You have the right to give instructions about what types of health care you want or do not want. You also have the right to name someone else to make health care decisions for you when you are unable to make them yourself. You may do either of these by telling your family or your doctor, but it is generally better for you and your family if you write down your wishes. You may use this form in its entirety or you may use any part of it. For example, if you simply want to choose an agent in Part One, you may do so and go directly to Part Five to sign this in the presence of appropriate witnesses. You are also free to use a different form as long as it is properly signed and witnessed.

Part One of this form lets you name a person as your “agent” to make health care decisions for you if you become unable to make your own decisions. You may also name alternate agents. You should choose as your agent (and alternates) people you trust, who are going to be comfortable making what might be hard decisions on your behalf. They should know you and be guided by your values in making choices for you.

You should notify your agent and alternates that you have named them, and they need to agree to act as your agent if asked to do so. Your agent does not have authority to make decisions for you until you are unable to make your own decisions.

If you do not appoint an agent, and then become unable to make your own decisions, someone will be found to make health care decisions for you.

Part Two of this form lets you state Treatment Wishes. Choices are provided for you to express your wishes about having, not having or stopping treatment necessary to keep you alive under certain circumstances. Space is also provided for you to write out any additional or specific wishes based on your values, health condition or beliefs.

Part Three of this form lets you express your wishes about organ or tissue donation.

Part Four is for you to express your wishes about autopsy and funeral arrangements.

Part Five of this form is for signatures. You must sign and date the form in the presence of two witnesses. The following persons may not serve as witnesses: your agent and alternate agents; your spouse or partner; your heirs; your doctor (or doctor’s employee); an employee or the owner of the residential care facility where you live; staff or owners of a funeral service or any person to whom you owe money.

You should give copies of the completed form to your agent and alternate agents, to your physician, your family and to any health care facility where you reside or at which you are likely to receive care. You should keep a list of those who have copies in case you revoke or revise the document in the future. You have the right to revoke all or part of this advance directive for health care or replace this form at any time. If you do revoke it, all old copies should be destroyed.

You may wish to read the booklet Taking Steps that includes worksheets to help you think about and discuss different choices and situations with your agent or loved ones. You may also use this section to nominate a guardian of your person, should someone need to be appointed at some future time to make decisions for you. Also, if you have a specific illness or condition and wishes that relate to it, this is a good place to note that.

My Name _________ Date of Birth S.S #_

Address ____________________________________________________________

Part One: Appointment of My Health Care Agent

I appoint ________________________ Address ______________________________

Tel. #s(days) ______________ cellphone _____________________________

(eves.)______________ email:________________________________

as my Health Care Agent to make any and all health care decisions for me, except to the extent that I state otherwise in this document.

If this health care agent is unavailable, unwilling or unable to do this for me, I appoint _______________________to be my Alternate Agent.

Address: ______________________________________

Tel. #s_____________________cellphone and email____________________________

(Use additional sheet to appoint additional agents or alternates.)

Others who can be consulted about medical decisions on my behalf include:

______________________________________________________________

Those who should NOT be consulted include:

______________________________________________________________

Your agents should have been notified that you appointed them, they should understand your wishes and they should agree to make health care decisions for you when you can no longer make them for yourself.

(Optional space below is to identify your doctor or health care provider:) *Your doctor cannot also serve as your health care agent.

Primary care physician ____________________ Address ____________________

(or other health care professional) Office Telephone:___________________

Name___________________ Date of Birth______ S.S.#_______________

Part Two: Treatment Wishes

Please express your preferences that follow by checking or initialing the statements. You may check or initial more than one choice. If you do nothing, your agent or others such as family members and doctors treating you will assume you want them to decide for you. If you do not state a preference for withholding or withdrawing artificial food (tube feeding) and hydration, your agent may not have authority to withhold or withdraw it, without a court order, if you are being treated in a New York or New Hampshire hospital.

_____ A. My Choice is to Limit Treatment - I do not want to be kept alive if:

( Initial those statements below that you agree with)

____ 1. I am so sick that I will die within a relatively short time (I cannot get better and have only weeks, days or hours left to live),

____ 2. I become unconscious or unaware of my surroundings and most doctors agree that I will never regain consciousness,

_____ 3. I become unable to think or act for myself (and won’t get better), or

____ 4. The likely risks and burdens of treatment would outweigh the expected benefits. (For example: I will be in pain, or I will be unable to do things for myself, or the costs of caring for me will be beyond my willingness to pay.)

____5. If it is possible that I might recover with treatment and more time is needed to determine if I can get better or not, I wish my medical team to start the necessary treatments to keep me alive. If, over time, these treatments do not improve my chances of living or my physical condition, I wish to have life-sustaining treatment stopped.

____ 6. If I have initialed or checked any of the situations above and am also unable to swallow enough food and water to stay alive, I do want food and water to be given to me by vein or by feeding tube.

____ 7. If I have initialed or checked situations 1-5, I do not want food and water to be given to me by vein or feeding tube, but I will accept medication for pain and agitation through an intravenous line.

____ 8. Other specific instructions are as follows:

______ B. My Choice is to Sustain Life - I want to be kept alive as long as possible

through any means possible regardless of my condition or awareness.

Specific Care Wishes Near the End of My Life

______ If it becomes clear to my doctor, my agent and those caring for me that I am dying, I want palliative care for my pain, worries, nausea and other conditions that bother me. I want sufficient pain medication even though it may hasten my death.

______I want hospice care when I am dying, if possible and appropriate.

______ I prefer to die at home, if this is possible.

Spiritual and Other Care Concerns:

I am of the ______________faith. Below is the contact information (if known).

Church, Synagogue or Worship Center: ____________________________Address:________________Leader_______________ phone # _____________

Other people to notify if I have a life-threatening illness:

The following items or music or readings would be a comfort to me:

Part Three: Specific Instructions about ORGAN DONATION

I want my agent (if I have appointed one), family, friends and all who care about me to follow my wishes about organ donation if that is an option at the time of my death. (Initial below all that apply.)

______ I do not wish to be an organ donor.

______ I wish to donate the following organs and tissues:

____ any needed organs or tissues

____ major organs (heart, lungs, kidneys, etc.)

____ tissues such as skin and bones

____ eye tissue such as corneas

_____ I desire to donate my body to research or educational programs. (Note: you will have to make your own arrangements through a Medical School or other program.)

It is very important that you talk with your family and your health care agent about your wishes regarding organ donation.

_______ If an autopsy is suggested for any reason, I give my permission to have it done.

Part Four: My Wishes for Disposition of my Remains after my Death:

I. The person I want to serve as my agent for disposition of my body:

a.)____ I want my health care agent to decide arrangements after my death.

____ If he or she is not available, I want my alternate agent to decide.

b.)____ Regardless of my appointment of a health care agent in Part One, I appoint the following person to decide about and arrange for the disposition of my body after my death:

Name _______________________ Address_______________________

Telephone _____________ Cellphone___________ Email____________

c.) _____ I want my family to decide.

II. My preference for Burial or Disposition of My Remains after Death:

a.) ______ I want a funeral followed by burial in a casket at the following location, if possible (please tell us where the burial plot is located and whether it has been pre-purchased):

b.) ______I want to be cremated and have my ashes buried or distributed as follows:

c.) _____ I want to have arrangements made at the direction of my agent or family.

I have a pre-need contract for funeral arrangements with the following Funeral Service:

__________________________________________Tel._______________

Part Five: Signed Declaration of Wishes

Signed _________________________ Date______________

The witnesses below confirm the signature of the maker of this document and that it is being signed by that person as a free and voluntary act. Appointed agents, family members, heirs, health care providers, funeral service staff and anyone to whom you owe money may not be witnesses.

Witness (and address)_____________________________________________________

If the maker is a current patient or resident in a hospital, nursing home or residential care home, the following additional witness confirms the maker’s capacity, understanding, and freedom from undue influence (Hospital Explainer or Long-term-care Ombudsman or clergy, attorney, probate court designee):

Prepared by the Vermont Ethics Network

ADVANCE DIRECTIVE

My Name _________ Date of Birth S.S #_

Address ____________________________________________________________

Part One: Appointment of My Health Care Agent

Specific Care Wishes Near the End of My Life

Part Three: Specific Instructions about ORGAN DONATION

Part Five: Signed Declaration of Wishes

Important!

Prepared by the Vermont Ethics Network

ADVANCE DIRECTIVE

My Name _____________________ Date of Birth __________S.S #___________

Address ____________________________________________________________

Part One: Appointment of My Health Care Agent

Specific Care Wishes Near the End of My Life

Part Three: Specific Instructions about ORGAN DONATION

Part Five: Signed Declaration of Wishes

Important!

My Name _________ Date of Birth S.S #_