Advanced Health Care Directives
Download the Informational Brochure
Under the law, 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. These forms let you do either or both of these things. They also let you express your wishes regarding the designation of your primary physician. If you use one of these forms, you may complete or modify all or any part of it. You are free to use a different form.
The first (longer) form also lets you express your wishes regarding organ donations, the designation of your health care provider and information about your spiritual advisors. If you use this form, you may complete or modify all or any part of it. Once again, you are free to use a different form. The second (short) form is intended for individuals who have limited instructions or who are in a hurry or who may have difficulty with the long form.
If you make a new advance health care directive you should locate any old ones and replace them. It is a good practice to safeguard the original and keep it with your other important papers. Let people know where you keep this important document and how they can get it in an emergency.
It is also a good idea to perform the Advanced Directive Checklist to ensure that you have completted all the necessary elements of a good Advanced Directive for Health Care. You may view this checklist online by clicking here, or download the complete Informational Brochure by following the links at the left of this window.
Long Form
Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may name an alternate agent to act for you if your first choice is not willing, able, or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator, or employee of a residential long-term health care institution at which you are receiving care. Unless the form you sign limits the authority of your agent, your agent may make all health care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to:
(a) Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a physical or mental condition;
(b) Select or discharge health care providers and institutions;
(c) Approve or disapprove diagnostic tests, surgical procedures, programs of medication, and orders not to resuscitate; and
(d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care.
Part 2 of this long form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration, as well as the provision of pain relief. You may also add provisions relating to mental illness. Space is provided for you to add to the choices you have made or for you to write in any additional wishes.
Part 3 of this long form gives you options relating to the disposition of your organs/ body.
Part 4 lets you designate a physician/facility to have primary responsibility for your health care.
Part 5 pertains to religious or spiritual information you may wish to provide.
After completing either the long or short form, sign and date it at the end and have it witnessed by one of the two alternative methods indicated. Give a copy of the signed and completed form to your physician, to any other health care providers you may have, to any health care institution at which you are receiving care, and to any health care agents you have named. You have the right to revoke or replace this document at any time.
Short Form
The short form may be used if you do not desire to complete the long form. It does not provide the detail found in the long form and may not address all your needs.
Part 1 of this form is a simplified power of attorney for health care. Part 1 lets you name another individual as agent to make health-care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may name an alternate agent to act for you if your first choice is not willing, able, or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator, or employee of a health-care institution where you are receiving care.
Part 2 of this form provides basic options for instructions about your health care. Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration, as well as the provision of pain relief medication. Limited space is provided for you to add to the choices you have made or for you to write out any additional wishes.
After completing either the long or short form, sign and date it at the end and have it witnessed by one of the two alternative methods indicated. Give a copy of the signed and completed form to your physician, to any other health care providers you may have, to any health care institution at which you are receiving care, and to any health care agents you have named. You have the right to revoke or replace this document at any time.