Suggested Format for an Advance Medical Directive

Suggested Format for an Advance Medical Directive

(See “Health Care Decisions Act” in the Code of Virginia - §§54.1-2981 through 54.1-2996)

§ 54.1-2984. Suggested form of written advance directives.

An advance directive executed pursuant to this article may, but need not, be in the following form:

ADVANCEMEDICALDIRECTIVE

I,...... ,willinglyandvoluntarilymakeknownmywishesintheevent

thatIamincapableofmakinganinformeddecision,asfollows:

Iunderstandthatmyadvancedirectivemayincludetheselectionofanagent

aswellassetforthmychoicesregardinghealthcare.Theterm"healthcare"

meansthefurnishingofservicestoanyindividualforthepurposeof

preventing,alleviating,curing,orhealinghumanillness,injuryorphysical

disability,includingbutnotlimitedto,medications;surgery;blood

transfusions;chemotherapy;radiationtherapy;admissiontoahospital,

nursinghome,assistedlivingfacility,orotherhealthcarefacility;

psychiatricorothermentalhealthtreatment;andlife-prolongingprocedures

andpalliativecare.

Thephrase"incapableofmakinganinformeddecision"meansunableto

understandthenature,extentandprobableconsequencesofaproposedhealth

caredecisionorunabletomakearationalevaluationoftherisksand

benefitsofaproposedhealthcaredecisionascomparedwiththerisksand

benefitsofalternativestothatdecision,orunabletocommunicatesuch

understandinginanyway.

ThedeterminationthatIamincapableofmakinganinformeddecisionshallbe

madebymyattendingphysicianandacapacityreviewer,ifcertificationbya

capacityreviewerisrequiredbylaw,afterapersonalexaminationofmeand

shallbecertifiedinwriting.Suchcertificationshallberequiredbefore

healthcareisprovided,continued,withheldorwithdrawn,beforeanynamed

agentshallbegrantedauthoritytomakehealthcaredecisionsonmybehalf,

andbefore,orassoonasreasonablypracticableafter,healthcareis

provided,continued,withheldorwithdrawnandevery180daysthereafterwhile

theneedforhealthcarecontinues.

If,atanytime,Iamdeterminedtobeincapableofmakinganinformed

decision,Ishallbenotified,totheextentIamcapableofreceivingsuch

notice,thatsuchdeterminationhasbeenmadebeforehealthcareisprovided,

continued,withheld,orwithdrawn.Suchnoticeshallalsobeprovided,assoon

aspractical,tomynamedagentorpersonauthorizedby§54.1-2986tomake

healthcaredecisionsonmybehalf.IfIamlaterdeterminedtobecapableof

makinganinformeddecisionbyaphysician,inwriting,uponpersonal

examination,anyfurtherhealthcaredecisionswillrequiremyinformed

consent.

(SELECTANYORALLOFTHEOPTIONSBELOW.)

OPTIONI:APPOINTMENTOFAGENT(CROSSTHROUGHOPTIONSIANDIIBELOWIFYOUDO

NOTWANTTOAPPOINTANAGENTTOMAKEHEALTHCAREDECISIONSFORYOU.)

Iherebyappoint...... (primaryagent),of...... (addressandtelephone

number),asmyagenttomakehealthcaredecisionsonmybehalfasauthorized

inthisdocument.If...... (primaryagent)isnotreasonablyavailableor

isunableorunwillingtoactasmyagent,thenIappoint...... (successor

agent),of...... (addressandtelephonenumber),toserveinthatcapacity.

Iherebygranttomyagent,namedabove,fullpowerandauthoritytomake

healthcaredecisionsonmybehalfasdescribedbelowwheneverIhavebeen

determinedtobeincapableofmakinganinformeddecision.Myagent's

authorityhereunderiseffectiveaslongasIamincapableofmakingan

informeddecision.

Inexercisingthepowertomakehealthcaredecisionsonmybehalf,myagent

shallfollowmydesiresandpreferencesasstatedinthisdocumentoras

otherwiseknowntomyagent.Myagentshallbeguidedbymymedicaldiagnosis

andprognosisandanyinformationprovidedbymyphysiciansastothe

intrusiveness,pain,risks,andsideeffectsassociatedwithtreatmentor

nontreatment.Myagentshallnotmakeanydecisionregardingmyhealthcare

whichheknows,oruponreasonableinquiryoughttoknow,iscontrarytomy

religiousbeliefsormybasicvalues,whetherexpressedorallyorinwriting.

IfmyagentcannotdeterminewhathealthcarechoiceIwouldhavemadeonmy

ownbehalf,thenmyagentshallmakeachoiceformebaseduponwhathe

believestobeinmybestinterests.

OPTIONII:POWERSOFMYAGENT(CROSSTHROUGHANYLANGUAGEYOUDONOTWANTAND

ADDANYLANGUAGEYOUDOWANT.)

Thepowersofmyagentshallincludethefollowing:

A.Toconsenttoorrefuseorwithdrawconsenttoanytypeofhealthcare,

treatment,surgicalprocedure,diagnosticprocedure,medicationandtheuseof

mechanicalorotherproceduresthataffectanybodilyfunction,including,

butnotlimitedto,artificialrespiration,artificiallyadministered

nutritionandhydration,andcardiopulmonaryresuscitation.Thisauthorization

specificallyincludesthepowertoconsenttotheadministrationofdosages

ofpain-relievingmedicationinexcessofrecommendeddosagesinanamount

sufficienttorelievepain,evenifsuchmedicationcarriestheriskof

addictionorofinadvertentlyhasteningmydeath;

B.Torequest,receive,andreviewanyinformation,verbalorwritten,

regardingmyphysicalormentalhealth,includingbutnotlimitedto,medical

andhospitalrecords,andtoconsenttothedisclosureofthisinformation;

C.Toemployanddischargemyhealthcareproviders;

D.Toauthorizemyadmissiontoordischarge(includingtransfertoanother

facility)fromanyhospital,hospice,nursinghome,assistedlivingfacility

orothermedicalcarefacility.IfIhaveauthorizedadmissiontoahealth

carefacilityfortreatmentofmentalillness,thatauthorityisstated

elsewhereinthisadvancedirective;

E.Toauthorizemyadmissiontoahealthcarefacilityforthetreatmentof

mentalillnessfornomorethan10calendardaysprovidedIdonotprotestthe

admissionandaphysicianonthestaffofordesignatedbytheproposed

admittingfacilityexaminesmeandstatesinwritingthatIhaveamental

illnessandIamincapableofmakinganinformeddecisionaboutmyadmission,

andthatIneedtreatmentinthefacility;andtoauthorizemydischarge

(includingtransfertoanotherfacility)fromthefacility;

F.Toauthorizemyadmissiontoahealthcarefacilityforthetreatmentof

mentalillnessfornomorethan10calendardays,evenovermyprotest,ifa

physicianonthestaffofordesignatedbytheproposedadmittingfacility

examinesmeandstatesinwritingthatIhaveamentalillnessandIam

incapableofmakinganinformeddecisionaboutmyadmission,andthatIneed

treatmentinthefacility;andtoauthorizemydischarge(includingtransfer

toanotherfacility)fromthefacility.[Myphysicianorlicensedclinical

psychologistherebyatteststhatIamcapableofmakinganinformeddecision

andthatIunderstandtheconsequencesofthisprovisionofmyadvance

directive:______];

G.Toauthorizethespecifictypesofhealthcareidentifiedinthisadvance

directive[specifycross-referencetoothersectionsofdirective]evenover

myprotest.[Myphysicianorlicensedclinicalpsychologistherebyattests

thatIamcapableofmakinganinformeddecisionandthatIunderstandthe

consequencesofthisprovisionofmyadvancedirective:

______];

H.TocontinuetoserveasmyagentevenintheeventthatIprotestthe

agent'sauthorityafterIhavebeendeterminedtobeincapableofmakingan

informeddecision;

I.Toauthorizemyparticipationinanyhealthcarestudyapprovedbyan

institutionalreviewboardorresearchreviewcommitteeaccordingto

applicablefederalorstatelawthatofferstheprospectofdirecttherapeutic

benefittome;

J.Toauthorizemyparticipationinanyhealthcarestudyapprovedbyan

institutionalreviewboardorresearchreviewcommitteepursuanttoapplicable

federalorstatelawthataimstoincreasescientificunderstandingofany

conditionthatImayhaveorotherwisetopromotehumanwell-being,even

thoughitoffersnoprospectofdirectbenefittome;

K.TomakedecisionsregardingvisitationduringanytimethatIamadmitted

toanyhealthcarefacility,consistentwiththefollowingdirections:

...... ;and

L.Totakeanylawfulactionsthatmaybenecessarytocarryoutthese

decisions,includingthegrantingofreleasesofliabilitytomedical

providers.

Further,myagentshallnotbeliableforthecostsofhealthcarepursuantto

hisauthorization,basedsolelyonthatauthorization.

OPTIONIII:HEALTHCAREINSTRUCTIONS

(CROSSTHROUGHPARAGRAPHSAAND/ORBIFYOUDONOTWANTTOGIVEADDITIONAL

SPECIFICINSTRUCTIONSABOUTYOURHEALTHCARE.)

A.IspecificallydirectthatIreceivethefollowinghealthcareifitis

medicallyappropriateunderthecircumstancesasdeterminedbymyattending

physician:......

B.Ispecificallydirectthatthefollowinghealthcarenotbeprovidedtome

underthefollowingcircumstances(youmayspecifythatcertainhealthcare

notbeprovidedunderanycircumstances):......

OPTIONIV:ENDOFLIFEINSTRUCTIONS

(CROSSTHROUGHTHISOPTIONIFYOUDONOTWANTTOGIVEINSTRUCTIONSABOUTYOUR

HEALTHCAREIFYOUHAVEATERMINALCONDITION.)

IfatanytimemyattendingphysicianshoulddeterminethatIhaveaterminal

conditionwheretheapplicationoflife-prolongingprocedures-including

artificialrespiration,cardiopulmonaryresuscitation,artificially

administerednutrition,andartificiallyadministeredhydration-wouldserve

onlytoartificiallyprolongthedyingprocess,Idirectthatsuchprocedures

bewithheldorwithdrawn,andthatIbepermittedtodienaturallywithonly

theadministrationofmedicationortheperformanceofanymedicalprocedure

deemednecessarytoprovidemewithcomfortcareortoalleviatepain.

OPTION:OTHERDIRECTIONSABOUTLIFE-PROLONGINGPROCEDURES.(Ifyouwishto

provideyourowndirections,orifyouwishtoaddtothedirectionsyouhave

givenabove,youmaydosohere.Ifyouwishtogivespecificinstructions

regardingcertainlife-prolongingprocedures,suchasartificialrespiration,

cardiopulmonaryresuscitation,artificiallyadministerednutrition,and

artificiallyadministeredhydration,thisiswhereyoushouldwritethem.)I

directthat:

______

______

______;

OPTION:MyotherinstructionsregardingmycareifIhaveaterminalcondition

areasfollows:

______

______

______;

Intheabsenceofmyabilitytogivedirectionsregardingtheuseofsuch

life-prolongingprocedures,itismyintentionthatthisadvancedirective

shallbehonoredbymyfamilyandphysicianasthefinalexpressionofmy

legalrighttorefusehealthcareandacceptanceoftheconsequencesofsuch

refusal.

OPTIONV:APPOINTMENTOFANAGENTTOMAKEANANATOMICALGIFTORORGAN,TISSUE

OREYEDONATION(CROSSTHROUGHIFYOUDONOTWANTTOAPPOINTANAGENTTOMAKE

ANANATOMICALGIFTORANYORGAN,TISSUEOREYEDONATIONFORYOU.)

Uponmydeath,Idirectthatananatomicalgiftofallofmybodyorcertain

organ,tissueoreyedonationsmaybemadepursuanttoArticle2(§32.1-289.2

etseq.)ofChapter8ofTitle32.1andinaccordancewithmydirections,if

any.Iherebyappoint...... asmyagent,of...... (addressand

telephonenumber),tomakeanysuchanatomicalgiftororgan,tissueoreye

donationfollowingmydeath.Ifurtherdirectthat:...... (declarant's

directionsconcerninganatomicalgiftororgan,tissueoreyedonation).

Thisadvancedirectiveshallnotterminateintheeventofmydisability.

AFFIRMATIONANDRIGHTTOREVOKE:Bysigningbelow,IindicatethatIam

emotionallyandmentallycapableofmakingthisadvancedirectiveandthatI

understandthepurposeandeffectofthisdocument.IunderstandImayrevoke

alloranypartofthisdocumentatanytime(i)withasigned,datedwriting;

(ii)byphysicalcancellationordestructionofthisadvancedirectiveby

myselforbydirectingsomeoneelsetodestroyitinmypresence;or(iii)by

myoralexpressionofintenttorevoke.

______

(Date)(SignatureofDeclarant)

Thedeclarantsignedtheforegoingadvancedirectiveinmypresence.

(Witness)______

(Witness)______