Advance Directives. Making your health care choices known if you can't speak for yourself.

Size: px
Start display at page:

Download "Advance Directives. Making your health care choices known if you can't speak for yourself."

Transcription

1 Advance Directives Making your health care choices known if you can't speak for yourself.

2 ADVANCE DIRECTIVES Making your health care choices known if you can t speak for yourself This booklet contains Advance Directive forms and general information about making Advance Directives. It is provided courtesy of Bryan Medical Center of Lincoln, Nebraska. For more information or to receive additional copies, call You may complete an Advance Directive before, during your hospital stay or wait until you are back in your own home. It is highly recommended that you take time to read this information, and discuss your wishes with family and loved ones before completing an Advance Directive. If you are a patient at the medical center and desire further assistance in completing an Advance Directive, please tell your nurse.

3 General Information about Advance Directives What are Advance Directives? Advance Directives are legal documents stating your choices about medical treatment or naming the people you want to make these decisions if you are unable to make them for yourself. In Nebraska, there are two types of Advance Directives: the Power of Attorney for Health Care and the Rights of the Terminally Ill Declaration (sometimes called the Living Will ). It is your right as an adult citizen of Nebraska to sign either or both of them. If recovery from a severe medical condition seems unlikely, some patients do not want the burden of continued treatment, but other patients might choose to continue treatment. Your Advance Directive is one way of helping to make sure your own individual values and choices will be respected when you are not able to make your own medical decisions. By completing Advance Directives and talking with your physician and family about your decisions, you can guide the direction of your future care. What is Informed Consent? It is your right as a competent adult patient to consent to or to reject medical or surgical treatment. Your physician will tell you about your medical condition and options for treatment. He or she will talk about the benefits, risks and consequences of starting, stopping or withholding treatment and about other treatment options you may have. The decisions you make should be truly your own, based on what you believe is best. What happens if I don t have an Advance Directive? The presence or absence of an Advance Directive will not prejudice the medical attention you receive. If you are unable to make your own medical decisions and you do not have an Advance Directive, your physician and other health care providers usually ask family members or close friends about your treatment wishes. However, if there is disagreement about what should be done, physicians and your health care facility may seek assistance from the Hospital Ethics Committee, or they may ask the court to appoint a legal guardian to make medical decisions for you. 1

4 How do I make Advance Directives? In order to make an Advance Directive, you must be an adult. In Nebraska, this means you must be 19 years old or older. If you are not yet 19 but are married (or have been married), you are an adult. To make an Advance Directive, read the instructions in this booklet carefully. Then read the Advance Directive forms. Discuss the forms and instructions with your family and your physician. Talk about your treatment options and your feelings, beliefs and values. Then complete the forms according to instructions. Nebraska law does not require you to consult a lawyer to make Advance Directives, although you may find it helpful to visit with a lawyer about making your Advance Directives. When you have filled out your Advance Directives, you must sign and date them in front of witnesses or a notary public. This protects you. The signature of witnesses or a notary shows that no one forced you to sign Advance Directives or signed your name for you. Witnesses should be people who know you, but who are not related to you (by blood, marriage or adoption). You cannot choose anyone who is entitled to any portion of your estate. Your physician cannot be a witness. Your attorney-in-fact or your successor attorney-in-fact cannot be a witness. Anyone employed by your life or health insurance companies cannot be a witness. Only one of the witnesses can be employed by the hospital or care provider where you are a patient or resident. How much do Advance Directives cost? There is no cost to make Advance Directives. Just follow the instructions in this booklet. If you prefer to use a lawyer to make your Advance Directives, then there may be a charge for this service. Can Advance Directives be changed? You can cancel or change your Advance Directives at any time. To cancel an Advance Directive, destroy the original copy. Tell your physician and family members (whoever has a copy) and your health care facility that you have canceled the Advance Directive. To change an Advance Directive, complete a new form and make sure it is signed, dated and witnessed or notarized. This can be done at any time as long as you are competent to make your own medical decisions. 2

5 When do Advance Directives take effect? Advance Directives become legal documents when you sign and date the completed forms and have them witnessed or notarized. It is important to remember that your Advance Directives will not be used as long as you are able to make your own medical decisions and give informed consent. If you can t make your own medical decisions (either temporarily or permanently), your Advance Directives take effect. If you wish, specify in your Advance Directives that a determination that you are incapable of making health care decisions must be confirmed by a second physician. Will my Advance Directives be followed? Yes, as long as they are in keeping with the laws of Nebraska. When you become a patient or resident, your healthcare facility will ask for copies of your Advance Directives which will become a part of your medical record. If your healthcare providers cannot follow the instructions in your Advance Directives for any reason, they must tell you and help arrange for your transfer to another care provider or facility. Will my Nebraska Advance Directives be honored in another state? Laws about Advance Directives are different in each state. So, if you plan to spend more than just a little time in another state, you may wish to sign Advance Directive forms for that state. Making Advance Directives in another state does not invalidate your Nebraska Advance Directives. Are Advance Directives from another state valid in Nebraska? Advance Directives that comply with another state s laws will be honored in Nebraska if they comply with Nebraska law. Must an Advance Directive be renewed? No. Once you have signed and dated your Advance Directives and had them properly signed or notarized, they remain in effect for an indefinite period of time (unless you cancel or change them). However, it is a good idea to review your Advance Directives periodically, especially if there have been important changes in your medical condition or family situation. What should I do with my Advance Directives? When you have signed and dated your completed Advance Directives and had them witnessed or notarized, keep the original documents in a safe and convenient place but not in a safe deposit box. Give copies to your attorney-in-fact, to family members or close friends and to your physician and tell them where the originals are kept. You also may want to give copies to other people, such as your clergy person and your lawyer. Keep a card in your wallet that shows you have Advance Directives. A wallet card is provided at the back of this booklet. 3

6 Information about the Power of Attorney for Health Care What is a Power of Attorney for Health Care (PAHC)? A PAHC is a legal document that gives the person you designate as your attorney-in-fact the power to make health care decisions for you when you are temporarily or permanently unable to make decisions for yourself. Usually people choose their spouse or another family member, a clergy person or a close friend. Your attorney-in-fact must be an adult and should be someone who knows you well and respects your decisions about medical treatment. Discuss your decisions, wishes and beliefs with the person you choose to make sure he or she accepts the responsibility of making medical decisions for you. The person you designate has a duty to act consistently with your desires as stated in your PAHC or otherwise made known by you. If your wishes are unknown, he or she must act in your best interests. The person you designate has the right to withdraw from this duty at any time. You cannot appoint any of these people as your attorney-in-fact: Your physician, An employee of your physician (unless he or she is related to you by blood, marriage or adoption), An owner, operator or employee of the health care facility in which you are a patient or resident (unless he or she is related to you by blood, marriage or adoption). You also can appoint a successor attorney-in-fact to be an alternate decision maker if your attorney-in-fact is unavailable. He or she then would have the same powers as your attorney-in-fact. Neither your attorney-in-fact nor your successor attorney-in-fact can be held liable for treatment decisions they make in good faith or for the cost of any treatment authorized just because he or she is your attorney-in-fact. Is a Power of Attorney for Health Care (PAHC) the same as a Power of Attorney? Power of Attorney documents usually refer to financial decisions but some may contain a section on health care decisions as well. A PAHC deals only with health care and does not give your attorney-in-fact the power to make financial decisions on other non-medical decisions for you. 4

7 Should I have both a PAHC and a Living Will? A PAHC takes effect whenever you are unable to make your own medical decisions. In your PAHC, you may give your attorney-in-fact instructions about what you do and do not want done for you. Following your guidelines, your attorney-in-fact is able to make decisions in all types of health care situations, even those you may not have been able to anticipate. For this reason, it is important to choose someone you trust as your attorney-in-fact. Some people may not have close family or know anyone they would feel comfortable naming as their attorney-in-fact. A Living Will may be helpful for them. A Living Will takes effect only when you have a terminal illness or are in a persistent vegetative state and cannot speak for yourself. What instructions should I give my attorney-in-fact? Your instructions should reflect your own personal values, beliefs and faith. Your instructions should address the use of life-sustaining procedures, such as: A mechanical ventilator (respirator), which helps breathe for you; Kidney dialysis, which is used if your kidneys can t function; Cardiopulmonary resuscitation (CPR), which is used if your heart or breathing stops; or Artificially administered nutrition (food) and hydration (fluids). Life-sustaining procedures do not provide a cure for a terminal illness. They may prolong the process of dying. In this booklet you will find two PAHC forms. They are identical except that one form has blank spaces in which you can write your instructions, limitations and decisions about life-sustaining treatment and/or artificially administered nutrition and hydration. Because some people are not sure what instructions to write, another form is provided that has examples of instructions. If these instructions are satisfactory to you, you can sign this form instead. Or you can use these instructions as examples in writing your own instructions. Although you are not obligated to give instructions in your PAHC, your attorney-in-fact will not have the authority to consent to the withholding or withdrawal of life sustaining procedures or artificially administered nutrition and hydration unless you give him or her that authority. What is a Living Will? A Living Will (known officially in Nebraska as the Rights of the Terminally Ill Declaration) is a legal document that takes effect if you have a terminal illness or are in a persistent vegetative state and cannot make your own medical decisions. This document tells your physician and health care facility that you do not want life-sustaining procedures. It also affirms your decision to accept or continue any treatments or procedures that are given for the purpose of making you comfortable or alleviating pain. 5

8 Information about the Living Will Rights of the Terminally Ill Declaration Is a Living Will the same as a will or a living trust? No, they are not the same. A Living Will takes effect while you are alive but a will takes effect only after your death. Wills and living trusts assure the distribution of your financial assets but say nothing about your medical wishes and decisions. What is an incurable, irreversible condition? An incurable and irreversible condition is a terminal disease or medical condition that has no presently known medical cure and that is expected to lead to death within a fairly short time, usually several weeks or months. What is a persistent vegetative state? A persistent vegetative state is a condition of irreversible unconsciousness or permanent coma in which a patient is completely unaware of self, loved ones, events or surroundings. Persistent means that this condition cannot change, and presently there is no known medical cure. When does a Living Will take effect in Nebraska? A Nebraska Living Will takes effect only when: You have been diagnosed by a physician to have an irreversible and incurable condition or a persistent vegetative state. You are not able to make your own medical decisions. In addition, a Nebraska Living Will cannot take effect if you are pregnant and it is probable that the unborn child will develop to the point of a live birth with the continued use of life-sustaining procedures. 6

9 NEBRASKA POWER OF ATTORNEY FOR HEALTH CARE I appoint, whose address is, and whose telephone number is ( ), as my attorney-in-fact for health care. I appoint, whose address is, and whose telephone number is ( ), as my successor attorney-in-fact for health care. I authorize my attorney-in-fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions. I have read the warnings stated in this document and understand the consequences of executing a power of attorney for health care. I direct that my attorney-in-fact comply with the following instructions or limitations: I direct my attorney-in-fact to authorize the withholding or withdrawal of any medical procedure, treatment or intervention that uses mechanical or other artificial means to sustain, restore, or supplant a spontaneous vital function which would, when applied to me, serve only to prolong my dying process or persistent vegetative state. I direct that my attorney-in-fact comply with the following instructions on life-sustaining treatment: If I should lapse into a persistent vegetative state or have an incurable and irreversible condition that, without the administration of life-sustaining treatment which could include but is not limited to artificially administered nutrition and hydration, will, in the opinion of my attending physician, serve only to prolong my dying process or persistent vegetative state, I direct my attorney-in-fact to authorize the withholding or withdrawal of life-sustaining treatment that is not necessary for my comfort or to alleviate pain. I direct that my attorney-in-fact comply with the following instructions on artificially administered nutrition and hydration: I direct my attorney-in-fact to authorize the withholding or withdrawal of artificially administered nutrition and hydration which would, when given to me, serve only to prolong my dying process or my persistent vegetative state. 7

10 I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY ATTORNEY-IN-FACT, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN. DECLARANT SIGNATURE Signed this day of, 20 Signature Social Security Number Printed Name Printed Address DECLARATION OF WITNESSES We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care in our presence, that the principal appears to be of sound mind and not under duress or undue influence, and that neither of us nor the principal s attending physician is the person appointed as attorney-in-fact by this document. Witnessed By: (Signature of Witness/Date) (Signature of Witness/Date) (Printed Name of Witness) (Printed Name of Witness) - OR - NOTARY (You may sign this document before a notary public instead of having it witnessed above.) State of Nebraska ) ) ss. County of ) Notary Public My commission expires 8

11 NEBRASKA POWER OF ATTORNEY FOR HEALTH CARE I appoint, whose address is, and whose telephone number is ( ), as my attorney-in-fact for health care. I appoint, whose address is, and whose telephone number is ( ), as my successor attorney-in-fact for health care. I authorize my attorney-in-fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions. I have read the warnings stated in this document and understand the consequences of executing a power of attorney for health care. I direct that my attorney-in-fact comply with the following instructions or limitations: I direct that my attorney-in-fact comply with the following instructions on life-sustaining treatment: I direct that my attorney-in-fact comply with the following instructions on artificially administered nutrition and hydration: 9

12 I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY ATTORNEY-IN-FACT, MY PHYSICIAN OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN. DECLARANT SIGNATURE Signed this day of, 20 Signature Social Security Number Printed Name Printed Address DECLARATION OF WITNESSES We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care in our presence, that the principal appears to be of sound mind and not under duress or undue influence, and that neither of us nor the principal s attending physician is the person appointed as attorney-in-fact by this document. Witnessed By: (Signature of Witness/Date) (Signature of Witness/Date) (Printed Name of Witness) (Printed Name of Witness) - OR - NOTARY (You may sign this document before a notary public instead of having it witnessed above.) State of Nebraska ) ) ss. County of ) Notary Public My commission expires: 10

13 RIGHTS OF THE TERMINALLY ILL DECLARATION (NEBRASKA LIVING WILL DECLARATION) If I should lapse into a persistent vegetative state or have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Rights of the Terminally Ill Act, to withhold or withdraw life-sustaining treatment that is not necessary for my comfort or to alleviate pain. DECLARANT SIGNATURE Signed this day of, 20 Signature Social Security Number Printed Name Printed Address DECLARATION OF WITNESSES We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this Rights of the Terminally Ill Declaration in our presence and that the principal appears to be of sound mind and not under duress or undue influence. Witnessed By: (Signature of Witness/Date) (Signature of Witness/Date) (Printed Name of Witness) (Printed Name of Witness) - OR - NOTARY (You may sign this document before a notary public instead of having it witnessed above.) State of Nebraska ) ) ss. County of ) Notary Public My commission expires: 11

14 12

15 What Should I Do With My Advance Directives? You should send a completed copy to the people who are likely to be asked about your choices. For your records, you can write below the names of the people who have a copy of your Advance Directives or who know what kind of health care you want. Family members Attorney-in-fact for health care Physician Other health care provider(s) Attorney Clergy person Hospital Other health care facility NOTICE TO HEALTH CARE PROVIDERS Name Social Security Number I have a living will. I have a power of attorney for health care and my attorney-in-fact is: Name Phone (day) (evening) (over) FOLD Copies of this document have been given to: Phone Phone Phone Bryan Medical Center 1600 S. 48th St. Lincoln, NE bryanhealth.org Clip

16 Bryan Medical Center Bryan East Campus 1600 S. 48th St. Lincoln, NE bryanhealth.org Form 354, (Rev. 03/18) Bryan Medical Center Bryan West Campus 2300 S. 16th St. Lincoln, NE

Planning Ahead: How to Make Future Health Care Decisions NOW. Washington

Planning Ahead: How to Make Future Health Care Decisions NOW. Washington Washington Planning Ahead: How to Make Future Health Care Decisions NOW Your Questions Answered About Washington Living Wills and Powers of Attorney for Health Care Table of Contents P 1 What You Need

More information

Health Care Directive. Choose whether you want life-sustaining treatments in certain situations.

Health Care Directive. Choose whether you want life-sustaining treatments in certain situations. Durable Power of Attorney (DPOA) for Health Care Health Care Directive Documents are legally valid in Washington What is advance care planning? Advance care planning is for all adults 18 and older. It

More information

Health Care Directive. Choose whether you want life-sustaining treatments in certain situations.

Health Care Directive. Choose whether you want life-sustaining treatments in certain situations. Durable Power of Attorney (DPOA) for Health Care Health Care Directive Documents are legally valid in Washington What is advance care planning? Advance care planning is for all adults 18 and older. It

More information

A PERSONAL DECISION

A PERSONAL DECISION A PERSONAL DECISION Practical information about determining your future medical care including declaration, powers of attorney for health care and organ donation Determining Your Medical Care is Your

More information

NEBRASKA Advance Directive Planning for Important Health Care Decisions

NEBRASKA Advance Directive Planning for Important Health Care Decisions NEBRASKA Advance Directive Planning for Important Health Care Decisions CaringInfo 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 CaringInfo, a program of the National Hospice

More information

Thank you for your interest in completing an Advance Directive.

Thank you for your interest in completing an Advance Directive. Advance Directives Thank you for your interest in completing an Advance Directive. Writing an Advance Directive is an opportunity to direct your future health needs in advance of an illness or crisis.

More information

Advance Directives. Important information on health care decision-making: You Have the Right to Decide

Advance Directives. Important information on health care decision-making: You Have the Right to Decide Advance Directives Important information on health care decision-making: You Have the Right to Decide The documents provided in this package are being presented to you in accordance with the Federal Patient

More information

ALASKA ADVANCE HEALTH CARE DIRECTIVE for Client

ALASKA ADVANCE HEALTH CARE DIRECTIVE for Client ALASKA ADVANCE HEALTH CARE DIRECTIVE for Client PART 1 DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS (1) DESIGNATION OF AGENT. I designate the following individual as my agent to make health care

More information

CALIFORNIA Advance Directive Planning for Important Health care Decisions

CALIFORNIA Advance Directive Planning for Important Health care Decisions CALIFORNIA Advance Directive Planning for Important Health care Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program

More information

INSTRUCTIONS FOR YOUR CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE

INSTRUCTIONS FOR YOUR CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE California maintains an Advance Directive Registry. By filing your advance directive with the registry, your health care provider and loved ones may be able to find a copy of your directive in the event

More information

Advance Directives The Patient s Right To Decide CH Oct. 2013

Advance Directives The Patient s Right To Decide CH Oct. 2013 Advance Directives The Patient s Right To Decide CH80850040 Oct. 2013 Advance Directives Your Right To Make Health Care Decisions Under The Law In Tennessee Tennessee and federal law give every competent

More information

UNDERSTANDING ADVANCE DIRECTIVES

UNDERSTANDING ADVANCE DIRECTIVES UNDERSTANDING ADVANCE DIRECTIVES If you have questions, call 377-3439 or pager 790-7284. Watch the Advance Directives film on Channel 4 at 9:00 a.m. and 5:30 p.m. NORTH MISSISSIPPI MEDICAL CENTER North

More information

YOUR RIGHT TO MAKE YOUR OWN HEALTH CARE DECISIONS

YOUR RIGHT TO MAKE YOUR OWN HEALTH CARE DECISIONS Upon admission to Western Connecticut Health Network, you will be asked if you have any form of an Advance Directive such as a Living Will or a Health Care Representative. If you have such a document,

More information

Making Decisions About Your Health Care. (Information about Durable Power of Attorney for Health Care and Living Wills)

Making Decisions About Your Health Care. (Information about Durable Power of Attorney for Health Care and Living Wills) Making Decisions About Your Health Care (Information about Durable Power of Attorney for Health Care and Living Wills) Following guidelines set by federal regulations, we would like to inform you of your

More information

NEW HAMPSHIRE ADVANCE DIRECTIVE PAGE 4 OF 11 PART I: NEW HAMPSHIRE DURABLE POWER OF ATTORNEY FOR HEALTH CARE. I,, (name)

NEW HAMPSHIRE ADVANCE DIRECTIVE PAGE 4 OF 11 PART I: NEW HAMPSHIRE DURABLE POWER OF ATTORNEY FOR HEALTH CARE. I,, (name) NEW HAMPSHIRE ADVANCE DIRECTIVE PAGE 4 OF 11 PART I: NEW HAMPSHIRE DURABLE POWER OF ATTORNEY FOR HEALTH CARE PRINT YOUR NAME PRINT THE NAME AND ADDRESS OF YOUR AGENT I,, (name) hereby appoint (name of

More information

YOUR RIGHT TO DECIDE YOUR RIGHT TO DECIDE YOUR RIGHT TO DECIDE

YOUR RIGHT TO DECIDE YOUR RIGHT TO DECIDE YOUR RIGHT TO DECIDE YOUR RIGHT TO DECIDE YOUR RIGHT TO DECIDE YOUR RIGHT TO DECIDE YOUR RIGHT TO DECIDE Communicating Your Health Care Choices In 1990, Congress passed the Patient Self-Determination Introduction Act. It requires

More information

NEW HAMPSHIRE Advance Directive Planning for Important Health Care Decisions

NEW HAMPSHIRE Advance Directive Planning for Important Health Care Decisions NEW HAMPSHIRE Advance Directive Planning for Important Health Care Decisions CaringInfo 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 CaringInfo, a program of the National

More information

INDIANA Advance Directive Planning for Important Health Care Decisions

INDIANA Advance Directive Planning for Important Health Care Decisions INDIANA Advance Directive Planning for Important Health Care Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program of

More information

CONNECTICUT Advance Directive Planning for Important Health Care Decisions

CONNECTICUT Advance Directive Planning for Important Health Care Decisions CONNECTICUT Advance Directive Planning for Important Health Care Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program

More information

Advance Directives. Planning Ahead For Your Healthcare

Advance Directives. Planning Ahead For Your Healthcare Advance Directives Planning Ahead For Your Healthcare Core Values Catholic Health Initiatives core values of Reverence, Integrity, Compassion, and Excellence are the guiding principles that provide focus,

More information

NEBRASKA Advance Directive Planning for Important Healthcare Decisions

NEBRASKA Advance Directive Planning for Important Healthcare Decisions NEBRASKA Advance Directive Planning for Important Healthcare Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program of

More information

CALIFORNIA Advance Directive Planning for Important Health Care Decisions

CALIFORNIA Advance Directive Planning for Important Health Care Decisions CALIFORNIA Advance Directive Planning for Important Health Care Decisions Caring Info 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Info, a program of the National

More information

WEST VIRGINIA Advance Directive Planning for Important Health Care Decisions

WEST VIRGINIA Advance Directive Planning for Important Health Care Decisions WEST VIRGINIA Advance Directive Planning for Important Health Care Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program

More information

CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE

CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE Explanation You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you.

More information

My Voice - My Choice

My Voice - My Choice My Voice - My Choice My Advance Directive Table of Contents Introduction... 2 Words You Need to Know... 3 Legal Document... 4 Helpful Information about your Advance Directive... 10 What makes your life

More information

ADVANCE HEALTH CARE DIRECTIVE Including Power of Attorney for Health Care (California Probate Code Sections effective JULY 1, 2000)

ADVANCE HEALTH CARE DIRECTIVE Including Power of Attorney for Health Care (California Probate Code Sections effective JULY 1, 2000) ADVANCE HEALTH CARE DIRECTIVE Including Power of Attorney for Health Care (California Probate Code Sections 4600-4805 effective JULY 1, 2000) Introduction. This form lets you exercise your right to give

More information

LOUISIANA ADVANCE DIRECTIVES

LOUISIANA ADVANCE DIRECTIVES LOUISIANA ADVANCE DIRECTIVES Legal Documents To Make Sure Your Choices for Future Medical Care or the Refusal of Same are Honored and Implemented by Your Health Care Providers ADVANCE DIRECTIVES INTRODUCTION

More information

STATUTORY FORM ADVANCE HEALTH CARE DIRECTIVE (California Probate Code Section 4701)

STATUTORY FORM ADVANCE HEALTH CARE DIRECTIVE (California Probate Code Section 4701) STATUTORY FORM ADVANCE HEALTH CARE DIRECTIVE (California Probate Code Section 4701) EXPLANATION You have the right to give instructions about your own health care. You also have the right to name someone

More information

Saint Agnes Medical Center. Guidelines for Signers

Saint Agnes Medical Center. Guidelines for Signers 597 Saint Agnes Medical Center Page 1 Guidelines for Signers What is an Advance Health Care Directive? An "Advance Health Care Directive" is a document you can use to appoint another person, such as a

More information

State of Ohio Health Care Power of Attorney of

State of Ohio Health Care Power of Attorney of Page1 State of Ohio Health Care Power of Attorney of (Print Full Name) (Birth Date) I state that this is my Health Care Power of Attorney and I revoke any prior Health Care Power of Attorney signed by

More information

Georgia Advance Directive for Healthcare

Georgia Advance Directive for Healthcare Navicent Health Georgia Advance Directive for Healthcare GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE By: Date of Birth: (Print Name) (Month/Day/Year) PART ONE HEALTH CARE AGENT This part allows you to choose

More information

CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE (California Probate Code Section 4701)

CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE (California Probate Code Section 4701) CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE (California Probate Code Section 4701) You have the right to give instructions about your own health care. You also have the right to name someone else to make

More information

Advanced Directive. Artificial nutrition and hydration--when food and water are fed to a person through a tube.

Advanced Directive. Artificial nutrition and hydration--when food and water are fed to a person through a tube. This form is a combined durable power of attorney for health care and a living will (in some jurisdictions). With this form, you can name someone to make medical decisions for you if in the future you're

More information

Your Guide to Advance Directives

Your Guide to Advance Directives Starting Points: Your Guide to Advance Directives Values Statements Healthcare Directives Durable Power of Attorney for Healthcare 1 2 Advances in medicine are helping people to live longer than ever before.

More information

Frequently Asked Questions and Forms

Frequently Asked Questions and Forms 1-877-209-8086 www.wvendoflife.org Advance Directives for Health Care Decision-Making in West Virginia Frequently Asked Questions and Forms FORMS INSIDE: Living Will - Medical Power of Attorney Combined

More information

FORM 1 Health care power of attorney PAGE 1

FORM 1 Health care power of attorney PAGE 1 FORM 1 Health care power of attorney PAGE 1 This form allows you, the principal, to name a person to make health care decisions for you if you are unable to do so. You should also name alternate agents

More information

SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY

SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY INFORMATION ABOUT THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: 1. THIS DOCUMENT GIVES

More information

ADVANCE DIRECTIVE Planning Guide. Information Provided as a Community Service

ADVANCE DIRECTIVE Planning Guide. Information Provided as a Community Service ADVANCE DIRECTIVE Planning Guide Information Provided as a Community Service If a medical tragedy strikes, you have the RIGHT TO CHOOSE what medical care you do or do not want. It is best if you make this

More information

CONNECTICUT Advance Directive Planning for Important Health Care Decisions

CONNECTICUT Advance Directive Planning for Important Health Care Decisions CONNECTICUT Advance Directive Planning for Important Health Care Decisions CaringInfo 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 CaringInfo, a program of the National

More information

ADVANCE HEALTH CARE DIRECTIVE

ADVANCE HEALTH CARE DIRECTIVE FORM 3-1 ADVANCE HEALTH CARE DIRECTIVE INSTRUCTIONS Part 1 of this form lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions,

More information

Advance Health Care Directive Form Instructions

Advance Health Care Directive Form Instructions Advance Health Care Directive Form Instructions You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. The

More information

Hillside Memorial Park and Mortuary Advance Health Care Directive

Hillside Memorial Park and Mortuary Advance Health Care Directive Hillside Memorial Park and Mortuary Advance Health Care Directive Advance Health Care Directive This booklet lets you name another individual as an agent to make health care decisions for you if you are

More information

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE By: Date of Birth: (Print Name) (Month/Day/Year) This advance directive for health care has four parts: PART ONE HEALTH CARE AGENT. This part allows you to choose

More information

LOUISIANA ADVANCE DIRECTIVES

LOUISIANA ADVANCE DIRECTIVES LOUISIANA ADVANCE DIRECTIVES Legal Documents that Ensure that Your Choices for Future Medical Care or the Refusal of Same are Honored and Implemented by Your Health Care Providers Peoples Health is a Medicare

More information

Basic Guidelines for Using the Advance Health Care Directive Form

Basic Guidelines for Using the Advance Health Care Directive Form Basic Guidelines for Using the Advance Health Care Directive Form Is this AHCD different from a durable power of attorney for health care or declaration to physician? Yes and no. The other two forms are

More information

Advance Health Care Directives. Form Instructions

Advance Health Care Directives. Form Instructions Advance Health Care Directives Form Instructions You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you.

More information

GEORGIA S ADVANCE DIRECTIVE FOR HEALTH CARE

GEORGIA S ADVANCE DIRECTIVE FOR HEALTH CARE GEORGIA S ADVANCE DIRECTIVE FOR HEALTH CARE The Georgia General Assembly has long recognized the right of individuals to control all aspects of their personal care and medical treatment, including the

More information

OHIO Advance Directive Planning for Important Health Care Decisions

OHIO Advance Directive Planning for Important Health Care Decisions OHIO Advance Directive Planning for Important Health Care Decisions Caring Info 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Info, a program of the National Organization

More information

Your Right to Make Health Care Decisions in Colorado

Your Right to Make Health Care Decisions in Colorado Your Right to Make Health Care Decisions in Colorado This e-book informs you about your right to make health care decisions, including the right to accept or refuse medical treatment. It explains the following

More information

ADVANCE DIRECTIVE INFORMATION

ADVANCE DIRECTIVE INFORMATION ADVANCE DIRECTIVE INFORMATION NOTE: This Advance Directive Information and the form Living Will and Durable Power of Attorney for Health Care on the Arkansas Bar Association s website are being provided

More information

Georgia Advance Directive for Health Care

Georgia Advance Directive for Health Care Georgia Advance Directive for Health Care By: (Print Name) Date of Birth: (Month/Day/Year) This advance directive for health care has four parts: PART ONE PART TWO PART THREE HEALTH CARE AGENT. This part

More information

ADVANCE HEALTH CARE DIRECTIVE (California Probate Code Section 4701)

ADVANCE HEALTH CARE DIRECTIVE (California Probate Code Section 4701) ADVANCE HEALTH CARE DIRECTIVE (California Probate Code Section 4701) For: EXPLANATION You have the right to give instructions about your own health care. You also have the right to name someone else to

More information

A Personal Decision. Illinois State Medical Society. Practical Information About Determining Your Future Medical Care.

A Personal Decision. Illinois State Medical Society. Practical Information About Determining Your Future Medical Care. A Personal Decision 2016 EDITION Practical Information About Determining Your Future Medical Care Living wills Powers of attorney for health care Mental health treatment preference declarations Uniform

More information

Advance Health Care Directive (California Probate Code section 4701)

Advance Health Care Directive (California Probate Code section 4701) Advance Health Care Directive (California Probate Code section 4701) PART 1 Power of Attorney For Health Care 1.1 DESIGNATION OF AGENT: I designate the following individual as my agent to make health care

More information

COLORADO Advance Directive Planning for Important Health Care Decisions

COLORADO Advance Directive Planning for Important Health Care Decisions COLORADO Advance Directive Planning for Important Health Care Decisions CaringInfo 1731 King St., Suite 100 Alexandria, VA 22314 www.caringinfo.org 800/658-8898 CaringInfo, a program of the National Hospice

More information

Health Care Proxy Appointing Your Health Care Agent in New York State

Health Care Proxy Appointing Your Health Care Agent in New York State Health Care Proxy Appointing Your Health Care Agent in New York State The New York Health Care Proxy Law allows you to appoint someone you trust for example, a family member or close friend to make health

More information

Directive To Physicians and Family Or Surrogates (Living Will)

Directive To Physicians and Family Or Surrogates (Living Will) Directive To Physicians and Family Or Surrogates (Living Will) INSTRUCTIONS FOR COMPLETING THIS DOCUMENT: This is an important legal document known as an Advance Directive. It is designed to help you communicate

More information

ADVANCE HEALTH CARE DIRECTIVE. (California Probate Code Section 4701) Explanation

ADVANCE HEALTH CARE DIRECTIVE. (California Probate Code Section 4701) Explanation ADVANCE HEALTH CARE DIRECTIVE (California Probate Code Section 4701) Explanation You have the right to give instructions about your own health care. You also have the right to name someone else to make

More information

Your Right To Make Your Own Health Care Decisions

Your Right To Make Your Own Health Care Decisions Your Right To Make Your Own Health Care Decisions Sinai Hospital of Baltimore 2401 West Belvedere Avenue Baltimore, Maryland 21215-5271 WHAT YOU NEED TO KNOW ABOUT ADVANCE DIRECTIVES Sinai Hospital is

More information

ADVANCE DIRECTIVE Your Durable Power ofattorney for Health Care, Living Will and Other Wishes

ADVANCE DIRECTIVE Your Durable Power ofattorney for Health Care, Living Will and Other Wishes ADVANCE DIRECTIVE Your Durable Power ofattorney for Health Care, Living Will and Other Wishes Introduction: INSTRUCTIONS AND DEFINITIONS This form is a combined Durable Power of Attorney for Health Care

More information

Advance Directive. my wish for: my voice my choice. health care power of attorney and living will

Advance Directive. my wish for: my voice my choice. health care power of attorney and living will health care power of attorney and living will print your name date of birth for information contact: patient relations at 910 615-6120 my voice my choice. my wish for: The person I want to make care decisions

More information

NEVADA Advance Directive Planning for Important Health Care Decisions

NEVADA Advance Directive Planning for Important Health Care Decisions NEVADA Advance Directive Planning for Important Health Care Decisions CaringInfo 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 CaringInfo, a program of the National Organization

More information

GEORGIA Advance Directive Planning for Important Health Care Decisions

GEORGIA Advance Directive Planning for Important Health Care Decisions GEORGIA Advance Directive Planning for Important Health Care Decisions CaringInfo 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 CaringInfo, a program of the National Organization

More information

TENNESSEE Advance Directive Planning for Important Healthcare Decisions

TENNESSEE Advance Directive Planning for Important Healthcare Decisions TENNESSEE Advance Directive Planning for Important Healthcare Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program of

More information

WISCONSIN Advance Directive Planning for Important Health Care Decisions

WISCONSIN Advance Directive Planning for Important Health Care Decisions WISCONSIN Advance Directive Planning for Important Health Care Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program

More information

Part One: Durable Power of Attorney for Health Care Decisions GRANT OF AUTHORITY TO AGENT. I,, (name) designate and appoint: (name of agent) (address)

Part One: Durable Power of Attorney for Health Care Decisions GRANT OF AUTHORITY TO AGENT. I,, (name) designate and appoint: (name of agent) (address) INSTRUCTIONS KANSAS ADVANCE DIRECTIVE PAGE 1 OF 5 Part One: Durable Power of Attorney for Health Care Decisions GRANT OF AUTHORITY TO AGENT PRINT YOUR NAME PRINT THE NAME, ADDRESS, AND TELEPHONE NUMBERS

More information

ADVANCE MEDICAL DIRECTIVES

ADVANCE MEDICAL DIRECTIVES ADVANCE MEDICAL DIRECTIVES Health Care Declaration (Living Will) and Medical Power of Attorney What is an Advance Directive? Many people are concerned about what would happen if, due to a mental or physical

More information

ADVANCE HEALTH CARE DIRECTIVE HEALTH CARE POWER OF ATTORNEY AND LIVING WILL

ADVANCE HEALTH CARE DIRECTIVE HEALTH CARE POWER OF ATTORNEY AND LIVING WILL ADVANCE HEALTH CARE DIRECTIVE A HEALTH CARE POWER OF ATTORNEY AND LIVING WILL INSIDE: LEGAL DOCUMENTS AND INSTRUCTIONS TO ASSIST YOU WITH IMPORTANT HEALTH CARE DECISIONS Health Care Decision Making Modern

More information

ILLINOIS Advance Directive Planning for Important Health Care Decisions

ILLINOIS Advance Directive Planning for Important Health Care Decisions ILLINOIS Advance Directive Planning for Important Health Care Decisions CaringInfo 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 CaringInfo, a program of the National Hospice

More information

~ Rhode Island ~ Durable Power of Attorney For Health Care Christian Version

~ Rhode Island ~ Durable Power of Attorney For Health Care Christian Version ~ Rhode Island ~ Durable Power of Attorney For Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT You have the right to make decisions about your health care. No health care may be given

More information

MISSOURI Advance Directive Planning for Important Healthcare Decisions

MISSOURI Advance Directive Planning for Important Healthcare Decisions MISSOURI Advance Directive Planning for Important Healthcare Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program of

More information

An Advance Directive For North Carolina

An Advance Directive For North Carolina Introduction An Advance Directive For North Carolina A Practical Form for All Adults This form allows you to express your wishes for future health care and to guide decisions about that care. It does not

More information

MASSACHUSETTS ADVANCE DIRECTIVES

MASSACHUSETTS ADVANCE DIRECTIVES MASSACHUSETTS ADVANCE DIRECTIVES Advance directives are legal documents that protect your right to refuse medical treatment you do not want, or to request treatment you do want, in the event you lose the

More information

PART 1 POWER OF ATTORNEY FOR HEALTH CARE. (address) (city) (state) (zip code)

PART 1 POWER OF ATTORNEY FOR HEALTH CARE. (address) (city) (state) (zip code) [PRINT THIS FORM] PART 1 POWER OF ATTORNEY FOR HEALTH CARE (1.1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me: OPTIONAL: If I revoke my agent's

More information

DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES Advance Directives Act (see , Health and Safety Code) DIRECTIVE

DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES Advance Directives Act (see , Health and Safety Code) DIRECTIVE DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES Advance Directives Act (see 166.033, Health and Safety Code) Instructions for completing this document: This is an important legal document known as an

More information

PATIENT INFORMATION ON NEVADA STATE LAW CONCERNING ADVANCE DIRECTIVES TODAY S HEALTHCARE CHOICES

PATIENT INFORMATION ON NEVADA STATE LAW CONCERNING ADVANCE DIRECTIVES TODAY S HEALTHCARE CHOICES PATIENT INFORMATION ON NEVADA STATE LAW CONCERNING ADVANCE DIRECTIVES Attachment A TODAY S HEALTHCARE CHOICES Years ago we didn t have the choices in medical care that we have today. Seriously ill people,

More information

DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Rhode Island Version) You must be at least eighteen (18) years of age.

DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Rhode Island Version) You must be at least eighteen (18) years of age. MASSASOIT INTERNAL MEDICINE (401) 434-2704 massasoitmed.com DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Rhode Island Version) THE DURABLE POWER OF ATTORNEY FOR HEALTH CARE DOCUMENT lets you appoint someone

More information

WASHINGTON STATUTORY HEALTH CARE DIRECTIVE

WASHINGTON STATUTORY HEALTH CARE DIRECTIVE WASHINGTON STATUTORY HEALTH CARE DIRECTIVE Directive made this day of (month, year). I, having the capacity to make health care decisions, willfully, and voluntarily make known my desire that my dying

More information

State of Ohio Living Will Declaration with Donor Registry Enrollment Form and State of Ohio Health Care Power of Attorney

State of Ohio Living Will Declaration with Donor Registry Enrollment Form and State of Ohio Health Care Power of Attorney State of Ohio Living Will Declaration with Donor Registry Enrollment Form and State of Ohio Health Care Power of Attorney May 2012 Ohio State Bar Association State of Ohio Living Will Declaration Notice

More information

~ Tennessee ~ Advance Directive and Appointment of Health Care Agent Christian Version WARNING TO PERSON EXECUTING THIS DOCUMENT

~ Tennessee ~ Advance Directive and Appointment of Health Care Agent Christian Version WARNING TO PERSON EXECUTING THIS DOCUMENT ~ Tennessee ~ Advance Directive and Appointment of Health Care Agent Christian Version WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document. Before executing this document you

More information

RHODE ISLAND DECLARATION

RHODE ISLAND DECLARATION RHODE ISLAND DECLARATION I,, being of sound mind willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare:

More information

VIRGINIA Advance Directive Planning for Important Health Care Decisions

VIRGINIA Advance Directive Planning for Important Health Care Decisions VIRGINIA Advance Directive Planning for Important Health Care Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 CARING CONNECTIONS Caring Connections,

More information

Advance Directive for Health Care

Advance Directive for Health Care Advance Directive for Health Care Inmate Name: Date: CDC Number: Date of Birth: / / Institution: What is an Advance Directive for Health Care? Advance directive is a general term used for documents that

More information

REVISED 2005 EDITION. A Personal Decision

REVISED 2005 EDITION. A Personal Decision REVISED 2005 EDITION A Personal Decision Practical information about determining your future medical care, including living wills, powers of attorney for health care, mental health treatment preference

More information

ATTORNEY COUNTY OF. Page 1 of 5

ATTORNEY COUNTY OF. Page 1 of 5 STATE OF NORTH CAROLINA HEALTH CARE POWER OF ATTORNEY COUNTY OF (Notice: This document gives the person you designate your health care agent broad powers to make health care decisions, including mental

More information

MAKING YOUR WISHES KNOWN: Advance Care Planning Guide

MAKING YOUR WISHES KNOWN: Advance Care Planning Guide MAKING YOUR WISHES KNOWN: Advance Care Planning Guide ADVANCE CARE PLANNING The process of learning about the type of medical decisions that may need to be made, considering those decisions ahead of time

More information

(4) "Health care power of attorney" means a durable power of attorney executed in accordance with this section.

(4) Health care power of attorney means a durable power of attorney executed in accordance with this section. SOUTH CAROLINA STATUTES SECTION 62-5-504. Definitions. (A) As used in this section: (1) "Agent" or "health care agent" means an individual designated in a health care power of attorney to make health care

More information

SAMPLE FLORIDA HEALTH CARE DIRECTIVE (LIVING WILL / DESIGNATION OF HEALTH CARE SURROGATE) Jane Doe

SAMPLE FLORIDA HEALTH CARE DIRECTIVE (LIVING WILL / DESIGNATION OF HEALTH CARE SURROGATE) Jane Doe FLORIDA HEALTH CARE DIRECTIVE (LIVING WILL / DESIGNATION OF HEALTH CARE SURROGATE) OF Jane Doe [This section will appear if you select living will and will vary depending on your choices in regards to

More information

North Dakota: Advance Directive

North Dakota: Advance Directive North Dakota: Advance Directive NOTE: This form is being provided to you as a public service. The attached forms are provided as is and are not the substitute for the advice of an attorney. By providing

More information

Living Will Sample Massachusetts (aka "Advanced Medical Directive")

Living Will Sample Massachusetts (aka Advanced Medical Directive) Living Will Sample Massachusetts (aka "Advanced Medical Directive") Online Living Will Form $8.99 (free trial) click here ADVANCE MEDICAL DIRECTIVE AND HEALTH CARE PROXY GIVEN BY JAMES ROBERT HEDGES THIS

More information

Advance Health Care Directive Form Instructions

Advance Health Care Directive Form Instructions Advance Health Care Directive Form Instructions You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. The

More information

State of Ohio Durable Power of Attorney for Health Care

State of Ohio Durable Power of Attorney for Health Care State of Ohio Durable Power of Attorney for Health Care Provided by Danny N. Crank Butler County Recorder 1. DESIGNATION OF ATTORNEY-IN-FACT. I,, presently residing at, Ohio, (the Principal ) being of

More information

ARIZONA HEALTH CARE DIRECTIVE SAMPLE (LIVING WILL / HEALTH CARE POWER OF ATTORNEY) John Doe

ARIZONA HEALTH CARE DIRECTIVE SAMPLE (LIVING WILL / HEALTH CARE POWER OF ATTORNEY) John Doe ARIZONA HEALTH CARE DIRECTIVE (LIVING WILL / HEALTH CARE POWER OF ATTORNEY) OF John Doe I, John Doe, being of sound mind and disposing mind and memory, do hereby make and declare this to be my health care

More information

ABOUT ADVANCE DIRECTIVES

ABOUT ADVANCE DIRECTIVES ABOUT ADVANCE DIRECTIVES You have a right to decide what treatments you want or don t want, and who makes these decisions should you be unable to make them for yourself. This booklet will tell you how.

More information

*1214* [1214] ADVANCE HEALTH CARE DIRECTIVE FORM 3-1 INSTRUCTIONS

*1214* [1214] ADVANCE HEALTH CARE DIRECTIVE FORM 3-1 INSTRUCTIONS FORM 3-1 ADVANCE HEALTH CARE DIRECTIVE INSTRUCTIONS Part 1 of this form lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions,

More information

Advance [Health Care] Directive

Advance [Health Care] Directive Advance [Health Care] Directive Introduction I have completed this Advance Directive with much thought. This document gives my treatment choices and preferences, and/or appoints a Health Care Agent (also

More information

TENNESSEE Advance Directive Planning for Important Health Care Decisions

TENNESSEE Advance Directive Planning for Important Health Care Decisions TENNESSEE Advance Directive Planning for Important Health Care Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program

More information

Connecticut: Advance Directive

Connecticut: Advance Directive Connecticut: Advance Directive NOTE: This form is being provided to you as a public service. The attached forms are provided as is and are not the substitute for the advice of an attorney. By providing

More information

PENNSYLVANIA Advance Directive Planning for Important Health Care Decisions

PENNSYLVANIA Advance Directive Planning for Important Health Care Decisions PENNSYLVANIA Advance Directive Planning for Important Health Care Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program

More information

MARYLAND Advance Directive Planning for Important Healthcare Decisions

MARYLAND Advance Directive Planning for Important Healthcare Decisions MARYLAND Advance Directive Planning for Important Healthcare Decisions Caring Info 1731 King St, Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Info, a program of the National Organization

More information