Durable Power of Attorney for Health Care & Health Care Directive Documents are legally valid in Alaska, California, Idaho, Montana, and Washington. What is advance care planning? Advance care planning is for all adults 18 and older. It is talking about future health care decisions if you had a sudden event, like a serious accident or illness, and could not make your own decisions. A person close to you would need to make choices for you. This person is called a Health Care Agent or Durable Power of Attorney for Health Care (DPOAH). It is important to write down your goals, values, and preferences using the following documents. These documents should be updated regularly and shared with your health care providers and loved ones. You may complete one or both of the documents. 1) Health Care Agent Durable Power of Attorney for Health Care. Choose a Health Care Agent, or DPOAH, to make medical decisions for you if you cannot speak for yourself. 2) My Wishes for Medical Treatment Health Care Directive. Give instructions about your wishes for medical care on a Health Care Directive. This form lets you choose whether you want lifesustaining treatments if you have a serious accident or illness and cannot speak for yourself. IMPORTANT: Ask your doctor if, in addition to these documents, you should also complete a physician order for life sustaining treatment (POLST) form. A POLST form is a medical order that is used to communicate medical care decisions to health care providers and emergency responders. It may be appropriate for you if you are seriously ill or frail now. For more information and additional resources go to www.honoringchoicespnw.org. Date: Date of Birth: Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 1
Health Care Agent Durable Power of Attorney for Health Care What is a Health Care Agent? A Health Care Agent, or DPOAH, is the person you choose to make medical decisions for you if you cannot speak for yourself. You authorize this person to make decisions with your health care providers about your care. The guide below will assist you with selecting a Health Care Agent. What will happen if I do not choose a Health Care Agent? If you cannot speak for yourself and do not choose a Health Care Agent, your doctors will follow your state s law to find a decision-maker for you. This probably means they will ask your closest family members to make decisions, or ask the court to appoint a legal guardian. Who should I select as my Health Care Agent? There are several things to think about when making this decision. Your Health Care Agent should: Be at least 18 years or older. Not be your health care provider or an employee at your hospital or clinic (unless he/she is your spouse, or adult child, brother, or sister or in certain states, a domestic partner). Understand what the Health Care Agent does and is willing to do this role. Be able to talk on your behalf about your goals, values, and preferences and what living well or a good day means to you. Carry out your decisions (even if he or she does not agree with them). Be able to make decisions in difficult or stressful times. What kind of decisions can my Health Care Agent make on my behalf? Your Health Care Agent will need to follow the health care choices you have made on the document My Wishes for Medical Treatment Health Care Directive. If you have not completed a Health Care Directive, your Health Care Agent will need to follow any other direction you have provided about your health care choices. Consistent with your choices, your Health Care Agent can: Give permission to perform or withhold cardiopulmonary resuscitation (CPR), breathing machines, feeding tubes, and other treatments. Give permission for treatments and surgeries to treat your conditions. Review and authorize the release of medical records as needed for your care and/or for application for public or private health care insurance benefits. Decide which health care providers and organizations may provide your medical treatment. Interpret any instructions and decisions you have provided in your Health Care Directive or given in other discussions according to the understanding of your wishes and values. Make decisions about care, organ donation, and disposition of the body after death. The authority of a Health Care Agent can extend after death. In Alaska and Montana, this requires an additional document which can be found at www.honoringchoicespnw.org. Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 2
Health Care Agent Durable Power of Attorney for Health Care The person I choose as my Health Care Agent is: Full Relationship to me: Home Phone: Cell Phone: City/State/Zip: Email Alternate Agents If the person listed above: Decides they are not able, willing, or available, or Has divorced or legally separated from me and I have not initialed the box below, or Has died. Then, the people listed below are my first and second alternate choices: #1 Alternate: Full Relationship to me: Home Phone: Cell Phone: City/State/Zip: Email #2 Alternate: Full Relationship to me: Home Phone: Cell Phone: City/State/Zip: Email Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 3
Health Care Agent Durable Power of Attorney for Health Care Initial the line below if you agree with this statement. I want my agent, if they are my spouse or domestic partner, to continue as my Health Care Agent even if there is a dissolution, annulment, or termination of our marriage or domestic partnership. Initial the line below if this situation applies to you. I do not have a Health Care Agent. Note: If no Health Care Agent has been appointed, it may be necessary for your medical team to ask a court to appoint a guardian who can then use your health care directive for guidance. Statement of General Authority and Powers of My Health Care Agent: My Health Care Agent is specifically authorized to give consent for health care treatments and surgeries when I am not capable of doing so and carry out my wishes regarding life-sustaining treatments such as feeding tubes, CPR, breathing machine, and kidney dialysis. This includes but is not limited to consent to start, continue, or stop medical treatment. This extends after I die to actions such as organ donation and care and disposal of the body. In Alaska and Montana, a separate document is required to grant the authority for organ donation and care and disposal of the body to a Health Care Agent or other person. This form can be found at www.honoringchoicespnw.org. Sign Form I understand the importance and meaning of this document and my decisions. I understand that I can change my mind at any time. I revoke any prior Durable Power of Attorney for Health Care. I have filled out this document willingly. I am thinking clearly. The Durable Power of Attorney for Health Care reflects my Health Care Agent choice(s). My Signature: Date: My Name (printed): This ends the Health Care Agent Durable Power of Attorney for Health Care. Exception: Alaska and California residents must have form witnessed (see next page). Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 4
Health Care Agent Durable Power of Attorney for Health Care For Alaska and California Residents ONLY: Witness Signatures Alaska and California require that the Durable Power of Attorney for Health Care form be witnessed. This page is not required for Washington, Montana, and Idaho. If you live in these states, you can skip this page. Rules for Witnesses: Must be at least 18 years of age and competent. Must watch you sign this form. Cannot be related to you by blood, marriage, or adoption. Would not be entitled to any portion of your estate upon death. Cannot be your attending physician, an employee or owner of a health facility where you are a patient, or any person who has claim against any portion of your estate at the time of signature of this document. Cannot be your designated Health Care Agent(s). Witness #1 Signature: Date: Name (printed): City, State, ZIP: Witness #2 Signature: Date: Name (printed): City, State, ZIP: This ends the Health Care Agent Durable Power of Attorney for Health Care. Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 5
My Wishes for Medical Treatment Health Care Directive In completing this form, I am sharing my health care wishes. If the time comes that I cannot speak for myself, I want these wishes followed. Print full name: Date of birth: Religious, spiritual, or cultural beliefs I would want the following person contacted: Phone number: Place of Worship: Treatment I do not want based on my religious, spiritual, or cultural beliefs: Treatment I want based on my religious, spiritual, or cultural beliefs: Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 6
My Wishes for Medical Treatment Health Care Directive What is important? What matters the most to me? This section helps you think about and communicate what matters to you if you ever have a serious accident or illness and cannot speak for yourself. Instructions: - Initial on the line next to each statement if you agree (example: DS Feed, bathe, or take care of myself). - Draw a line through the statement if you disagree (example: Be free or have minimal pain). To me, living well or a good day means that I am able to: (choose all that apply) Communicate with my family and friends Know who I am or who I am with Be free of or have minimal pain Feed, bathe, or take care of myself Live without life-sustaining equipment See my loved ones reach milestones Physically and mentally do the things I love The following is what living well or a good day means to me in my own words: If I am dying, I would like to be: At home, if care is available In a hospital or skilled nursing facility It does not matter to me Information About Life Sustaining Treatment Options Life-sustaining treatment is medical treatment that may help you live longer, but it comes with risks. To read more about CPR (cardiopulmonary resuscitation), breathing machine, and feeding tube go to: www.honoringchoicespnw.org. Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 7
My Wishes for Medical Treatment Health Care Directive My Choices Imagine this scenario: A sudden event (such as a car accident or illness) left you unable to communicate. You are getting all the care to keep you alive and comfortable. The doctors believe there is little chance you will recover the ability to know who you are or who you are with. I want my health care providers and health care agent to do the following: Continue medical treatment to keep me alive, even if there is little chance of getting better. Exception: Do not try the following medical treatments (e.g. breathing machine, feeding tube, kidney dialysis): Stop medical treatment and allow a natural death. I want my Health Care Agent to decide for me. Imagine this scenario: You are permanently unconscious or have an incurable or irreversible injury, disease, illness, or condition that is terminal. You are no longer able to communicate or make decisions about life-sustaining treatment. I want my health care providers and health care agent to do the following: Continue medical treatment to keep me alive, even if there is little chance of getting better. Exception: Do not try the following medical treatments (e.g. breathing machine, feeding tube, kidney dialysis): Stop medical treatment and allow a natural death. I want my Health Care Agent to decide for me. Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 8
My Wishes for Medical Treatment Health Care Directive Cardiopulmonary Resuscitation (CPR) Choice: I want to have CPR attempted if my heart or breathing stops. I want CPR attempted if my heart or breathing stops unless my health care provider has determined that I have any of the following: A disease or injury that cannot be cured, and I am dying; or Little chance of survival if my heart stops; or Little chance of any long-term survival if my heart stops and the efforts to bring me back to life would cause me suffering; or Little chance of returning to the quality of life I wish for and have already discussed with my health care agent. I do not want CPR attempted if my heart or breathing stops, but rather I want to die naturally. For women of childbearing years: If I am pregnant and I cannot speak for myself: I would want all care possible regardless of what is selected above. I would want all of my wishes honored as I have selected above. I would want my Health Care Agent or if I do not have one my family or guardian (whichever is applicable) to decide for me. Additional Information Write any additional information you want your health care providers, Health Care Agent, or others to know about your health care wishes. Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 9
My Wishes for Medical Treatment Health Care Directive Organ and Tissue Donation Your health care providers may ask about organ or tissue donation after you die. Donating your organs or tissue can help sick people who need them. If you want to be a donor, please tell your physician or family and indicate below. During organ and tissue donation, the body is treated with respect and dignity. Funerals do not need to be delayed. All costs related to organ or tissue donation are covered by the agency responsible for obtaining them. The family does not pay for this cost. For Alaska and Montana Residents: A separate form is required to say whether and how your organs are donated and what should happen to your body after you die. Please go to the following website for a form that meets your state s requirements: www.honoringchoicespnw.org. For California, Idaho, and Washington Residents: I want to donate my organs and tissue. I want to donate only the following organs or tissue, if possible. (Name the specific organs or tissue) I do not want to donate any organs or tissue. I want my Health Care Agent to decide. For more information on organ and tissue donation and how to register in your state, visit: www.lcnw.org. Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 10
My Wishes for Medical Treatment Health Care Directive Sign Form I understand the importance and meaning of this document and my decisions. I understand that I can change my mind at any time. I revoke any prior Health Care Directives. I have filled out this document willingly. I am thinking clearly that the Health Care Directive are my personal medical wishes. My Signature: Date: My Name (printed): Witness Signatures Rules for Witnesses: Must be at least 18 years of age and competent. Must watch you sign this form. Cannot be related to you by blood, marriage, or adoption. Would not be entitled to any portion of your estate upon death. Cannot be your attending physician, an employee or owner of a health facility where you are a patient, or any person who has claim against any portion of your estate at the time of signature of this document. Cannot be your designated Health Care Agent(s). Witness #1 Signature: Date: Name (printed): City, State, ZIP: Witness #2 Signature: Date: Name (printed): City, State, ZIP: This ends the Health Care Directive. Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 11
Share Your Wishes Once you complete the written documents, share your wishes and the documents with your physician, health care agent, and hospital. If applicable, consider sharing them with your nursing home or assisted living facility. It is important that everyone have an updated copy. Additional information on how to share your wishes is at www.honoringchoicespnw.org. What if I change my mind about my wishes? If your wishes change, tell your health care agent, your family, your physician, and everyone who has copies of this advance directive. Fill out a new advance directive with your current wishes. Give copies of the new form to your Health Care Agent and your doctor. My Health Care Agent and/or Health Care Directive are stored at: My Hospital: My Doctor s Office: My Healthcare Agent: Other: Printing Instructions: Do not double side document so it can be easily scanned into an electronic medical record. Rev 05/16 Pg. 12