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Fillable Form Advance Health Care Directive Letter

An advance health care directive letter is a document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions.

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What is an Advance Health Care Directive Form?

An Advance Health Directive Form is a legal document that states what you want in regard to your future health care and which directions, procedures, and precautions you are opting for in various medical conditions.

You may dictate that your directive be put into action at any time when you are unable to decide for yourself, or you may want it to be applicable only if you are in critical condition or suffering from a terminal illness.

It comes into effect only if you are unable to make your own decisions. There may come a time wherein you are unable to verbalize or think with a sound mind and, upon completion of this form, you can dictate your medical treatment, wishes, and process before that time comes.

This form deals with your future health care.

How to fill out an Advance Health Care Directive Form?

Since the Advance Health Care Directive form involve specific instructions regarding medical treatments, procedures, and processes that may lead to the difference between life or death, it is important to consider first these points before choosing to accomplish the form:

  • Does your illness have no cure or do you have little to no chance of recovering from it?
  • Are the damages done by the illness irreversible?
  • Are life-prolonging measures and tools like tube-feeding, CPR, ventilators, intravenous fluids okay with you?

It is important to consider and highlight the quality of life that would be acceptable to you and would best suit your medical condition.

The Advance Health Care Directive form is split into five (5) parts that require filling out, namely:

  1. Advance Health Care Directive Form
  2. Appointment of Patient Advocate
  3. Other Patient Advocate Authority
  4. Health Care Wishes (Living Will)
  5. Making My Directive Legal

For the Advance Health Care Directive form section, please affix your full name on the line provided to confirm that you are of sound mind and are freely and voluntarily appointing a patient advocate (agent) to aid you in making decisions about your medical treatments in the future in case you are not able to communicate or relay your wishes yourself.

For the Appointment of Patient Advocate section, please affix your chosen agent’s full name, your relationship to them, their current residential address, and contact number on the lines provided for each.

  • Please make sure to go through and review the ‘Patient Advocate Authority’ located below the ‘Appointment of Patient Advocate’ for further details of the power you are giving to your chosen agent come your inability to communicate your wishes.

For the Other Patient Advocate Authority section, please go through and review thoroughly the additional powers you are willing to give to your appointed agent. Once reviewed, please initial ‘Yes’ on the statements you agree to let your agent have power to.

  • You are also given writing space below to print/type down any limit or expansion of the power of your agent.

For the Health Care Wishes (Living Will) section, please choose only one box of instructions that you wish to have followed by your appointed agent. Choose the box by marking it through.

  • If you selected the option that states you choose not to receive care for the purpose of prolonging life, you must select between additional instructions labeled option a or b.
    • If you choose option A, you will have to choose between five (5) additional options to explain why your appointed agent has no power limit.
  • You are also given writing space below to print/type down any additional instructions about your health care wishes.
  • Please make sure to go through and review ‘Revoking or Changing a Directive’ for instructions on how to void or change some conditions written in the Advance Health Care Directive form.

For the Making My Directive Legal section, please affix your full name, address, and signature along with the date of when you signed the form to the lines provided for each.

Your witness should affix their full name, address, and signature along with the date of when they signed the form to the lines provided for each as well.

Frequently Asked Questions About an Advance Health Directive Form

Why should I file an Advance Health Care Directive form?

It is in the legal and lawful right of every responsible adult over the age of eighteen (18) to either accept or refuse any recommended health care. This is something feasible for healthy and well individuals to dictate and decide on. On the other hand, individuals suffering from critical conditions, severe illnesses, or terminal illnesses are often unconscious during such critical moments of decision-making and it renders them unable to speak their wishes.

By completing the Advance Health Care Directive form, you may dictate your wishes and your opted medical direction when such a time of illness comes.

Who should file an Advance Health Care Directive form?

Any legal adult over the age of eighteen (18) and has an intellectual capacity mature enough to understand the implications of life-or-death situations can file for an Advance Health Care Directive. Moreover, the legal individual must be able to understand the nature of their decisions and foresee the effect their decisions can have.

Other points to consider when deciding if you are at a capacity to file for an Advance Health Care Directive:

  • You understand the nature and consequences of your health care decisions.
  • You understand the nature and effect of the directive.
  • You understand that you are freely and voluntarily making these decisions.
  • You can communicate your decisions in some way.

It should be noted that there are three (3) people involved in the completion of the Advance Health Care Directive form:

  1. You
  2. Patient Advocate Authority (also referred to as the ‘agent’ or ‘attorney-in-fact’.)
  3. Second (2nd) Patient Advocate Authority (this is in case the first choice cannot serve, is not willing, able, or reasonably available to make health care decisions for you.)

It should also be noted that your Advance Health Care Directive should be witnessed by two (2) legal adults over the age of eighteen (18) and are able to vouch and certify that you are of sound mind and mature mental capacity or signed before a notary public. Depending on your state, though, you may need both witnesses and notarization.

Depending on your state, it should be noted that a witness cannot be:

  • a health care provider
  • an employee of a healthcare provider or health care facility
  • your agent designated in the Advance Health Care Directive

At least one of the witnesses must be someone who is not a relative to you and is not entitled to any part of your estate or Last Will.

When to make an Advance Health Care Directive form?

Now is the best time to make an Advance Health Care Directive, when you are currently clear of any illness or still functioning at a healthy capacity. However, it is crucial to make one if:

  • You are about to be admitted to a hospital.
  • Your medical condition/illness will most likely end up affecting your decision-making process.
  • Your illness is a chronic medical condition that could impact your health drastically (heart disease, kidney disease, etc.)

It is recommended that you reassess your Advance Health Care Directive every few years that pass or when any “Five (5) Ds” take place. The Five (5) Ds are:

  1. Decade - when a new decade (10 years) of your life begins.
  2. Death - when there is death of a loved one.
  3. Divorce - when you and your spouse separate.
  4. Diagnosis - when your health condition is diagnosed with a serious sickness/illness/disease.
  5. Decline - when the state of your health drastically diminishes and impacts your lifestyle significantly.

What do advance healthcare advance directives cover?

Advance healthcare directives cover a broad range of living wills, medical powers-of-attorney, and other health care planning documents. They are intended to allow patients or their designated proxies to specify in advance what steps should be taken to keep them alive when they cannot communicate this for themselves. As documents that in a sense deal with life and death, advance directives must be specific and unambiguous. They should lay out exactly what steps should be taken to keep a patient alive and when those measures should stop. Standard forms often include a "do not resuscitate" order, or DNR, which instructs medical staff not to attempt CPR if the patient stops breathing.

In general, these are some of the important healthcare decisions that healthcare directives cover:

  • Do not attempt resuscitation if a patient's breathing or heartbeat stops, also known as a "no-code" or, in some cases, "allow natural death," directive.
  • Give or withhold specified medical treatment for a patient who is unable to communicate his wishes due to injury, illness, disease, anesthesia, unconsciousness, or other permanent conditions.
  • Authorize a surrogate decision-maker to make healthcare decisions on the patient's behalf if he is not able to do so for himself, also known as a healthcare proxy.
  • Select people who can serve as surrogate decision-makers and/or authorize them to act on the patient's behalf.
  • Request that a patient's wishes regarding resuscitation or other treatments be honored by healthcare providers even if those procedures might cause pain or discomfort.
  • Give permission or refuse permission for specific medical investigations, including surgery and the administration of medication to the patient.
  • Authorize a person to obtain from an outside source such as an ambulance service or rescue squad vital signs, other health information, or samples of the patient's blood and other bodily fluids.
  • Be specific about which treatments should be used in an emergency situation if the patient cannot provide informed consent for treatment even if he regains consciousness.

How does an advance healthcare directive work?

An advance healthcare directive work by giving healthcare professionals, family members, and your friends clear instructions on the kind of medical treatments that you would consider acceptable or unacceptable. You can also specify under what conditions you want to be treated (for example if you are in a coma).

A directive contains four main categories:

  1. Do Not Prolong Life Order — This is one of the most important documents to fill out because it lets your doctors know that you do not want life-sustaining treatments administered to you when all hope for recovery is gone, or if there are no reasonable treatment options for your condition. Without this document, doctors must do everything possible to keep you alive including surgery or putting you on life support equipment. That means that if the doctor feels that he can prolong your life even though there is no chance of recovery, then they might put you through more pain and suffering than is necessary.
  2. Do Not Resuscitate Order — This indicates that you do not want cardiopulmonary resuscitation (CPR) or any other medical treatment used to restart your heart if it stops beating.
  3. Comfort Measures Only Directive — Lets people know that you do not want extreme treatments, such as a breathing machine or a feeding tube, and instead, you only want to be treated with pain medications and other methods to make you as comfortable as possible.
  4. A Living Will — This is a document that contains your preferences for end-of-life medical treatment, especially if you become unable to communicate those wishes yourself. It provides guidance about the treatments that you would like (or not like) to receive, and it lets your doctors know who should direct your healthcare decisions if you are unable to make those choices yourself. This directive helps to prevent any family members or friends from making poor or emotional decisions during this difficult time.

What is the difference between a living will and a healthcare directive?

A living will and a healthcare directive are common legal terms for documents that can help your family and medical providers know how you want end-of-life medical decisions to be handled.

A living will states the type of care or treatment you do or don't want in case you are unconscious or otherwise unable to express your wishes. It also lets your family and medical providers know whether or not you would like to be resuscitated. If you don't want to be kept alive by machines, you can make that clear in your living will. This document is also referred to as a Directive to Physicians and/or Directives for Surgery and/or Surrogate Medical Power of Attorney.

A healthcare directive is a separate legal document from a living will that states who you would like to make medical decisions if you are unable to do so for yourself. It also provides information on whether or not you want to be resuscitated and the types of treatments and cares that you do or don't want at any time, not just at the end of life. This legal document is also referred to as a Healthcare Power of Attorney or Surrogate Healthcare Power of Attorney.

A living will and a healthcare directive should complement one other and provide your family and medical providers with a common understanding of your wishes. When both documents are completed, they serve as a guide for those involved in making difficult healthcare decisions for you if necessary.

Can I write my own advance healthcare directive?

Yes, you can write your own advance healthcare directive. If you can still make decisions about medical treatment, you can put in writing how much or how little medical care you wish to receive when you are unable to speak for yourself. It will serve as your voice and will be respected by healthcare professionals so long as it is valid.

Think of an advance directive as a living, breathing document that you can re-visit and update – not just for major life decisions – but anytime your wishes may change. The challenge with any legal document is to keep it relevant and up-to-date. A living will is effective only for the specific time period in which it was created.

There are many terms for this document, including “living will,” “advance directive," "healthcare proxy" and "durable healthcare power of attorney." Regardless of what you call it, the basic premise remains the same - write down your wishes for future medical treatment and have a family member or trusted friend keep it for you.

To create your own advance directives, follow these steps:

  1. Decide what kind of decisions you are making. Are you completing a living will or appointing someone else to speak on your behalf for medical care? While the terms can be used interchangeably, advance directives are legal documents that allow patients to name another person (proxy) who is authorized to make healthcare decisions on their behalf. This document is called a "healthcare power of attorney" in some states, so be sure to check your state laws.
  2. Gather the information you need to create an advance directive. You will need the name and phone number of your doctor(s), prescription records, health insurance policy or card, medical summary statement (if available), and any information about health conditions, including medications you are taking. A full medical history is helpful when creating an advance directive.
  3. Write your wishes in the document. Be clear and concise about what kind of medical treatment you wish to receive or refuse when you wish certain procedures to begin or end (in terms of timing), and whom you wish to make decisions for you. Don't assume your wishes will be honored so spell out your preferences.
  4. Have the document notarized, witnessed by two adults, or simply signed in front of two witnesses. This makes it legal and official; they must sign in front of a notary public, an adult witness who is not related to you, and another witness. Be sure they sign their name as it appears on the document (for example, if your witness is known by two names, both must be used) and notes the date of signing.
  5. Keep one copy with you at all times, give one to your healthcare proxy or surrogate decision-maker, and keep the original in a safe place.

Next, you need to make sure your decision maker has access to all of your medical information and understands what kind of care you would like to receive under certain conditions. Have him or her complete an Advanced Directive Disclosure Statement that lists all known allergies, current medications, doctors' names, and your medical history. Be sure to date and sign this document as well.

Can my family override my healthcare advance directive?

Your family can override your healthcare advance directive only when you are in a persistent vegetative state or when you have been declared legally brain dead. Otherwise, your family does not have the authority to make those decisions for you.

However, there is another situation where a healthcare directive can be overridden: when it would pose a risk of serious harm to others. In other words, if what you asked for in your end-of-life plan would put other people at risk of harm, then the medical team can step in. Furthermore, if certain conditions exist, healthcare providers are required to take whatever action they can within the bounds of their professional knowledge and experience to minimize that risk.

What should be included in a healthcare directive?

A healthcare directive should include the following:

  • patient's name, address, date of birth, religion, next-of-kin contact information
  • the type or types of healthcare that patient wishes to receive in the event that he/she becomes unable to communicate their health care desires
  • healthcare surrogates' names and their contact information (if someone has been chosen as a surrogate to make healthcare decisions for the patient)
  • any specific treatments or types of treatment that patient does not want to receive in the event that he/she becomes unable to communicate their health care desires (e.g., blood transfusions, CPR)
  • the name and contact information of a person who knows the patient's wishes regarding healthcare, as well as how those wishes were communicated

A healthcare directive should not include the following:

  • the names of health care providers, institutions, or procedures
  • the patient's diagnosis or prognosis

Does advance directive need to be notarized?

A healthcare directive must be notarized or witnessed and signed by two individuals to be legally binding.

What is the difference between a DNR and an advance directive?

A DNR and an advance directive are two different things. a DNR or Do Not Resuscitate means that you do not want your heart and lungs to be used in case you have a cardiac or respiratory arrest, while an advance directive is any other type of legal document which expresses what kind of medical treatment you do or don't want. You can create one to let everyone know that you do not want any life support in certain situations, or you could leave it open-ended so that your family gets to decide.

A do not resuscitate order or DNR for short is a medical order which you give to your doctor saying that if you have an out-of-hospital cardiac arrest, you do not want any attempts at cardiopulmonary resuscitation (CPR), intubation, or assisted ventilation. Moreover, if you are an inpatient, it prohibits your doctors from starting CPR for you.

Advance directives are legal documents that record what you would like to happen in the event that you become unable to make these decisions for yourself. There are two primary types of advance directives: living wills and durable power of attorney documents. A living will contains your desires regarding life-prolonging treatments. This is also called a natural death directive. A durable power of attorney documents are tools that allow you to name someone to make health care decisions for you if you are unable to do so.

The most important aspect of advance directives is communicating your end-of-life wishes clearly. Many people believe that they want medical treatment stopped at the end of their lives, but they haven't communicated this to their doctors or family members.

What is the difference between a health care directive and a power of attorney?

A healthcare directive and a power of attorney are two important documents that are not only related but are often confused. Many people do not know how to write these documents or know what they entail. There are few differences between the two that everyone needs to be aware of in order to make an informed decision when writing these documents for their own use, for someone else's use, or when being asked by others what powers they wish to give or what instructions they would like to leave.

Both documents are used by either the individual making the document (if written for themselves) or by a person granted permission (by the maker of the document if made for someone else) to make healthcare decisions on behalf of that person, should he or she be unable to communicate his or her wishes. The healthcare directive can be a "living will," which only states the person's desires for end-of-life care, or a healthcare proxy or power of attorney, which grants another individual decision-making authority over all other medical decisions.

The difference between a healthcare directive and a power of attorney is that a healthcare directive does not bestow any authority to the person named as agent or proxy. The appointing of an agent or proxy is done by another document, a Durable Power of Attorney.

A healthcare directive should not be confused with a will that designates guardians for minor children and residuary beneficiaries for property not disposed of by will. Healthcare directives are related to but are not wills.

A healthcare directive is a document that specifies the type of medical treatment one wishes to receive in case he or she becomes unable to make decisions due to illness. It gives specific instructions and establishes guidelines for the person they wish to carry out these instructions when they are incapacitated. A power of attorney grants decision-making powers but only with respect to specific matters. It is important for people to understand that if they want to give their agent decision-making power over all healthcare decisions, they need to appoint them as a proxy with "full" powers in the healthcare directive.

A durable power of attorney is granted by an individual (the principal) to his or her attorney-in-fact, sometimes called the "agent" or "attorney-in-fact. A durable power of attorney goes into effect immediately, continues in force during the principal's physical and/or mental incapacity, and remains effective even after a principal is deceased. There are two kinds of durable powers of attorney: a general power of attorney and an enduring power of attorney.

Are advance healthcare directives the same in every state?

Every state has its own guidelines on advance healthcare directives. They influence who makes medical decisions for you if you lack the capacity to make your own. Moreover, they affect who gets access to your medical records.

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