GEORGIA
ADVANCE
DIRECTIVE
FOR
HEALTH
CARE
Revised March 2016
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Purpose:
In recognizing the right of individuals to (1) control all aspects of his
or her personal care and medical treatment, (2) insist upon medical
treatment, (3) decline medical treatment, or (4) direct that medical
treatment be withdrawn, the General Assembly has in the past, provided
statutory forms for both the living will and durable power of attorney for
health care. To help reduce confusion, inconsistency, out-of-date
terminology, and confusing and inconsistent requirements for execution,
and to follow the trend set by other states to combine the concepts of the
living will and health care agency into a single legal document, the efforts
of a significant number of individuals representing the academic, medical,
legislative, and legal communities, state officials, ethics scholars, and
advocacy groups produced the development of a consolidated advance
directive for health care. This newly created form using understandable
and everyday language is meant to encourage more citizens of Georgia to
voluntarily execute advance directives for health care to make their wishes
more clearly known.
The General Assembly takes note that the clear expression of
individual decisions regarding health care, whether made by the individual
or an agent appointed by the individual, is of critical importance not only to
citizens but also to the health care and legal communities, third parties, and
families. In furtherance of these purposes, the General Assembly enacted a
new Chapter 32 of Title 31. This Chapter sets forth general principles
governing the expression of decisions regarding health care and the
appointment of a health care agent, as well as a form of advance directive
for health care.
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Guide to Contents
INSTRUCTIONS ....................................................................... 14 pages
1. Effect of 07/01/07 Changes ................................................................................ 4
2. Definitions ............................................................................................................ 5
3. Certification of Declarant´s Condition ................................................................ 7
4. Use of Other Forms ............................................................................................. 8
5. How the New form differs from the former Living Will and Durable Power of
Attorney for Health Care forms ............................................................................... 8
6. The New Form Described ................................................................................... 9
7. Executing an Advance Directive for Health Care .............................................. 9
8. Health Care Agent ............................................................................................. 10
Restrictions
............................................................................................................ 10
Duty
........................................................................................................................ 10
Responsibilities
...................................................................................................... 10
Prohibited Activities
............................................................................................... 11
9. Refusal to Comply with Directive ..................................................................... 12
10. Revoking a Directive ........................................................................................ 13
11. Completed form ................................................................................................ 13
12. For Additional Information .............................................................................. 14
ADVANCE DIRECTIVE – FORM ............................................... 15 pages
Description of Four Parts ............................................................................... 1
Part One-Health Care Agent ............................................................... 3
ID of Agent ......................................................................................... 3
Back-up Agent(s) ............................................................................... 4
General Powers of Agent ................................................................... 5
Guidance for Agent ............................................................................ 6
Agent’s Powers after Declarant’s Death ........................................... 7
Part Two-Treatment Preferences ...................................................... 8
Conditions when Effective ................................................................. 9
Treatment Preferences ...................................................................... 9
Part Three – Guardianship ................................................................. 12
Part Four- Effectiveness/Signatures ................................................ 13
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INSTRUCTIONS
The effect of the Georgia Advance Directive for Health Care Act
on the Georgia Living Will and Georgia Durable Power of Attorney
for Health Care Laws.
Georgia’s laws on advance directives changed significantly on July 1, 2007.
The Georgia Advance Directive for Health Care Act replaced the
Georgia Living Will as the new Chapter 32 of Title 31 of the Official
Code of Georgia.
Chapter 36 of Title 31 of the Official Code of Georgia creating the
Durable Power of Attorney for HealthCare was repealed and that
chapter reserved, meaning that for now, no law will be found in
Chapter 36, but the space and the Chapter number will be reserved
for future use.
The Living Will and Durable Power of Attorney for Health Care will
no longer be available as options for advance directives in Georgia.
Validly executed Living Wills created between March 28, 1986 and
June 30, 2007 remain valid until revoked.
Validly executed Durable Powers of Attorney for Health Care
created before June 30, 2007 remain valid until revoked.
To know if your current Living Will and/or Durable Power of Attorney for
Health Care is valid, find a copy of the old code sections to confirm the
witnessing requirements or consult an attorney who can compare it with the
law in effect prior to July 1, 2007.
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If one chooses to complete a Georgia Advance Directive for Health Care, it
will replace any other advance directive for health care, durable power of
attorney for health care, health care proxy, or living will that currently is in
place. One may choose not to complete this form and his/her current Living
Will and/or Durable Power of Attorney for Health Care form, if valid now,
remains valid.
Definitions:
(1) 'Advance directive for health care' means a written document
voluntarily executed by a declarant in accordance with the requirements of
Code Section 31-32-5.
(2) 'Attending physician' means the physician who has primary
responsibility at the time of reference for the treatment and care of the
declarant.
(3) 'Declarant' means a person who has executed an advance directive for
health care authorized by this chapter.
(4) 'Durable power of attorney for health care' means a written document
voluntarily executed by an individual creating a health care agency in
accordance with Chapter 36 of this title; as such chapter existed on and
before June 30, 2007.
(5) 'Health care' means any care, treatment, service, or procedure to
maintain, diagnose, treat, or provide for a declarant´s physical or mental
health or personal care.
(6) 'Health care agent' means a person appointed by a declarant to act for
and on behalf of the declarant to make decisions related to consent, refusal,
or withdrawal of any type of health care and decisions related to autopsy,
A Georgia Advance Directive for Health Care is Never Required
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anatomical gifts, and final disposition of a declarant´s body when a
declarant is unable or chooses not to make health care decisions for
himself or herself. The term 'health care agent' shall include any back-up
or successor agent appointed by the declarant.
(7) 'Health care facility' means a hospital, skilled nursing facility, hospice,
institution, home, residential or nursing facility, treatment facility, and any
other facility or service which has a valid permit or provisional permit
issued under Chapter 7 of this title or which is licensed, accredited, or
approved under the laws of any state, and includes hospitals operated by
the United States government or by any state or subdivision thereof.
(8) 'Health care provider' means the attending physician and any other
person administering health care to the declarant at the time of reference
who is licensed, certified, or otherwise authorized or permitted by law to
administer health care in the ordinary course of business or the practice of
a profession, including any person employed by or acting for any such
authorized person.
(9) 'Life-sustaining procedures' means medications, machines, or other
medical procedures or interventions which, when applied to a declarant in a
terminal condition or in a state of permanent unconsciousness, could in
reasonable medical judgment keep the declarant alive but cannot cure the
declarant and where, in the judgment of the attending physician and a
second physician, death will occur without such procedures or
interventions. The term 'life-sustaining procedures' shall not include the
provision of nourishment or hydration but a declarant may direct the
withholding or withdrawal of the provision of nourishment or hydration in
an advance directive for health care. The term 'life-sustaining procedures'
shall not include the administration of medication to alleviate pain or the
performance of any medical procedure deemed necessary to alleviate pain.
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(10) 'Living will' means a written document voluntarily executed by an
individual directing the withholding or withdrawal of life-sustaining
procedures when an individual is in a terminal condition, coma, or
persistent vegetative state in accordance with this chapter, as such chapter
existed on and before June 30, 2007.
(11) 'Physician' means a person lawfully licensed in this state to practice
medicine and surgery pursuant to Article 2 of Chapter 34 of Title 43; and if
the declarant is receiving health care in another state, a person lawfully
licensed in such state.
(12) 'Provision of nourishment or hydration' means the provision of
nutrition or fluids by tube or other medical means.
(13) 'State of permanent unconsciousness' means an incurable or
irreversible condition in which the declarant is not aware of himself or
herself or his or her environment and in which the declarant is showing no
behavioral response to his or her environment.
(14) 'Terminal condition' means an incurable or irreversible condition which
would result in the declarant´s death in a relatively short period of time.
Certification of a terminal condition or state of permanent
unconsciousness
Before any action can be taken to withdraw or withhold life sustaining
procedures or to withdraw or withhold nourishment or hydration for a
declarant in a state of permanent unconsciousness or is in a terminal
condition, that condition must be certified in writing. The attending
physician and one other physician must personally examine the declarant
and certify in writing based upon the declarant’s condition found during the
course of their examination and in accordance with current accepted
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medical standards that the declarant does meet the criteria for terminal
condition or state of permanent unconsciousness as defined above.
The difference between this advance directive form and the Living
Will and Durable Power of Attorney for Health Care
The Georgia Advance Directive for Health Care is an attempt to combine
the best features of the Living Will and Durable Power of Attorney for
Health Care into one written document. An effort has also been made to
make the execution (signing and witnessing) of this document easier and
more convenient. The effect of this new document still does not constitute
suicide, physician assisted suicide, homicide or euthanasia. Completing one
has no affect on insurance, annuities or anything else contingent on the life
or death of the person making the advance directive (hereafter, “the
declarant”).
No limitation on the use of other advance directives forms
Using this form of advance directive for health care is completely
optional. Other forms of advance directives for health care that
substantially comply with this form may be used in Georgia.
This includes using forms from other states.
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Three parts of the Georgia Advance Directive for Health Care
Part One: allows an agent to be appointed to carry out health care
decisions (formerly the Durable Power of Attorney for Health Care)
Part Two: allows choices about withholding or withdrawing life support
and accepting or refusing nutrition and/or hydration (formerly the Living
Will)
Part Three: allows one to nominate someone to be appointed as Guardian
if a court determines that a guardian is necessary.
Requirements for the person making an advance directive for
health care
Must be of sound mind
Must be 18 years of age or older
Or
An emancipated minor
Executing the advance directive for health care
1) the declarant must sign or expressly direct someone else do it for
him/her
2) two witnesses required, who are
of sound mind
18 years of age or older
Witnesses do not have to see the declarant sign
Witnesses do not have to see each other sign the
advance directive
3) the declarant must see both witnesses sign
4) Restriction on witnesses
Not the health care agent
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Not knowingly be in line to inherit anything from or benefit from
the death of the declarant
Not directly involved in the health care of the declarant
Only one of the two witnesses can be an employee, agent or on
the medical staff of the health care facility where the declarant
is receiving his/her health care
Restrictions on the health care agent
A physician or health care provider directly involved in the care of the
declarant may not serve as health care agent.
Duty of the health care agent to act
A health care agent has no duty to act, even if named.
If the health care agent does choose to act, s/he must not make
decisions that are different or that contradict the decisions of the
declarant.
All of the health care agent’s actions must be consistent with the
intentions and desires of the declarant.
If those intentions and desires are not clear, the health care agent’s
actions must be in the best interests of the declarant considering all of
the benefits, burdens, risks and treatments options.
Authorized responsibilities/duties of the health care agent related
to the necessary care of the declarant
1) Consent to, authorize, withdraw consent from, refuse, withhold, any and
all types of medical/surgical care, treatment, programs and/or
procedures
2) Sign and deliver all instruments (documents)
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3) Negotiate and enter into all agreements and contracts binding the
declarant
4) Accompany him/her in an ambulance or air ambulance
5) Admit to or discharge the declarant from any health care facility
6) Visit and consult with the declarant as necessary
7) Examine, copy and consent to disclosure of all the declarant’s medical
records deemed relevant
8) Do all other acts reasonably necessary and carry out duties and
responsibilities in person or through those employed by the health care
agent; this does not include delegating the authority to make health care
decisions
9) Consent to an anatomical gift of the declarant´s body, in whole or part,
an autopsy and direct the final disposition of declarant´s remains,
including funeral arrangements, burial, or cremation (
Note: the law
states that the agent can bind the declarant to pay but does not expressly
mention binding the estate of the declarant. It may be a good idea to
make all arrangements prior to the death of the declarant.
)
Prohibited actions by the health care agent
The health care agent may not consent to psychosurgery, sterilization, or
involuntary hospitalization or treatment under the Mental Health Code, Title
37.
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When the attending physician, health care provider and/or health
care facility refuse to honor the advance directive for health care
The law states:
For health care decisions with which health care providers are unwilling to
comply, after this decision is communicated with the agent, the agent is
responsible for arranging for the declarant´s transfer to another health care
provider. [O.C.G.A. §31-32-8(2)] This section of the law does not
expressly include life-sustaining procedures, nourishment or hydration in
“health care decisions.”
For a declarant´s decision to withhold or withdraw life-sustaining
procedures or withhold or withdraw the provision of nourishment or
hydration, attending physicians who fail or refuse to comply are
responsible for making a good faith attempt to effect the transfer of the
declarant to
another physician
who will comply or must permit the agent,
next of kin or legal guardian to obtain another physician who will comply.
[O.C.G.A. §31-32-9 (d) (1-2)]
If it is the health care facility that refuses to comply with the declarant´s
decision to withhold or withdraw life-sustaining procedures or nutrition or
hydration, the law does not expressly state whose responsibility it is to
ensure the declarant is transferred to another health care facility.
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Revoking this advance directive for health care
The Georgia Advance Directive for Health Care may be revoked at any
time, regardless of the declarant´s mental state or competency. It remains
effective even if a Guardian is appointed for the declarant unless a court
specifically orders otherwise.
Revocation
can occur in any of the following ways:
By completing a new advance directive for health care
By burning, tearing up, or otherwise destroying the existing advance
directive for health care
By writing a clear statement expressing the intent to revoke the advance
directive for health care
By orally expressing the intent to revoke the advance directive for
health care in the presence of a witness 18 years of age or older who
confirms this in writing within 30 days. The revocation is effective when
the treating physician documents it in the medical record.
Marrying after executing an advance directive for health care revokes
any agent other than the declarant´s spouse
Divorcing or otherwise dissolving a marriage after the execution of an
advance directive for health care revokes the designation of the spouse
as the health care agent
What to do with the completed form
You should give a copy of this completed form to people who might need it,
such as your health care agent, your family, and your physician. Keep a
copy of this completed form at home in a place where it can easily be found
if it is needed. Review this completed form periodically to make sure it still
14
reflects your preferences. If your preferences change, complete a new
advance directive for health care.
Copies of this form and its instructions are available at no cost from the
Georgia Department of Human Services Division of Aging Services, 2
Peachtree Street NW, Suite 33.384, Atlanta, GA 30303-3142. For
additional information, call the Division at 1-866-552-4464.
This information was revised March 2016
Page 1 of 15
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE
By: _________________________________________Date of Birth: ______________
(Print Name) ( (Print Name) (mm/dd/yyyy)
This advance directive for health care has four parts:
PART ONE
PART TWO
PART
THREE
Page 2 of 15
PART FOUR
You may fill out any or all of the first three parts listed above. You must fill
out PART FOUR of this form in order for this form to be effective.
Page 3 of 15
PART ONE: HEALTH CARE AGENT
[PART ONE will be effective even if PART TWO is not completed. A
physician or health care provider who is directly involved in your health
care may not serve as your health care agent. If you are married, a future
divorce or annulment of your marriage will revoke the selection of your
current spouse as your health care agent. If you are not married, a future
marriage will revoke the selection of your health care agent unless the
person you selected as your health care agent is your new spouse.]
(1) HEALTH CARE AGENT
I select the following person as my health care agent to make health care
decisions for me:
Name: ___________________________________________________________
Address:________________________________________________________________
___________________________________________________________
_________________________________________________________________
Telephone Numbers:
_________________________________________________________________
(Home)
_________________________________________________________________
(Work)
_________________________________________________________________
(Mobile/Cell)
E-Mail Address: ____________________________________________________
Page 4 of 15
(2) BACK-UP HEALTH CARE AGENT
[This section is optional. PART ONE will be effective even if this section is
left blank.]
If my health care agent cannot be contacted in a reasonable time period and
cannot be located with reasonable efforts or for any reason my health care
agent is unavailable or unable or unwilling to act as my health care agent,
then I select the following, each to act successively in the order named, as
my back-up health care agent(s):
First Back–up Agent
Name: ___________________________________________________________
Address: _________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers: ________________________________________________
_________________________________________________________________
(Home, Work, and Mobile/Cell)
E-Mail Address: ___________________________________________________
Second Back-up Agent
Name: ___________________________________________________________
Address: _________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers:________________________________________________
_________________________________________________________________
(Home, Work, and Mobile/Cell)
E-Mail Address:____________________________________________________
Page 5 of 15
(3) GENERAL POWERS OF HEALTH CARE AGENT
My health care agent will make health care decisions for me when I am
unable to communicate my health care decisions or I choose to have my
health care agent communicate my health care decisions.
My health care agent will have the same authority to make any health care
decision that I could make. My health care agent’s authority includes the
following powers:
To authorize my admission to or discharge (including transfers) from
any hospital, skilled nursing facility, hospice, or other health care facility
or service;
To request, consent to, withhold, or withdraw any type of health care;
and to
Contract for any health care facility or service for me, and to obligate
me to pay for these services (and my health care agent, acting in this
official capacity, will not be financially liable for any services or care
contracted for me or on my behalf).
My health care agent will be my personal representative for all purposes of
federal or state law related to privacy of medical records. This includes
the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
My health care agent will have the same access to my medical records that
I have and can disclose the contents of my medical records to others for
my ongoing health care.
My health care agent may accompany me in an ambulance or air ambulance
if in the opinion of the ambulance personnel protocol permits a passenger
and my health care agent may visit or consult with me in person while I am
Page 6 of 15
in a hospital, skilled nursing facility, hospice, or other health care facility or
service if its protocol permits visitation.
My health care agent may present a copy of this advance directive for
health care in lieu of the original and the copy will have the same meaning
and effect as the original.
I understand that under Georgia law:
My health care agent may refuse to act as my health care agent;
A court can take away the powers of my health care agent if it finds
that my health care agent is not acting properly; and
My health care agent does not have the power to make health care
decisions for me regarding psychosurgery, sterilization, or treatment or
involuntary hospitalization for mental or emotional illness, developmental
disability, or addictive disease.
(4) GUIDANCE FOR HEALTH CARE AGENT
When making health care decisions for me, my health care agent should
think about what action would be consistent with past conversations we
have had, my treatment preferences as expressed in PART TWO (if I have
filled out PART TWO), my religious and other beliefs and values, and how I
have handled medical and other important issues in the past. If what I
would decide is still unclear, then my health care agent should make
decisions for me that my health care agent believes are in my best interest,
considering the benefits, burdens, and risks of my current circumstances
and treatment options.
Page 7 of 15
(5) POWERS OF HEALTH CARE AGENT AFTER DEATH
(A) AUTOPSY
My health care agent will have the power to authorize an autopsy of my
body unless I have limited my health care agent’s power by initialing below.
__________ (Initials) My health care agent will not have the power to
authorize an autopsy of my body (unless an autopsy is required by law).
(B) ORGAN DONATION AND DONATION OF BODY
My health care agent will have the power to make a disposition of any part
or all of my body for medical purposes pursuant to the Georgia Revised
Uniform Anatomical Gift Act, unless I have limited my health care agent’s
power by initialing below.
[Initial each statement that you want to apply.]
__________ (Initials) My health care agent will not have the power to make a
disposition of my body for use in a medical study program.
__________ (Initials) My health care agent will not have the power to donate
any of my organs.
(C) FINAL DISPOSITION OF BODY
My health care agent will have the power to make decisions about the final
disposition of my body unless I have initialed below.
__________ (Initials) I want the following person to make decisions about the
final disposition of my body:
Page 8 of 15
Name: ___________________________________________________________
Address: __________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers: ________________________________________________
_________________________________________________________________
(Home, Work, and Mobile/Cell)
E-Mail Address: ____________________________________________________
I wish for my body to be:
__________ (Initials) Buried OR __________ (Initials) Cremated
PART TWO: TREATMENT PREFERENCES
[PART TWO will be effective only if you are unable to communicate your
treatment preferences after reasonable and appropriate efforts have been
made to communicate with you about your treatment preferences. PART
TWO will be effective even if PART ONE is not completed. If you have not
selected a health care agent in PART ONE, or if your health care agent is
not available, then PART TWO will provide your physician and other health
care providers with your treatment preferences. If you have selected a
health care agent in PART ONE, then your health care agent will have the
authority to make all health care decisions for you regarding matters
covered by PART TWO. Your health care agent will be guided by your
treatment preferences and other factors described in Section (4) of PART
ONE.]
Page 9 of 15
(6) CONDITIONS
PART TWO will be effective if I am in any of the following conditions:
[Initial each condition in which you want PART TWO to be effective.]
_________ (Initials) A terminal condition, which means I have an incurable or
irreversible condition that will result in my death in a relatively short
period of time.
_________ (Initials) A state of permanent unconsciousness, which means I
am in an incurable or irreversible condition in which I am not aware of
myself or my environment and I show no behavioral response to my
environment.
My condition will be determined in writing after personal examination by
my attending physician and a second physician in accordance with currently
accepted medical standards.
(7) TREATMENT PREFERENCES
[State your treatment preference by initialing (A), (B), or (C). If you choose
(C), state your additional treatment preferences by initialing one or more of
the statements following (C). You may provide additional instructions about
your treatment preferences in the next section. You will be provided with
comfort care, including pain relief, but you may also want to state your
specific preferences regarding pain relief in the next section.]
If I am in any condition that I initialed in Section (6) above and I can no
longer communicate my treatment preferences after reasonable and
appropriate efforts have been made to communicate with me about my
treatment preferences, then:
Page 10 of 15
(A) _________ (Initials)
Try to extend my life for as long as possible
, using
all medications, machines, or other medical procedures that in reasonable
medical judgment could keep me alive. If I am unable to take nutrition or
fluids by mouth, then I want to receive nutrition or fluids by tube or other
medical means.
OR
(B) _________ (Initials)
Allow my natural death to occur.
I do not want any
medications, machines, or other medical procedures that in reasonable
medical judgment could keep me alive but cannot cure me. I do not want to
receive nutrition or fluids by tube or other medical means except as needed
to provide pain medication.
OR
(C) _________ (Initials) I do not want any medications, machines, or other
medical procedures that in reasonable medical judgment could keep me
alive but cannot cure me, except as follows:
[Initial each statement that you want to apply to option (C).]
_________ (Initials) If I am unable to take nutrition by mouth, I want to
receive nutrition by tube or other medical means.
_________ (Initials) If I am unable to take fluids by mouth, I want to receive
fluids by tube or other medical means.
_________ (Initials) If I need assistance to breathe, I want to have a
ventilator used.
Page 11 of 15
_________ (Initials) If my heart or pulse has stopped, I want to have
cardiopulmonary resuscitation (CPR) used.
(8) ADDITIONAL STATEMENTS
[This section is optional.
PART TWO will be effective even if this section is
left blank. This section allows you to state additional treatment
preferences, to provide additional guidance to your health care agent (if
you have selected a health care agent in PART ONE), or to provide
information about your personal and religious values about your medical
treatment. For example, you may want to state your treatment preferences
regarding medications to fight infection, surgery, amputation, blood
transfusion, or kidney dialysis. Understanding that you cannot foresee
everything that could happen to you after you can no longer communicate
your treatment preferences, you may want to provide guidance to your
health care agent (if you have selected a health care agent in PART ONE)
about following your treatment preferences. You may want to state your
specific preferences regarding pain relief.]
________________________________________________________________
________________________________________________________________
________________________________________________________________
(9) IN CASE OF PREGNANCY
[PART TWO will be effective even if this section is left blank.]
I understand that under Georgia law, PART TWO generally will have no
force and effect if I am pregnant unless the fetus is not viable and I indicate
by initialing below that I want PART TWO to be carried out.
_________ (Initials) I want PART TWO to be carried out if my fetus is not
viable.
Page 12 of 15
PART THREE: GUARDIANSHIP
(10) GUARDIANSHIP
[PART THREE is optional. This advance directive for health care will be
effective even if PART THREE is left blank. If you wish to nominate a
person to be your guardian in the event a court decides that a guardian
should be appointed, complete PART THREE. A court will appoint a
guardian for you if the court finds that you are not able to make significant
responsible decisions for yourself regarding your personal support, safety,
or welfare. A court will appoint the person nominated by you if the court
finds that the appointment will serve your best interest and welfare. If you
have selected a health care agent in PART ONE, you may (but are not
required to) nominate the same person to be your guardian. If your health
care agent and guardian are not the same person, your health care agent
will have priority over your guardian in making your health care decisions,
unless a court determines otherwise.]
[State your preference by initialing (A) or (B). Choose (A) only if you have
also completed PART ONE.]
(A) __________ (Initials) I nominate the person serving as my health care
agent under PART ONE to serve as my guardian.
OR
(B) __________ (Initials) I nominate the following person to serve as my
guardian:
Name: ___________________________________________________________
Address: _________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers: ________________________________________________
_________________________________________________________________
Page 13 of 15
(Home, Work, and Mobile/Cell)
E-Mail Address: ____________________________________________________
PART FOUR: EFFECTIVENESS AND SIGNATURES
This advance directive for health care will become effective only if I am
unable or choose not to make or communicate my own health care
decisions.
Completing this form revokes and replaces any advance directive for health
care, durable power of attorney for health care, health care proxy, or living
will that I have completed before this date.
Unless I have initialed below and have provided alternative future dates or
events, this advance directive for health care will become effective at the
time I sign it and will remain effective until my death (and after my death to
the extent authorized in Section (5) of PART ONE).
__________ (Initials) This advance directive for health care will become
effective on or upon _______________________________ and will terminate on
or upon
(
Optional: Specify a date or event
)
_______________________________________________________________.
(
Optional: Specify a date or event
)
Page 14 of 15
[You must sign and date or acknowledge signing and dating this form in the
presence of two witnesses.]
Both witnesses must be of sound mind and must be at least 18 years of
age, but the witnesses do not have to be together or present with you when
you sign this form.
A witness:
Cannot be a person who was selected to be your health care agent or
back-up health care agent in PART ONE;
Cannot be a person who will knowingly inherit anything from you or
otherwise knowingly gain a financial benefit from your death; or
Cannot be a person who is directly involved in your health care.
Only one of the witnesses may be an employee, agent, or medical staff
member of the hospital, skilled nursing facility, hospice, or other health care
facility in which you are receiving health care (but this witness cannot be
directly involved in your health care).]
By signing below, I state that I am emotionally and mentally capable of
making this advance directive for health care and that I understand its
purpose and effect.
_________________________________________ ________________
(Signature of Declarant) (Date)
Page 15 of 15
The declarant signed this form in my presence or acknowledged signing
this form to me. Based upon my personal observation, the declarant
appeared to be emotionally and mentally capable of making this advance
directive for health care and signed this form willingly and voluntarily.
______________________________________________ _______________
(Signature of First Witness) (Date)
Print Name: _______________________________________________________
Address: __________________________________________________________
_________________________________________________________________
______________________________________________ ________________
(Signature of Second Witness) (Date)
Print Name: _______________________________________________________
Address: __________________________________________________________
________________________________________________________________
[This form does not need to be notarized and a copy of a validly executed
advance directive for health care carries the same meaning and effect as the
original document.]