakiilkeyga daryeelka caafimaadka Part 2 General authority of the health care agent Qeybta 2aad - Awoodda guud ee wakiilka daryeelka caafimaadka Part 3 Statement of desires, care instructions or limits Qeybta 3aad - Oraahada rabitaanka, tilmaamaha daryeelka ama xuduudda Part 4 Making the document legal Qeybta 4aad - Sharciyeynta warqadda Follow the instructions in each of the four parts. Raac tilmaamaha ku jira mid kasta oo ka mid ah afarta qeyb. After you complete your advance directive Kaddib marka aad dhameysid dardaarankaada Take these steps: Qaad talaabadahaan: Talk to the person(s) you named as your agent(s) about your goals and preferences for future medical care, if you have not already. Make sure they feel able to do this important job for you in the future. La hadal qofka (dadka) aad u magacaawday in uu wakiil kaaga noqdo ujeedooyinkaada iyo waxyaabaha aad jeceshahay xagga daryeelka caafimaadka mustaqbalka, haddii aadan sidaas horay u samaynin. Hubso in ay dareemaan in ay awood u leeyahiin in ay adiga kuu fulliyaan hawshaan muhiimka ah mustaqbalka. Cover page. Not part of document. Do not scan. Bogga kore. Qeyb kama aha warqadda. Ha ku samaynin skan.

4 Give your agent(s) a copy of this advance directive. Waxaad wakiilkaada (wakiiladaada) siisaa koobiga dardaarankaan. Talk to the rest of your family and close friends who might be involved if you have a serious illness or injury. Make sure they know who your agent(s) is, and what your preferences are. La hadal inta ka hartay qoyskaada iyo asxaabta kuu dhaw ee laga yaabo in ay lug ku yeeshaan haddii aad qabtid cudur darran ama dhaawac. Hubso in ay ogsoon yahiin wakiilkaada (wakiiladaada), iyo waxa rabitaankaada yahay. Give a copy to your doctor and/or your health care facility. Make sure your preferences are understood. Waa in aad koobi siisid takhtarkaada iyo/ama hay adda daryeelka caafimaadkaada. Hubso in waxa aad rabtid la fahamsan yahay. Keep a copy of this advance directive where it can be easily found. Waxaad koobiga dardaarankaan dhigtaa meel si fudud looga heli karo. If you go to a hospital or nursing home, take a copy of this advance directive and ask that it be placed in your medical record. Haddii aad tagtid isbitaalka ama guriga xanaanada, horay u qaado koobiga dardaarankaan iyo weydiiso in la geliyo diiwaankaada caafimaadka. Cover page. Not part of document. Do not scan. Bogga kore. Qeyb kama aha warqadda. Ha ku samaynin skan.

5 Review and update this advance directive whenever any of the Five D s occur: Fiiri kaddibna casriyey dardaarankaan mar kasta aad la kullantid "Five D s" (Shanta D): Decade when you start each new decade of your life. Toban sanno marka aad bilowdid toban sanno kasta oo cusub noloshaada. Death (or Dispute) when a loved one or a health care agent dies (or disagrees with your preferences). Dhimasho (ama Qilaaf) marka uu dhinto qof aad jeceshahay ama wakiilka daryeelka caafimaadka (ama qilaafo waxyaabaha aad jeceshahay). Divorce when divorce (or annulment) happens. If your spouse or domestic partner is your agent, your advance directive is no longer valid. You must complete a new advance directive, even if you want your ex-spouse or ex-partner to remain your agent. Furiin marka lala kulmo furiin (ama guurka burburo). Haddii xaaskaada ama qofka aad la daggan tahay guriga yahay wakiilkaada, dardaarankaada ma shaqeeyo. Waa in aad dhamaystirtid dardaaran cusub, xattaa hadii aad rabtid in xaaskaadi hore ama qofkii hore aad la nooleyd sii ahaado wakiilkaada. Diagnosis when you are diagnosed with a serious illness. Baaritaanka marka laguugu sheego in aad qabtid cudur darran. Decline when your health gets worse, especially when you are unable to live on your own. Hoos u dhaca marka caafimaadkaada ka sii daro, khaas ahaan marka aadan awoodin in aad keligaa noolaatid. If your goals and preferences change: Haddii ujeedooyinkaada iyo waxa aad jeceshahay isbaddalaan: o Talk to your agent(s), your family, your doctor, and everyone who has copies of this advance directive. La hadal wakiilkaada (wakiiladaada), qoyskaada, takhtarkaada, iyo qof kasta oo haysta koobiyada dardaarankaan. o Then, complete a new advance directive. Kaddibna, dhamaystir dardaaran cusub. Cover page. Not part of document. Do not scan. Bogga kore. Qeyb kama aha warqadda. Ha ku samaynin skan.

6 Cut out the card below, fill it in, fold it and put it in your wallet. Gooy kaarka hoose, buuxi kaddibna geli boorsadaada jeebka. Dardaarankeyga wuxuu ku jiraa faylka yaal hay adaan daryeelka caafimaadka Magaca Taariikhda Dhallashada Magaalada/Gobolka Telefoonka Wakiilkeyga daryeelka caafimaadka waa Magaca Telefoonka Need help? Ma u baahan tahay kaalmo? If you need help to complete this advance directive, contact 1 (888) Haddii aad u baahan tahay kaalmo si aad u buuxisid dardaarankaan, la xariir 1 (888) Cover page. Not part of document. Do not scan. Bogga kore. Qeyb kama aha warqadda. Ha ku samaynin skan.

7 Advance Directive including Power of Attorney for Health Care Dardaaranka Awoodda kana mid ah Mattalaadda Daryeelka Caafimaadka (Power of Attorney for Health Care) For: Ee: Name (Magaca) Date of Birth (Taariikhda Dhallashada) Telephone (Cell) (Telefoon (Telefoonka Gacanta)) (Work) (Shaqada) (Home) (Guriga) Address (Cinwaanka) City (Magaalada) State/ZIP (Gobolka/ZIP) Copies of this document have been given to: Koobiyada warqadaan waxaa la siiyay: Name (Magaca) Name (Magaca) Name (Magaca) Name (Magaca) Name (Magaca) Health care professional/health care facility: Aqoonyaanka daryeelka caafimaadka/hay adda daryeelka caafimaadka: Name (Magaca) Name (Magaca) Name (Magaca) The name Honoring Choices Wisconsin is used under license from the Twin Cities Medical Foundation. June La isticmaalay magaca Honoring Choices Wisconsin sida hoos timaada shattiga laga qaatay Twin Cities Medical Foundation. June of

8 Notice to Person Making this Document Ogeysiiska la siiyo Qofka Sameeyo Warqadaan. You have the right to make decisions about your health care. No health care may be given to you over your objection, and necessary health care may not be stopped or withheld if you object. Waxaad xaq u leedahay in aad gaartid go aano ku saabsan daryeelka caafimaadkaada. Laguma siin karo daryeelka caafimaadka haddii aad diidid, mana la joojin doono ama lagaama ceshan karo daryeelka caafimaadka loo baahan yahay haddii aad diidid. Because your health care providers in some cases may not have had the opportunity to establish a long-term relationship with you, they are often unfamiliar with your beliefs and values and the details of your family relationships. This poses a problem if you become physically or mentally unable to make decisions about your health care. Bacdamaa ay dhici karto mararka qaar in bixiyeyaashaada daryeelka caafimaadka aysan fursad u helin in ay kula yeeshaan xariir muddo dheer, badanaa aqoon uma laha waxa aad aaminsan tahay iyo waxa aad qiimeysid iyo tafaasiisha xariirka ka dhexeeyo qoyskaada. Tani waxay dhallisaa dhibaato haddii aadan jir ahaan ama maskax ahaan awood u yeelanin in aad gaartid go aanada ku saabsan daryeelkaada caafimaadka. In order to avoid this problem, you may sign this legal document to specify the person whom you want to make health care decisions for you if you are unable to make those decisions personally. That person is known as your health care agent. You should take some time to discuss your thoughts and beliefs about medical treatment with the person or persons whom you have specified. You may state in this document any types of health care that you do or do not desire, and you may limit the authority of your health care agent. If your health care agent is unaware of your desires with respect to a particular health care decision, he or she is required to determine what would be in your best interests in making the decision. Si leysaga ilaaliyo dhibaatadaan, waxaad saxiixi kartaa warqadaan sharciyeysan si aad u sheegtid qofka aad rabtid in uu kuu gaaro go aanada daryeelka caafimaadka haddii aadan awoodin in aad qof ahaan gaartid go aanadaan. Qofkaas waxaa loo yaqaan in uu yahay wakiilkaaga daryeelka caafimaadka. Waa in aad qaadatid xoogaa waqti aad fikradahaada iyo waxa aad aaminsan tahay ee ku saabsan daweynta caafimaadka kala hadashid qofka ama dadka aad tilmaantay. Waxaad warqadaan ku sheegi kartaa noocyada daryeelka caafimaadka aad adiga rabtid ama aadan rabin, kaddibna waxaad xad u yeeli kartaa awoodda wakiilkaada daryeelka caafimaadka. Haddii wakiilkaada daryeelka caafimaadka uusan la soconin waxa aad rabtid xagga go aan gaar ah oo la xariira daryeelka caafimaadka, isaga ama iyada waxaa laga rabaa in uu ogaado maslaxadaada ugu wanaagsan marka uu gaaro go aanka. 2 of

9 This is an important legal document. It gives your agent broad powers to make health care decisions for you. It revokes any prior power of attorney for health care that you may have made. If you wish to change your power of attorney for health care, you may revoke this document at any time by destroying it, by directing another person to destroy it in your presence, by signing a written and dated statement or by stating that it is revoked in the presence of two witnesses. If you revoke, you should notify your agent, your health care providers, and any other person to whom you have given a copy. If your agent is your spouse or domestic partner and your marriage is annulled or you are divorced or the domestic partnership is terminated after signing this document, the document is invalid. Tani waa warqad sharci oo muhiim ah. Waxay wakiilkaada siisaa awood balaaran uu ku gaaro go aanadaada daryeelka caafimaadka. Waxay la noqotaa awoodda mattalaadda hore daryeelka caafimaadka ee laga yaabo in aad horay u sameysay. Haddii aad dooneysid in aad baddashid awoodda mattalaadda daryeelka caafimaadka, waxaad la noqon kartaa warqadaan waqti kasta adiga oo iyada burburiya, adiga oo qof kale fara in uu ku burburiyo hortaada, adiga oo saxiixa oraah qoran kuna qoran taariikhda ama labo marqaati hortooda ku sheega in aad la noqotay. Haddii aad la noqotid, waa in aad ogeysiisid wakiilkaada, bixiyeyaashaada daryeelka caafimaadka, iyo qof kasta oo aad siisay koobi. Haddii wakiilkaada tahay xaaskaada ama qofka aad wadaagtan guriga kaddibna guurkiina la burburiyo ama aad isfurtaan ama la soo afjaro iskaashiga guriga kaddib marka aad saxiixdid warqadaan, warqadda ma shaqeyso. You may also use this document to make or refuse to make an anatomical gift upon your death. If you use this document to make or refuse to make an anatomical gift, this document revokes any prior record of gift that you may have made. You may revoke or change any anatomical gift that you make by this document by crossing out the anatomical gifts provision in this document. Waxaad kaloo warqadaan u adeegsan kartaa in aad deeq ahaan u bixisid ama diidid jirkaada. Haddii aad isticmaashid warqadaan si aad u ogolaatid ama u diidid in aad bixisid deeqda xubinta, warqadaan waxay la noqon doontaa qoraal kasta oo horay loo sameyay kuna saabsan deeq kasta oo laga yaabo in aad horay u ogolaatay in aad bixisid. Waxaad la noqon kartaa ama baddali kartaa deeq kasta jirka aad ku bixisid warqadaan adiga oo xariiqan mariya qodobka deeqda jirka ee ku jirta warqadaan. Do not sign this document unless you clearly understand it. It is suggested that you keep the original of this document on file with your doctor. Ha saxiixin warqadaan ilaa aad si wanaagsan u fahamtid. Waxaa lagu tallinaa in aad asalka warqadaan ku dhaaftid faylka uu haayo takhtarkaada. 3 of

10 Part 1: My health care agent Qeybta 1aad: Wakiilkeyga daryeelka caafimaadka If you can no longer make your own health care decisions, this advance directive names the person you authorize to make these choices for you. This person will be your health care agent. State law says he or she will make your health care choices for you only after doctors have determined you are incapable of making health care decisions. Your agent will make decisions about your medical care as you would if you were able. You and your health care agent(s) should have ongoing talks about your health and health care choices. Haddii aadan gaari karin go aanada daryeelka caafimaadkaada, dardaarankaan wuxuu magacaabaa qofka aad awoodda u siisay in uu adiga wax kuu doorto. Qofkaan wuxuu ahaan doonaa wakiilkaada daryeelka caafimaadka. Sharciga gobolka wuxuu rabaa in isaga ama iyada kuu gaari doonto waxyaabaha aad u dooratid daryeelka caafimaadkaada oo keliya kaddib marka takhaatiirta go aan ku gaarto in adiga aadan awood u lahayn in aad gaartid go aanada daryeelka caafimaadka. Wakiilkaada wuxuu gaari doonaa go aano ku saabsan daryeelkaada caafimaadka sida adiga aad u samayn lahayd haddii aad awood lahaan lahayd. Adiga iyo wakiilkaada (wakiiladaada) daryeelka caafimaadka waa in aad wada hadal socda ka yeelataan xulashooyinka daryeelka caafimaadkaada. Choose someone who knows you well. It should be someone you trust and who respects your goals and values. This person should be able to make difficult decisions under stress. Often family members are good choices, but not always. Choose someone who will closely follow what you want and will be a good advocate for you. Discuss this document and your views with the person(s) you choose to be your health care agent(s). Dooro qof adiga si wanaagsan kuu yaqaan. Waa in uu ahaado qof aad ku kalsoon tahay oo xushmeya ujeedooyinkaada iyo waxa aad qiimeysid. Qofkaan waa in uu awood u leeyahay in uu gaaro go aano adag marka xaaladda culus tahay. Marmar xubnaha qoyska waa xulasho wanaagsan, balse ma aha sidaas mar kasta. Dooro qof oo hoosta kala socon doono waxa aad dooneysid, oo si wanaagsan kuugu doodi kara. Waxaad warqadaan iyo fikradahaada kala hadashaa qofka (dadka) aad u dooratid in uu ahaado wakiilkaada (wakiiladaada) daryeelka caafimaadka. A health care agent must be at least 18 years old. Your health care agent may not be one of your health care providers or an employee of your health care provider, unless he or she is a relative. Wakiilka daryeelka caafimaadka waa in uu jiro ugu yaraan 18 sanno. Wakiilkaada daryeelka caafimaadka ma noqon karo mid ka mid ah bixiyeyaasha daryeelka caafimaadkaada ama shaqaale ka tirsan bixiyaha daryeelka caafimaadkaada, ilaa isaga ama iyada tahay qaraabo. 4 of

11 The person I choose as my health care agent is: Qofka aan u doorto in uu ahaado wakiilkeyga daryeelka caafimaadka waa: Name (Magaca) Date of Birth (Taariikhda Dhallashada) Telephone (Cell) [Telefoon (Telefoonka Gacanta)] (Work) (Shaqada) (Home) (Guriga) Address (Cinwaanka) City (Magaalada) State/ZIP (Gobolka/ZIP) If that person is unable or unwilling to make decisions for me, then my next choice is: Haddii qofkaas uusan awoodin ama rabin in uu ii gaaro go aano, markaas xulashadeyda xigta waa: Second choice: Xulashada labaad: Name (Magaca) Date of Birth (Taariikhda Dhallashada) Telephone (Cell) [Telefoon (Telefoonka Gacanta)] (Work) (Shaqada) (Home) (Guriga) Address (Cinwaanka) City (Magaalada) State/ZIP (Gobolka/ZIP) If that person is unable or unwilling to make decisions for me, then my next choice is: Haddii qofkaas uusan awoodin ama rabin in uu ii gaaro go aano, markaas xulashadeyda xigta waa: 5 of

12 Third choice: Xulashada saddaxaad: Name (Magaca) Date of Birth (Taariikhda Dhallashada) Telephone (Cell) [Telefoon (Telefoonka Gacanta)] (Work) (Shaqada) (Home) (Guriga) Address (Cinwaanka) City (Magaalada) State/ZIP (Gobolka/ZIP) I do not have a health care agent. Instead, I want Part 3 of this document to guide my health care. Aniga ma lihi wakiilka daryeelka caafimaadka. Baddal ahaan, waxaan rabaa in Qeybta 3aad warqadaan hoggaamiso daryeelkeyga caafimaadka. 6 of

13 Part 2: General authority of the health care agent Qeybta 2aad: Awoodda guud ee wakiilka daryeelka caafimaadka To complete this part: Si aad u dhamaystirtid qeybtaan: Draw a line through anything in the box below you do not want your health care agent to do. For example, it should look like this: Decide on Xariiqan mari wax kasta oo ku jira gudaha sanduuqa hoose, aadna rabin in uu sameeyo wakiilkaada daryeelka caafimaadka. Tusaale ahaan, waa in ay sidaan u ekaato: Go aanso I want my health care agent to be able to: Aniga waxaan rabaa in wakiilkeyga daryeelka caafimaadka awood u yeesho in uu: Decide on tests, medicine, surgery and other medical care. If treatment has started, my agent can keep it going or stop it, based on my instructions or my best interests. Go aan ka gaaro baaritaanada, daawada, qaliinka iyo daryeelka kale ee la xariira daryeelka caafimaadka. Haddii la bilaabo daweynta, wakiilkeyga waa sii wadi karaa ama waa joojin karaa, taasoo ku saleysan sida aan faro ama daneheyga ugu fiican. Interpret my instructions based on what he or she knows of my preferences and values. Tarjamo waxa aan faro taasoo ku saleysan waxa isaga ama iyada ka ogsoon tahay waxyaabaha aan rabo iyo waxyaabaha aan qiimeeyo. Review and release my medical records and personal files as needed for my medical care. Fiiriyo iyo in uu sii daayo diiwaanadeyda caafimaadka iyo fayladeyda hadba sida loogu baahdo daryeelkeyga caafimaadka. Arrange for my medical care and treatment in Wisconsin or any other state. Isku habeeyo daryeelkeyga caafimaadka iyo daweynta Wisconsin ama gobol kale. Decide whether organs or tissues (anatomical gifts) can be donated after my death according to my preferences and values. Go aan ka gaaro haddii xubnaha ama hilibka (deeqda jirka) la bixin karo kaddib marka aan dhinto sida waafaqsan waxyaabaha aan aniga jeclahay iyo waxa aan qiimeeyo. 7 of

14 Limits on mental health treatment in Wisconsin Xuduudda daweynta caafimaadka madaxa ee Wisconsin Wisconsin law says my health care agent may not admit or commit me to an inpatient facility for mental health treatment. This means that in Wisconsin, my agent cannot admit me to: Sharciga Wisconsin wuxuu qabaa in wakiilkeyga daryeelka caafimaadka uusan i seexin karin ama igu qasbi karin in aan hoos imaado hay adda bukaan jiifka u qaabilsan daweynta caafimaadka madaxa. Tani macnaheeda waxay tahay in Gobolka Wisconsin, wakiilkeyga uusan i seexin karin: an institution for mental diseases hay ad ka shaqeysa cudurada madaxa an intermediate care facility for people with an intellectual disability, or hay adda daryeelka muddada dhexe ee loogu talogalay dadka qaba itaal darrida garashada, ama a state treatment facility for mental health. hay adda daweynta gobolka ee loogu talogalay caafimaadka madaxa. My health care agent may not agree to any drastic mental health treatments for me. These treatments include experimental mental health research, brain surgery, or electroshock therapy. Waxaa dhici karto in wakiilkeyga daryeelka caafimaadka uusan waafiqin in ley siiyo daweynta caafimaadka madax ee culus. Daweyntaan waxaa ka mid ah tijaabada cilmi baarista caafimaadka madaxa, qaliinka maskaxda, ama ku daweynta ku qabashada korantada. 8 of

15 To complete the next three questions: Si aad u dhamaystirtid saddaxda su aal xiga: Initial or check the box beside the one statement in each section you agree with. Ku qor xarfaha hore magacaada ama calaamee sanduuqa ku dhinac yaal oraahda aad waafaqsan tahay qeyb kasta. In Wisconsin, if you do not mark any box in a section, or you choose no, only a court can make the decision and not your health care agent. Wisconsin, haddii aadan calaameynin mid ka mid ah sanduuqyada qeybtaan, ama aad dooratid maya, ammar ka soo baxay maxkamadda keliya ayaa gaari kara go aanka ee ma aha wakiilkaada daryeelka caafimaadka. 1. Agent authority to make the decision to admit me to a nursing home or community-based residential facility for long-term care. Awoodda wakiilka u leeyahay in uu gaaro go aanka in uu i seexiyo guriga xanaanada ama hay adda guryaha ku-saleysan bulshada si aan u helo daryeelka muddada dheer. Note: Your health care agent has the authority to admit you to a nursing home or care facility (communitybased residential facility) for a short-term stay. For example, you might need care to recover after surgery and you expect to go home. Xasuusin: Wakiilkaada daryeelka caafimaadka wuxuu awood u leeyahay in uu ku seexiyo guriga xanaanada ama hay adda daryeelka (hay adda guryaha ku-saleysan bulshada) muddo-gaaban. Tusaale ahaan, waxaa dhici karto in aad u baahatid daryeel si aad uga soo bogsatid qaliin adiga oo rajeynaaya in aad tagtid guriga. If I need long-term care for any reason, then: Haddii aan u baahdo daryeelka muddada dheer sabab kasta ha noqoto, markaas: Yes, my agent can make the decision to admit me to a nursing home or community-based residential facility for a long-term stay. Haa, wakiilkeyga wuu gaari karaa go aanka in muddo dheer ley seexiyo guriga xanaanada ama hay adda guryaha ku-saleysan bulshada. No, my agent cannot make the decision to admit me to a nursing home or community-based residential facility for a long-term stay. Maya, Wakiilkeyga ma gaari karo go aanka in uu i seexiyo guriga xanaanada ama hay adda guryaha xanaanada ku-saleysan bulshada joogitaanka dheer. In Wisconsin, choosing no or leaving this section blank means I cannot be admitted to a Wisconsin long-term care facility without a court order. Wisconsin, macnaha doorashada maya ama in aad baneysid qeybtaan waa in aan leygu meeleyn karin hay adda daryeelka muddada dheer haddii uusan jirin ammar ka soo baxay maxkamadda. 9 of

16 2. Agent authority to make the decision to refuse or have removed a feeding tube and/or IV fluids. Awoodda wakiilka u leeyahay in uu gaaro go aanka uu ku diido ama laga saaro tubada quudinta iyo/ama dareeraha IV. Yes, my agent can make the decision to refuse or stop tube feedings and/or IV fluids. Haa, wakiilkeyga wuxuu gaari karaa go aanka lagu diido ama lagu joojiyo quudinta tubada iyo/ama dareeraha IV. No, my agent cannot make the decision to refuse or stop tube feedings and/or IV fluids. Maya, wakiilkeyga ma gaari karo go aanka uu ku diido ama joojiyo quudinta tubada iyo/ama dareeraha IV. In Wisconsin, choosing no or leaving this section blank means feeding tubes and IV fluids cannot be refused or stopped without a court order. Wisconsin, macnaha in la doorto maya ama in la baneeyo qeybtaan waa in aan ley diidi karin ama leyga joojin karin tubooyinka quudinta iyo dareeraha IV haddii uusan jirin ammar ka soo baxay maxkamadda. 3. Agent authority to make health care decisions during pregnancy. Awoodda wakiilka u leeyahay in uu gaaro go aanada daryeelka caafimaadka waqtiga uurka. Yes, my agent can make health care decisions for me if I am pregnant. Haa, wakiilkeyga wuxuu gaari karaa go aanada daryeelka caafimaadkeyga haddii aan xaamilo noqdo. No, my agent cannot make health care decisions if I am pregnant. Maya, wakiilkeyga ma gaari karo go aanada daryeelka caafimaadka haddii aan uur leeyahay. This does not apply to me. Tani ma i quseyso aniga. In Wisconsin, choosing no or leaving this section blank means health care decisions cannot be made for me while I am pregnant without a court order. Wisconsin, macnaha in la doorto maya ama in la baneeyo qeybtaan waa in aan ley gaari karin go aanada daryeelka caafimaadka inta aan xaamilo ahay haddii uusan jirin ammar ka soo baxay maxkamadda 10 of

17 Part 3: Statement of desires, care instructions or limits Qeybta 3aad: Oraahda waxyaabaha la rabo, tilmaamaha daryeelka ama xuduudda Part 3 allows you to make your preferences clear. Your health care agent and your doctors will refer to this section as they care for you. If you did not name a health care agent or if your health care agent cannot be reached, you can direct your care with the choices you make below. You should talk with your health care agent about the kind of care you want, even if you don t make choices in this section. Qeybta 3aad waxay kuu ogoshahay in aad caddeysid waxyaabaha aad rabtid. Wakiilkaada daryeelka caafimaadka iyo takhaatiirtaada waxay tixraaci doonaan qeybtaan inta ay ku hawlan yahiin daryeelkaada. Haddii aadan magacaabin wakiilka daryeelka caafimaadka ama haddii aan lala xariiri karin wakiilka daryeelka caafimaadka, waxaad daryeelkaada ku maamuli kartaa waxyaabaha aad dooratid ee ku qoran hoos. Waa in aad wakiilkaada daryeelka caafimaadka kala hadashid nooca daryeelka aad rabtid, xattaa haddii aadan waxba xullanin qeybtaan. You are not required to complete this part of the document. Lagaama rabo in aad buuxisid qeybtaan warqadda. To complete this part: Si aad u dhamaystirtid qeybtaan: Initial or check the box beside the one statement you agree with. Ku qor xarfaha hore magaca ama calaamee sanduuqa ku dhinac yaal halka oraah aad waafaqsan tahay. You may add other specific care instructions on page 14. Waxaad ku dari kartaa tilmaamo kale oo ku saabsan daryeelka kuna qoran bogga 14aad. 11 of

18 1. Treatments that may prolong life if I am in this situation. Dawooyinka laga yaabo in ay dheereyaan nolosha haddii aan ku sii jiro xaaladaan. If I am sick or injured and my doctors believe there is little chance I will recover the ability to know who I am, who my family and friends are, or where I am, this is my choice: Haddii aan xanuunsanahay ama dhaawac i soo gaaro iyo takhaatiirteyda aaminsan yahiin in ay jirto fursad yar in aan soo ceshto awoodda aan u leeyahay in aan ogaado qofka aan ahay, dadka ay yahiin qoyskeyga iyo asxaabteyda, tani waa wax aan aniga doortay. I want to refuse or stop all treatments. Some examples are a machine that breathes for me (respirator/ventilator), feeding tubes, blood products, antibiotics, or fluids given to me through an IV, treatments for chronic medical conditions, or other medications. Aniga waxaan rabaa in aan diido ama in aan joojiyo dhamaan daweynta. Tusaalooyinka qaar waa mashiin ii neefsada aniga (neefsade/marwaxad), tubooyinka quudinta, maadooyinka dhiigga, antibiyootiko, ama dareeraha leygu siiyo IV, daweynta xaaladaha caafimaadka soo noqnoqda, ama dawooyin kale I want to receive all treatments to keep me alive, unless my doctor determines the treatments would harm me more than help me. Aniga waxaan rabaa in ley siiyo dhamaan daweynta si aan u sii noolaado, haddii takhtarkeyga uusan go aan ku gaarin in daweynta ii keeni doonto waxyeelo ka badan kaalmada aan ka heli doono. With either choice, I understand I will be kept clean and comfortable. I will continue to receive pain and comfort medicines, and food and fluids by mouth if I can swallow safely. Mid kasta aan doorto, Aniga waxaan fahamsanahay in laga shaqeyn doono nadaafadeyda iyo raaxadeyda. Waxaan ku sii socon doonaa in aan afka ka qaato dawooyinka xanuunka iyo fiyoobida, iyo raashin iyo dareere haddii aan si ammaan ah u liqi karo. 12 of

19 2. Cardiopulmonary resuscitation (CPR). Dib u kicinta wadnaha-sambabaha (CPR). Based on my current health, this is my choice about CPR if my heart or breathing stops. Sida ku saleysan caafimaadkaada iminka, tani waa waxa aan doortay oo ku saabsan CPR haddii wadnaheyga ama neefteyda joogsato. I want CPR attempted unless my doctor determines: Aniga waxaan rabaa in leyskudayo CPR haddii takhtarkeyga uu sidaas soo jeediyo. I have a medical condition and no reasonable chance of survival with CPR, Aniga waxaan qabaa xaalad caafimaad mana jirto fursad macquul ah in aan ku noolaan doono CPR, OR AMA CPR would harm me more than help me. CPR waxay i gaarsiin doontaa dhibaato ka badan kaalmada aan ka helo. I do not want CPR. Let me die a natural death. Aniga ma rabo CPR. Aan u dhinto si caadi ah. If you do not want emergency personnel to give you CPR, you will need to talk to your doctor about other documents you need. Haddii aadan rabin in shaqaalaha degdegga ku siyaan CPR, waxaad u baahan tahay in aad takhtarkaada kala hadashid warqadaha kale aad u baahan tahay. 13 of

20 Specific care instructions to meet my goals and preferences in certain situations: Tilmaahmaha daryeelka gaarka ah si loola kulmo ujeedooyinka iyo waxyaabaha aan jeclahay xaaladaha qaar: Comfort preferences: These things are important to me for comfort (for example, favorite music, warm blankets, best positioning in bed). Roonaanta aan Jeclahay: Waxyaabahaan waxay ii yahiin muhiim si aan u helo fiyoobi (tusaale, muusikada aan jeclahay, busto diiran, qaabka ugu wanaagsan sariirta). 14 of

21 Including others when making decisions about my care: (If there is time, try to include these people in my care decisions.) Ku darista dadka kale marka aan go aan ka gaaro daryeelkeyga: (Haddii uu jiro waqti, iskuday in aad ku dartid dadkaan ku lugta leh go aanada daryeelkeyga.) If I am near death and cannot communicate, I want to give my friends and family these personal messages: Haddii aan ku dhawahay dhimasho oo aan awood u lahayn in aan sheego, Aniga waxaan rabaa in asxaabteyda iyo qoyskeyga siiyo fariimahaan shakhsiga: If I am near death, things I would want: (For example, favorite music, rituals, dim lighting, a visit from the hospital chaplain or someone from my faith community.) Haddii aan ku dhawaado dhimasho, waxyaabaha aan rabo: (Tusaale ahaan, muusikada la jecel yahay, hiddaha, iftiinka yar, booqashada wadaadka isbitaalka ama qof ka socda caqiidada bulshadeyda.) 15 of

22 To complete this part: Si aad u dhamaystirtid qeybtaan: Initial or check the box beside the statement you agree with. Ku qor xarfaha hore magacaada ama calaamee sanduuqa ku dhinac yaal oraahda aad waafaqsan tahay. After my death, these are some of my preferences: Kaddib marka aan dhinto, waa kuwaan qaar ka mid ah waxyaabaha aan jeclahay: 1. Donation of my organs or tissue (anatomical gifts) Deeqidda xubnaheyga ama hilibkeyga (deeqda jirka) Examples of organs are kidney, liver, heart, and lungs. Examples of tissue are eyes, skin, bones, and heart valves. Tusaalooyinka la xariira xubnaha waa kilyaha, beerka, wadnaha, iyo sambabaha. Tusaalooyinka hilibka waa indhaha, maqaarka, lafaha, iyo albaabada wadnaha.. A. I do not wish to donate any part of my body. Aniga ma rabi in aan deeq ahaan u bixiyo qeyb ka mid ah jirkeyga. B. After I die, I wish to donate any parts of my body that may help others.* Kaddib marka aan dhinto, Aniga waxaan rabaa in aan deeq ahaan u bixiyo qeybo ka mid ah jirkeyga oo laga yaabo in ay kaalmo u yahiin dad kale.* C. After I die, I wish to donate only these organs and tissue:* Kaddib marka aan dhinto, Aniga waxaan rabaa in aan deeq ahaan u bixiyo oo keliya xubnahaan iyo hilibkaan:* *If you checked B or C, register in your state at to make your preferences legal. *Haddii aad calaameysay sanduuq B ama C, iska diiwaan geli bogga internetka gobolkaada si aad u sharciyeysid waxa aad jeceshahay. 16 of

23 2. Autopsy preference Xulashada baaritaanka sababta ka dambeyso dhimashada Initial or check one box OR both B and C. Ku qor xarfaha magacaada ama calaamee hal sanduuq AMA labadaba B iyo C. A. I do not wish to have an autopsy. Aniga ma rabo in la sameeyo baaritaanka sababta ka dambeyso dhimashadeyda (autopsy). B. I would accept an autopsy if it can help my relatives and/or loved ones understand the cause of my death or if the findings may help them make their own health care choices. Aniga waxaan dooran doonaa in la baaro sababta ka dambeyso dhimashadeyda haddii ay kaalmo u tahay qaraabadeyda iyo/ama kuwa aan jeclahay si ay u fahmaan sababta dhimashadeyda ama haddii natiijadaha ku kaalmeyn karaan iyaga in ay doortaan daryeelka caafimaadkooda. C. I would accept an autopsy if it can help advance medical knowledge or medical education. Waxaan ogolahay in la sameeyo baaritaanka sababta ka dambeyso dhimashadeyda haddii ay kaalmo ka geysan karto horumarinta aqoonta caafimaadka ama barashada caafimaadka. 17 of

24 Part 4: Making the document legal Qeybta 4aad: Sharciyeynta warqadda In Wisconsin: This document must be signed and dated in the presence of two witnesses who meet the qualifications explained below. A notary public cannot be used instead of the two witnesses. Wisconsin: Waa in la saxiixo warqadaan laguna qoro taariikhda, labo marqaati hortooda, kuwaasoo buuxiya sharuudaha lagu sharaxay hoos. Lama adeegsan karo xafiiska dhaarta (notary public) baddalkii labo marqaati. In Minnesota or Iowa: This document must be signed and dated either in the presence of two witnesses who meet the qualifications explained below OR in the presence of a notary public. Minnesota ama Iowa: Waa in la saxiixo warqadaan laguna qoro taariikhda, labo marqaati hortooda, kuwaasoo buuxiya sharuudaha lagu sharaxay hoos AMA xafiiska dhaarta (notary public) hortiisa. My signature and date Saxiixeyga iyo taariikhda I am of sound mind. I agree with everything written in this document. Maskaxdeyda waa fiyowdahay. Aniga waxaan waafaqsanahay wax kasta oo ku qoran warqadaan. I have completed this document of my free will. Aniga waxaan dhamaystiray warqadaan taasoo ku saleysan rabitaankeyga madax banaan. My signature (Saxiixeyga) Date (Taariikhda) If I cannot sign my name, I ask (print name) to sign for me. Haddii aan saxiixi karin magaceyga, Aniga waxaan weydiisanaa (daabac magaca) in uu ii saxiixo. Signature of the person I asked to sign for me Saxiixa qofka aan Aniga weydiistay in uu ii saxiixo 18 of

25 Statement of witnesses Oraahda marqaatiyada A. By signing this document as a witness, I certify I am: Marka aan warqadaan u saxiixo sida marqaati, Aniga waxaan caddeynaa in: At least 18 years old. Aan jiro ugu yaraan 18 sanno. Not related by blood, marriage, domestic partnership, or adoption to the person signing this document. Aan ahayn qaraabo laxmi, guur, iskaashiga guriga, ama uu korsaday qofka saxiixaayo warqadaan. Not a health care agent appointed by the person signing this document. Aan ahayn wakiilka daryeelka caafimaadka uu magacaabay qofka saxiixaayo warqadaan. Not directly financially responsible for this person s health care. Aan toos ahaan mas uul ka ahayn maaliyadda daryeelka caafimaadka qofkaan. Not a health care provider directly serving the person at this time. Aan ahayn bixiyaha daryeelka caafimaadka ee toos ahaan u adeega qofka waqtigaan. Not an employee of a health care provider directly serving the person at this time. In Wisconsin, social workers and chaplains may serve as witnesses even if employed by the health care provider. Aan ahayn shaqaale ka tirsan bixiyaha daryeelka caafimaadka ee toos ahaan u adeega qofka waqtigaan. Wisconsin, shaqaalaha bulshada iyo wadaadada waxay noqon karaan marqaati xattaa haddii ay u shaqeyaan bixiyaha daryeelka caafimaadka. Not aware that I am entitled to or have a claim against the person s estate. Lama socdi in aan Aniga xaq u leeyahay ama leeyahay sheegasho ka soo horjeeda hantida maguuraanka qofka. B. I know this to be the person identified in the document. I believe this person to be of sound mind and at least 18 years old. I personally witnessed this person sign this document, and I believe that this person did so voluntarily. Aniga waan ogsoonahay in kani yahay qofkaa lagu aqoonsaday warqadda. Waxaan aaminsanahay in qofkaan maskaxdiisa caafimaad qabto iyo in uu jiro ugu yaraan 18 sanno. Qof ahaan, waxaan marqaati ka ahaay marka qofkaan uu saxiixay warqadaan, iyo waxaan aaminsanahay in qofkaan uu sidaa u sameyay iskiisa. 19 of

26 Witness Number One: Marqaatiga Nambarka Kowaad: Signature (Saxiixa) Date (Taariikhda) Print name (Daabac magaca) Address (Cinwaanka) City (Magaalada) State/ZIP (Gobolka/ZIP) Witness Number Two: Marqaatiga Nambarka Labaad: Signature (Saxiixa) Date (Taariikhda) Print name (Daabac magaca) Address (Cinwaanka) City (Magaalada) State/ZIP (Gobolka/ZIP) 20 of

27 Instructions for notarization (Minnesota or Iowa only) Residents of Iowa and Minnesota may have the document signed and stamped by a notary public authorized in their state instead of two witnesses. Notary Public: In the state of Minnesota/Iowa (circle one), County of. In my presence on (date), (name) acknowledged his or her signature on this document or authorized the person signing this document to sign on his or her behalf. I am not named as a health care agent or alternate health care agent in this document. Notary stamp (required): Signature of notary Title (and rank) My commission expires (date): 21 of