75-2a-117 - Optional form.
75-2a-117. Optional form.
(1) The form created in Subsection (2), or a substantially similar form, is presumed validunder this chapter.
(2) The following form is presumed valid under Subsection (1):
Part I: Allows you to name another person to make health care decisions for you when youcannot make decisions or speak for yourself.
Part II: Allows you to record your wishes about health care in writing.
Part III: Tells you how to revoke or change this directive.
Part IV: Makes your directive legal.
__________________________________________________________________________
Name: ____________________________________________________________________
Street Address: _____________________________________________________________
City, State, Zip Code: _____________________________________________________________
Telephone: _________________________ Cell Phone: ____________________________
Birth date: _________________________________________________________________________________________
A. No Agent
If you do not want to name an agent: initial the box below, then go to Part II; do not name anagent in B or C below. No one can force you to name an agent.
______ I do not want to choose an agent.
B. My Agent
Agent's Name:
______________________________________________________________
Street Address:
______________________________________________________________
City, State, Zip Code:
______________________________________________________________
Home Phone: ( ) _________ Cell Phone: ( ) _________ Work Phone: ( ) __________
C. My Alternate Agent
This person will serve as your agent if your agent, named above, is unable or unwilling to serve.
Alternate Agent's Name:
______________________________________________________
Street Address:
______________________________________________________________
City, State, Zip Code:
______________________________________________________________
Home Phone: ( ) _________ Cell Phone: ( ) _________ Work Phone: ( ) __________
D. Agent's Authority
If I cannot make decisions or speak for myself (in other words, after my physician or anotherauthorized provider finds that I lack health care decision making capacity under Section
75-2a-104 of the Advance Health Care Directive Act), my agent has the power to make anyhealth care decision I could have made such as, but not limited to:
* Consent to, refuse, or withdraw any health care. This may include care to prolong my life suchas food and fluids by tube, use of antibiotics, CPR (cardiopulmonary resuscitation), and dialysis,and mental health care, such as convulsive therapy and psychoactive medications. This authorityis subject to any limits in paragraph F of Part I or in Part II of this directive.
* Hire and fire health care providers.
* Ask questions and get answers from health care providers.
* Consent to admission or transfer to a health care provider or health care facility, including amental health facility, subject to any limits in paragraphs E and F of Part I.
* Get copies of my medical records.
* Ask for consultations or second opinions.
My agent cannot force health care against my will, even if a physician has found that I lack healthcare decision making capacity.
E. Other Authority
My agent has the powers below ONLY IF I initial the "yes" option that precedes the statement. Iauthorize my agent to:
YES _____ NO _____ Get copies of my medical records at any time, even when I canspeak for myself.
YES _____ NO _____ Admit me to a licensed health care facility, such as a hospital,nursing home, assisted living, or other facility for long-term placement other than convalescentor recuperative care.
F. Limits/Expansion of Authority
I wish to limit or expand the powers of my health care agent as follows:
____________________________________________________________________________
____________________________________________________________________________
G. Nomination of Guardian
Even though appointing an agent should help you avoid a guardianship, a guardianship may stillbe necessary. Initial the "YES" option if you want the court to appoint your agent or, if youragent is unable or unwilling to serve, your alternate agent, to serve as your guardian, if aguardianship is ever necessary.
YES _____ NO _____
I, being of sound mind and not acting under duress, fraud, or other undue influence, do herebynominate my agent, or if my agent is unable or unwilling to serve, I hereby nominate my alternateagent, to serve as my guardian in the event that, after the date of this instrument, I becomeincapacitated.
H. Consent to Participate in Medical Research
YES _____ NO _____ I authorize my agent to consent to my participation in medicalresearch or clinical trials, even if I may not benefit from the results.
I. Organ Donation
YES _____ NO _____ If I have not otherwise agreed to organ donation, my agent mayconsent to the donation of my organs for the purpose of organ transplantation.
____________________________________________________________________________
I want my health care providers to follow the instructions I give them when I am being treated,
even if my instructions conflict with these or other advance directives. My health care providersshould always provide health care to keep me as comfortable and functional as possible.
Choose only one of the following options, numbered Option 1 through Option 4, by placing yourinitials before the numbered statement. Do not initial more than one option. If you do not wishto document end-of-life wishes, initial Option 4. You may choose to draw a line through theoptions that you are not choosing.
Option 1
________ Initial
I choose to let my agent decide. I have chosen my agent carefully. I have talked with my agentabout my health care wishes. I trust my agent to make the health care decisions for me that Iwould make under the circumstances.
Additional Comments:
_____________________________________________________________________
Option 2
________ Initial
I choose to prolong life. Regardless of my condition or prognosis, I want my health care team totry to prolong my life as long as possible within the limits of generally accepted health carestandards.
Other:
_____________________________________________________________________
Option 3
________ Initial
I choose not to receive care for the purpose of prolonging life, including food and fluids by tube,antibiotics, CPR, or dialysis being used to prolong my life. I always want comfort care androutine medical care that will keep me as comfortable and functional as possible, even if that caremay prolong my life.
If you choose this option, you must also choose either (a) or (b), below.
______ Initial
(a) I put no limit on the ability of my health care provider or agent to withhold or withdrawlife-sustaining care.
If you selected (a), above, do not choose any options under (b).
______ Initial
(b) My health care provider should withhold or withdraw life-sustaining care if at least one ofthe following initialed conditions is met:
_____ I have a progressive illness that will cause death.
_____ I am close to death and am unlikely to recover.
_____ I cannot communicate and it is unlikely that my condition will improve.
_____ I do not recognize my friends or family and it is unlikely that my condition will improve.
_____ I am in a persistent vegetative state.
Other:
_____________________________________________________________________
Option 4
________ Initial
I do not wish to express preferences about health care wishes in this directive.
Other:
_____________________________________________________________________
Additional instructions about your health care wishes:
________________________________________________________________________________________________________________________________________________________
If you do not want emergency medical service providers to provide CPR or other life sustainingmeasures, you must work with a physician or APRN to complete an order that reflects yourwishes on a form approved by the Utah Department of Health.
I may revoke or change this directive by:
1. Writing "void" across the form, or burning, tearing, or otherwise destroying or defacing thisdocument or directing another person to do the same on my behalf;
2. Signing a written revocation of the directive, or directing another person to sign a revocationon my behalf;
3. Stating that I wish to revoke the directive in the presence of a witness who: is 18 years of ageor older; will not be appointed as my agent in a substitute directive; will not become a defaultsurrogate if the directive is revoked; and signs and dates a written document confirming mystatement; or
4. Signing a new directive. (If you sign more than one Advance Health Care Directive, the mostrecent one applies.)
I sign this directive voluntarily. I understand the choices I have made and declare that I amemotionally and mentally competent to make this directive. My signature on this form revokesany living will or power of attorney form, naming a health care agent, that I have completed inthe past.
____________________________________
Date
________________________________________________
Signature
____________________________________________________________________________
City, County, and State of Residence
I have witnessed the signing of this directive, I am 18 years of age or older, and I am not:
1. related to the declarant by blood or marriage;
2. entitled to any portion of the declarant's estate according to the laws of intestate succession ofany state or jurisdiction or under any will or codicil of the declarant;
3. a beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transferon death deed that is held, owned, made, or established by, or on behalf of, the declarant;
4. entitled to benefit financially upon the death of the declarant;
5. entitled to a right to, or interest in, real or personal property upon the death of the declarant;
6. directly financially responsible for the declarant's medical care;
7. a health care provider who is providing care to the declarant or an administrator at a healthcare facility in which the declarant is receiving care; or
8. the appointed agent or alternate agent.
_____________________________________ __________________________________
Signature of Witness Printed Name of Witness
_____________________________________ ___________ _________ _________
Street Address City State Zip Code
If the witness is signing to confirm an oral directive, describe below the circumstances underwhich the directive was made.
________________________________________________________________________________________________________________________________________________________
Amended by Chapter 99, 2009 General Session