Advance Directive for Health Care - Long Form

Use this form to create an Advance Directive for your health care. It is 11 pages long.

Use this text or the fillable PDF form below the text.
 

ADVANCE DIRECTIVE FOR HEALTH CARE

Your Name: [Write your name]

Date of Birth: [Write your date of birth]

Address: [Write your address]

YOUR HEALTH CARE AGENT

Your health care agent can make health care decisions for you when you cannot make decisions for yourself. You should pick someone that you trust. Talk to them about your wishes. Tell them that you are making them your agent in this advance directive.

I want this person to be my healthcare agent.

Name: [Write the name of the person to be agent] 

Address: [Write their address] 

Phone Home: [Write their home phone number]

Work Phone: [Write their work phone number]                                        

Cell Phone: [Write their cell phone number]          

Email: [Write their email address]                    

I want this person to be my alternate agent if the first person cannot do it.

Name: [Write the name of the alternate person to be agent]

Address: [Write their address] 

Phone Home: [Write their home phone number]

Work Phone: [Write their work phone number]                                        

Cell Phone: [Write their cell phone number]          

Email: [Write their email address]

I want my advance directive to start:

[Select one of the following]

When I cannot make my own decisions

Now

When this happens: [Describe the event]

APPOINTMENT OF CO-AGENTS

Please think carefully about appointing co-agents. Your co-agents need to agree about your treatment. What happens if your co-agents disagree about your medical treatment? What happens when only one of your co-agents is available? How would you want them to make a decision?

[Check this if it applies to you]

I want the persons listed above, and any additional persons listed in this section, to be my co-agents and for them to make medical decisions together for me.

Additional Co-Agent:

Name: [Write the name of the alternate person to be agent]

Address: [Write their address]

Phone Home: [Write their home phone number]

Work Phone: [Write their work phone number]

Cell Phone: [Write their cell phone number]

Email: [Write their email address]

Additional Co-Agent:

Name: [Write the name of the alternate person to be agent]

Address: [Write their address]

Phone Home: [Write their home phone number]

Work Phone: [Write their work phone number]

Cell Phone: [Write their cell phone number]

Email: [Write their email address]

Instructions for co-agents to make decisions if they don’t agree: [Write instructions]

What to do if only one co-agent is available: [Write what to do]

INVOLVEMENT OF OTHERS IN MY CARE

I want my agent to consult with these people about my care. My agent can give them information about me: [Write names of people]

I don’t want my agent to consult with these people about my care. My agent should not give them information about me: [Write names of people]

If I don’t have an agent, I want my medical information shared with these people: [Write names of people]

I don’t want this person to bring a court case about my advance directive: [Write name of person]

If I need a guardian in the future, I want this person to be my guardian: [Write name of person]

I don’t want this person to be my guardian: [Write name of person]

My primary healthcare doctor or clinician is: [Write name of doctor]

END OF LIFE TREATMENT WISHES

You can decide what kind of treatment you want or do not want at the end of life. You can have your end of life care wishes apply to all situations, or explain when you want them to apply. These are your choices for your care.

My wishes for end of life care (initial your choices):

[Write your initials next to the following choices]

I want all possible medical treatment to sustain life.

I do not want the following medical treatment (check your choices):

• breathing machine
• feeding tube
• food by I.V. (intravenously)
• fluid by I.V. (intravenously)
• other treatments

I do not want any medical treatment to extend my life.

My Choices Above for Medical Treatment Apply

[Check your choices]

To all end of life care decisions

To these specific situations (check your choices):

[Check your choices]

• If I am close to death and there is no hope of recovery, and life support would only prolong my dying.
• If I am unconscious and it is very unlikely I will ever be conscious again.
• If I have a progressive illness that is in an advanced stage and will only get worse, and I am unable to communicate and am completely dependent on others.
• Other specific situations: [Describe situations]

To all medical situations and conditions

My Wishes for a Trial Period for Treatment

[Check your choices]

If I am in a health care crisis that may be life-ending but more time is needed to know if I will get better, I want treatments started on a trial basis. This includes the use of breathing machines and feeding tubes.

If I don’t get better after a reasonable period of time for the trial, I want all life extending treatments stopped.

My Wishes about a DNR Order (Do Not Resuscitate Order)

A do not resuscitate (DNR) order means that if your heart stops, your doctors won’t try to get it started again, and you would die. A DNR order needs to be written by your doctor. If you want a DNR order now, talk to your doctor. If you don’t want your doctor to issue a DNR order, or to allow your agent to agree to a DNR for you, indicate that here.

[Check your choice]

I do not want a DNR order written for me at any time.

I may want a DNR order in the future, depending on my condition.

I consent to a DNR now.

Other instructions about a DNR order: [Write instructions]

My Wishes for Pain and Comfort Care

[Check your choices]

I want care that preserves my dignity and that provides comfort and relief from symptoms that are bothering me.

I want pain medication to be administered to me even though this may have the unintended effect of hastening my death.

I want hospice care when it is appropriate in any setting.

I prefer to die at home if this is possible.

SPECIAL TREATMENT WISHES

My Wishes for Hospitalization

If I need care in a hospital, I would want to go to the following hospital or treatment facility: [Write hospital name]

I do not want to go to this hospital or treatment facility: [Write hospital name]

My Wishes for Medications or Treatment

I prefer these medicines and treatments: [Write medicines or treatments]

Do not use the following medications or treatment: [Write medicines or treatments]

My Wishes If I Am Pregnant

If I am pregnant, I would want my treatment outlined above in Part 3 (End of Life Treatment Wishes) changed as follows: [Write the changes]

My Wishes for Mental Health Treatment

[Check your choices]

I want my agent to make decisions for me just like any other care

I do not want my agent to decide about mental health care

My agent should follow these instructions about mental health care: [Write the changes]

ORGAN DONATION AND DISPOSITION OF REMAINS

My Wishes about Organ Donation (initial your choice)

[Initial your choices]

I want to donate my organs as follows (check your choices):

[Check your choices]

• Any organs needed
• major organs (heart, lungs, kidneys, etc)
• tissues such as skin and bones
• eye tissue

I do not want to donate my organs

I want my health care agent to decide

My Directions for Burial or Disposition of My Remains after I Die:

[Check your choices]

I have a prepaid funeral contract with: [Write name of company]

These are my wishes about my burial or disposition of my remains: [Write instructions]

I want my family or my agent to make all decisions

DISTRIBUTION OF ADVANCE DIRECTIVE

I plan to give a copy of my advance directive to:

[Check your choices]

My agent. They have agreed to be my agent: Yes / No. [Select yes or no]

My doctor

The online registry

Other: [Write where a copy will go.]

SIGNATURE AND WITNESSES

You must sign this before two adult witnesses. Your agent, spouse, partner, brother, sister, parent, child, grandchild, or reciprocal beneficiary cannot be a witness.

You must sign and date the Advance Directive.

These are my wishes regarding my medical care. I am signing this advance directive of my own free will.

Sign your name here [Sign your name]

Date [Write the date]

Your witnesses must sign and date the Advance Directive.

I affirm that the Principal appeared to understand the nature of this advance directive and to be free from duress or undue influence at the time this was signed.

First Witness Signature [First witness signs here]

Date [Write the date]

Print name [Print first witness name]

Address (Town, State) [Write their address]

Second Witness Signature [Second witness signs here]

Date [Write the date]

Print name [Print second witness name]

Address (Town, State) [Write their address]

Patients and residents of hospitals, nursing homes, or residential care homes must have this section signed.

I explained the nature and effect of this advance directive to the Principal.

Signature of Ombudsman/Clergy/Attorney/Court Designee/Hospital Representative [They sign here]

Date [Write the date]

ATTACHMENT A: STATEMENT OF VALUES

Do you think your life should be preserved for as long as possible? [Write you answer here]

What is important to you in order to keep living ? (examples: recognize family or friends, talk to family or friends, wake up from a coma, think for yourself, feed, bathe or take care of yourself ) [Write you answer here]

How do you want your pain managed? What if it makes you less alert or shortens your life? [Write you answer here]

If you are dying where would you prefer to die? [Write you answer here]

How do your religious, moral or spiritual beliefs affect the way you feel about your care?  [Write you answer here]

Are there items or music or readings that are special to you? [Write you answer here]

Should financial considerations be important when making decisions about your medical care? [Write you answer here]

What else should your agent know about your values when making health care decisions for you? [Write you answer here]

Attachment B: Giving Your Agent the Authority to Consent to or to Refuse Medical Treatment for You Even If You Object

You can give your agent the ability to allow or refuse medical treatment for you in the future even if you object when that time comes. This changes a very important right. You would be giving up your right to object to having a medical treatment. This would happen only after you are unable to make decisions for yourself. By signing this, you give up the right to change your mind. If you sign this, your agent will do what you say here, even if you changed your mind then. You should think about this very carefully.

If you want to do this, you must have an agent. You need to list the specific kinds of treatment in this attachment. You must give your agent specific permission to allow or object to these treatments. For each treatment that you want to name, you must say directly that you want the treatment, or that you do not want the treatment, even though you are objecting.

Your agent needs to sign this attachment. Your doctor or clinician also needs to sign it. You also must have this attachment signed by an ombudsman, clergy member, lawyer, or a person assigned by the probate court. They need to say that this attachment was explained to you and that you understood what you were signing.

You must say that you are giving up the right to refuse or receive treatment at a time when you do not have the capacity to make your own decision. You must say that you understand that it will be a clinician who makes the decision about whether you have the capacity to make your own medical decisions. This attachment will only become effective if both your clinician and a second clinician say that you do not have the capacity to make healthcare decisions.

1. I give my agent permission to not allow the following treatment, even if I ask for it when I do not have the capacity to make my own decisions: [Describe the treatment]
2. I give my agent permission to approve the following treatment, even if I object when I do not have the capacity to make my own decisions: [Describe the treatment]
3. My agent can admit me to a hospital for voluntary treatment, even if I am saying I do not want to be admitted. Yes / No. [Answer yes or no]
4. My agent can agree that my discharge from the hospital can be delayed for up to four days. This time allows a decision to be made about whether or not I should be kept in the hospital by court order. Yes / No. [Answer yes or no]

Additional Signature Section for Attachment B: Treatment Over Your Objection

I am giving up the right to refuse or receive treatment when I am unable to make decisions for myself. I understand a doctor or other medical provider will decide if I can make medical decisions.

Principle signature [You sign here]

Date [Write the date]

I agree to authorize or withhold health care over the principal’s objection in the event that the principal lacks capacity to make healthcare decisions.

Agent signature [Agent signs here]

Alternate Agent signature [Alternate agent signs here]

The principal appeared to understand the benefits, risks, and alternatives to the health care being authorized or rejected by the principal in this provision.

Clinician signature [Clinician signs here]

I am an ombudsman, recognized member of the clergy, attorney licensed in Vermont, or a probate court designee (Please circle the appropriate designation below). I have explained the nature and effect of the provision to the principal, and affirm that the principal appeared to understand the explanation and be free from duress or undue influence.

Ombudsman/Clergy/Attorney/Probate Court Designee/Hospital Rep signature [They sign here]

 

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