A University of Alabama Law School Clinical Program funded in part by West Alabama Regional Commission

6. Form: Advance Health Care Directive

Following is the statutory form with slight changes and additions for clarity. In the definitions within the Living Will section there are minor grammatical changes and one or two other minor adjustments. There are several changes in the proxy appointment section, (1) to clarify that the appointment is intended to be effective in non-terminal as well as terminal situations, (2) to clairfy that naming persons for the physician to try to talk to before life-sustaining treatment is withdrawn does not give those named the right to override the declarant's decisions, and (3) to appoint the proxy as the declarant's HIPAA representative.

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Advance Health Care Directive
Living Will and Health Care Proxy

Section 1. Living Will

I, ___________________, being of sound mind and at least 19 years old, would like to make the following wishes known. I direct that my family, my doctors and health care workers, and all others, follow these directions that I am writing down. I have carefully considered my choices and understand their consequences. I know that at any time I can change my mind about these directions by tearing up this form and writing a new one. I can also do away with these directions by tearing them up and telling someone at least 19 years of age of my wishes and asking him or her to write them down.

I understand that these directions will only be used if I am not able to speak for myself.

If I become terminally ill or injured:

Terminally ill or injured: The point at which my doctor and another doctor decide that I have a condition that cannot be cured and that I will likely die in the near future from this condition.

Life sustaining treatment: Life sustaining treatment includes drugs, machines, or medical procedures that would keep me alive but would not cure me. I know that even if I choose not to have life sustaining treatment, I will still get medicines and treatments that ease my pain and keep me comfortable.

Place your initials by either “yes” or “no”:

I want to have life sustaining treatment if am terminally ill or injured.
_____________ Yes ______________No

Artificially provided food and hydration (Food and water through a tube or IV): I understand that if I am terminally ill or injured I may be given food or water through a tube or IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me.

Place your initials by either “yes” or “no”:

I want to have food and water provided through a tube or IV if I am terminally ill or injured.
____________ Yes _____________No

If I become permanently unconscious:

Permanent unconsciousness: The point at which my doctor and another doctor agree that within a reasonable degree of medical certainty I can no longer think, feel anything, knowingly move, or be aware of being alive. They believe this condition will last indefinitely without hope for improvement and have watched me long enough to make that decision. I understand that at least one of these doctors must be qualified to make such a diagnosis.

Life sustaining treatment: Life sustaining treatment includes drugs, machines or other medical procedures that would keep me alive but would not cure me. I know that even if I choose not to have life sustaining treatment I will still get medicines and treatments that ease my pain and keep me comfortable.

Place your initials by either “yes” or “no”:

I want to have life sustaining treatment if I am permanently unconscious.
___________ Yes ______________ No

Artificially provided food and hydration (Food and water through a tube or IV): I understand that if I become permanently unconscious, I may be given food and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me.

Place your initials by either “yes” or “no”.

I want to have food and water provided through a tube or IV if I am permanently unconscious.
__________ Yes ____________ No

Other Directions: Please list any other things you want done or not done.

In addition to the directions I have listed on this form, I also want the following:
____________________________________________________________
____________________________________________________________
____________________________________________________________

If you do not have other directions, place your initials here: _________

Section 2. If I need someone to speak for me.

This form can be used in the State of Alabama to name a person you would like to make medical decisions for you if you become too sick to speak for yourself. This person is called a health care proxy. You do not have to name a health care proxy. The directions in your Living Will will be followed even if you do not have a health care proxy.

Place your initials by only one answer:

_________ I do not want to name a health care proxy. (If you initial this answer, go to Section 3.)

________ I do want the person listed below to be my health care proxy, to make health care decisions for me not only in situations in which I am terminally ill or injured or permanently unconscious, but also in non-terminal situations in which I am unable to speak for myself. I have talked with him/her about my wishes.

Initial below if you want your proxy (and alternate) to have access to your private medical information, effective immediately:

_________ I appoint my proxy [and alternate proxy] as my Personal Representative(s) as that term is used in 45 C.F.R. § 164. ("HIPAA"), to have access to my personally identifiable health care and related information of all kinds and in any form, and to execute any other document that may be required or requested in order to do so. I authorize covered entities to provide those named with the same access to my health and related information as I have myself. I intend this authority to be effective immediately, whether or not I am able to make or communicate health care decisions fo rmyself. This authority shall remain in effect until my death unless earlier revoked by me, and I understand that I may revoke it at any time.

First choice for proxy: ____________________________________
Relationship to me: __________________________
Address: ________________________________________________
City: ____________________ State: ______________ Zip: ____________
Daytime phone: ________________ Nighttime phone: _______________

If the person named above is not able, not willing, or not available to be my health care proxy, then I appoint:

Second choice for proxy: ____________________________________
Relationship to me: __________________________
Address: ________________________________________________
City: ____________________ State: ______________ Zip: ____________
Daytime phone: _______________ Nighttime phone: _______________

Instructions for Proxy:

Place your initials by either “yes” or “no”:

I want my proxy to make decisions about whether to give me food and water through a tube or IV, guided by my wishes expressed in my Living Will, but based on the circumstances at the time, even if it means doing something from what I have stated in my Living Will.

___________ Yes __________ No

I want my proxy to strictly follow the directions in my Living Will about tube feeding.

____________ Yes ____________ No

I want my Proxy to make decisions about other matters that may not be addressed in or contemplated by this document.

____________ Yes ____________ No

Section 3. The things listed on this form are what I want.

I understand the following:

If my doctor, hospital, nursing home, assisted living facility or other provider does not want to follow the directions I have listed, (s)he/it must see that I get to a doctor or provider that will follow my directions.
If I am pregnant, or if I become pregnant, the choices I have made on this form will not be followed until after the birth of the baby.
If the time comes for me to stop receiving life sustaining treatment or food and water through a tube or an IV (or for a decision to be made not to begin such treatment), I direct that my doctor talk about the good and bad points of doing this, along with my wishes, with my health care proxy, if I have one, and the people listed below. I am not authorizing those named to override my wishes or those of my proxy.
___________________________________________________________
___________________________________________________________
___________________________________________________________

Section 4. My signature

Your name: _______________________________________

The month, day and year of your birth: ___________________________

Your signature: ____________________________________

Date signed: ___________________________

Section 5. Witnesses (need two witnesses to sign)

I am witnessing this form because I believe this person to be of sound mind. I did not sign the person’s signature, and I am not the health care proxy. I am not related to the person by blood, adoption or marriage, and not entitled to any part of his/her estate. I am at least 19 years old and am not directly responsible for his/her medical care.

Name of first witness: ____________________________

Signature: ______________________________________

Date: __________________________

Name of second witness: __________________________

Signature: ______________________________________

Date: ___________________________

Section 6. Signature of Proxy

I, _____________________, am willing to serve as health care proxy.

Signature: _____________________ Date: _________________

I, ______________________, am willing to serve as health care proxy if the first choice cannot serve.

Signature: _____________________ Date: ___________________

It is suggested that the pages be numbered (Page 1 of 5, Page 2 of 5, etc.) and each initialed or signed by the person executing the document.

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