Utah Advance Health Care Form – Fill Out and Use This PDF

C.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:

D.Agent's Authority

If I cannot make decisions or speak for myself (in other words, after my physician or

APRN 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 any health 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 such as 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 authority is 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 a mental 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 health care decision making capacity.

E.Other Authority

My agent has the powers below ONLY IF I initial the "yes" option that precedes the statement. I authorize my agent to:

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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 still be necessary. Initial the "YES" option if you want the court to appoint your agent or, if your agent is unable or unwilling to serve, your alternate agent, to serve as your guardian, if a guardianship is ever necessary.

H.Consent to Participate in Medical Research

PART II: MY HEALTH CARE WISHES (LIVING WILL)

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 providers should 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 your initials before the numbered statement. Do not initial more than one option. If you do not wish to document end-of-life wishes, initial Option 4. You may choose to draw a line through the options that you are not choosing.

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Additional Comments: ________________________________________________________

Other: _____________________________________________________________________

Other: _____________________________________________________________________

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Option 4

_______ I do not wish to express preferences about health care wishes in this

(Initial) directive.

If you do not want emergency medical service providers to provide CPR or other life sustaining measures, you must work with a physician or APRN to complete an order that reflects your wishes on a form approved by the Utah Department of Health.

PART III: REVOKING OR CHANGING A DIRECTIVE

I may revoke or change this directive by:

1.Writing "void" across the form, or burning, tearing, or otherwise destroying or defacing this document 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 revocation on my behalf;

3.Stating that I wish to revoke the directive in the presence of a witness who is 18 years of age or older; will not be appointed as my agent in a substitute directive; will not become a default surrogate if the directive is revoked; and signs and dates a written document confirming my statement; or

4.Signing a new directive. (If you sign more than one Advance Health Care Directive, the most recent one applies.)

PART IV: MAKING MY DIRECTIVE LEGAL

I sign this directive voluntarily. I understand the choices I have made and declare that I am emotionally and mentally competent to make this directive. My signature on this form revokes any living will or power of attorney form, naming a health care agent, that I have completed in the past.

___________________________________________________________________________

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 of any state or jurisdiction or under any will or codicil of the declarant;

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3.A beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transfer or 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 health care facility in which the declarant is receiving care; or

8.The appointed agent or alternate agent.

If the witness is signing to confirm an oral directive, describe below the circumstances under which the directive was made.

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