Vermont Directive Health Care Form – Fill Out and Use This PDF

Vermont Advance Directive for Health Care

Prepared by the Vermont Ethics Network

EXPLANATION & INSTRUCTIONS

■You have the right to:

1.Name someone else to make health care decisions for you when or if you are unable to make them yourself.

2.Give instructions about what types of health care you want or do not want.

■It is important to talk with those people closest to you and with your health care providers about your goals, wishes and preferences for treatment.

■You may use this form in its entirety or you may use any part of it. For example, if you only want to choose an agent in Part One, you may fill out just that section and then go to Part Five to sign in the presence of appropriate witnesses.

■You are free to use another form so long as it is properly witnessed. More detailed forms providing greater options and information regarding mental health care preference can be found on the VEN website at www.vtethicsnetwork.org.

Vermont Advance Directive for Health Care

PART ONE: YOUR HEALTH CARE AGENT

Your health care agent can make health care decisions for you when you are unable or unwilling to make decisions for yourself. You should pick someone that you trust, who understands your wishes and agrees to act as your agent. Your health care provider may NOT be your agent unless they are a relative.

Your agent may NOT be the owner, operator, employee or contractor of a residential care facility, health care

facility or correctional facility where you reside at the time your advance directive is completed.

I appoint this person to be my health care AGENT:

If this agent is unavailable, unwilling or unable to act as my agent, I appoint this person as my ALTERNATE AGENT:

ADDRESS

Others who may be consulted about medical decisions on my behalf include:

ADDRESS

ADDRESS

Those who should NOT be consulted include:

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I want my Advance Directive to start:

When I cannot make my own decisions

Now

When this happens:

PART TWO: HEALTH CARE GOALS AND SPIRITUAL WISHES

My overall health care goals include:

Additional Goals, Wishes, or Beliefs I wish to express include:

People to notify if I have a life-threatening illness:

If I am dying it is important for me to be (check choice):

At home

In the hospital

Other:

No preference

My Spiritual Care Wishes include:

My Religion/Faith:

ADDRESS

The following items or music or readings would be a comfort to me:

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PART THREE: LIMITATIONS OF TREATMENT

You can decide what kind of treatment you want or don't want if you become seriously ill or are dying. Regardless of the treatment limitations expressed, you have the right to have your pain and symptoms (nausea, fatigue, shortness of breath) managed. Unless treatment limitations are stated, the medical team is required and expected to do everything possible to save your life.

CPR means cardio (heart)-pulmonary (lung) resuscitation, including vigorous compressions of the chest, use of electrical stimulation, medications to support or restore heart function, and rescue breaths (forcing air into your lungs).

“Breathing machine” refers to a device that mechanically moves air into and out of your lungs such as a ventilator.

3. If I am unable to swallow enough food or water to stay alive (choose one):

NOTE: If you are being treated in another state your agent may not automatically have the authority to withhold or withdraw a feeding tube. If you wish to have your agent decide about feeding tubes please check the box below.

I authorize my agent to make decisions about feeding tubes.

4. If I am terminally ill or so ill that I am unlikely to get better (choose one):

If you have stated you DO NOT want CPR, a breathing machine, a feeding tube, or antibiotics under any circum- stances, please discuss this with your doctor who can complete a DNR/COLST form to ensure you don’t receive treatments you don’t want, particularly in an emergency situation. A DNR/COLST order will be honored outside of the hospital setting.

Additional Limitations of Treatment I wish to include:

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PART FOUR: ORGAN/TISSUE DONATION & BURIAL/DISPOSITION OF REMAINS

My wishes for organ & tissue donation (check your choices):

I consent to donate the following organs & tissues:

Any needed organs

Any needed tissue (skin, bone, cornea)

I do not wish to donate the following organs and tissues:

I do not want to donate any organs or tissues

I want my health care agent to decide

I wish to donate my body to research or educational program(s). (Note: you will have to make your own

arrangements with a medical school or other program in advance.)

My Directions for Burial/Disposition of My Remains after I Die (check & complete):

I have a Pre-Need Contract for Funeral Arrangements:

ADDRESS

I want the following individuals to decide about my burial or disposition of my remains (check your choices):

ADDRESS

Specific Wishes (check your choices): I want a Wake/Viewing

I prefer a Burial — If possible at the following location: (cemetery, address, phone number)

I prefer Cremation — With my ashes kept or scattered as follows:

I want a Funeral Ceremony with a burial or cremation to follow

I prefer only a Graveside Ceremony

I prefer only a Memorial Ceremony with burial or cremation preceding

Other Details: (such as music, readings, Officiant)

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PART FIVE: SIGNED DECLARATION OF WISHES

You must sign this before TWO adult witnesses. The following people may not sign as witnesses: your

agent(s), spouse, parents, siblings, children or grandchildren.

I declare that this document reflects my health care wishes and that I am signing this Advance Directive of my own free will.

I affirm that the signer appeared to understand the nature of this advance directive and to be free from duress or undue influence at the time this was signed. (Please sign and print)

FIRST WITNESS (PRINT NAME)

SECOND WITNESS (PRINT NAME)

If the person signing this document is being admitted to or is a current patient in a hospital, one of the follow- ing must sign and affirm that they have explained the nature and effect of the advance directive and the patient appeared to understand and be free from duress or undue influence at the time of signing: designated hospi- tal explainer, ombudsman, mental health patient representative, recognized member of the clergy, Vermont attorney, or Probate Court designee.

If the person signing this document is being admitted to or is a resident in a nursing home or residential care facility, one of the following must sign and affirm that they have explained the nature and effect of the advance directive and the resident appeared to understand and be free from duress or undue influence at the time of sign- ing: an ombudsman, recognized member of the clergy, Vermont attorney, Probate Court designee, des- ignated hospital explainer, mental health patient representative, clinician not employed by the facility, or appropriately trained nursing home/residential care facility volunteer.

The explainer as outlined above may also serve as one of the two required witnesses.

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The following have a copy of my Advance Directive (please check):

Vermont Advance Directive Registry		Date registered:
Health care agent
Alternate health care agent
Doctor/Provider(s):
Hospital(s):
Family Member(s): Please list:

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

Other:

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

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1.Read the Registration Policy, and complete this Registration Agreement. Please type or print clearly. Be sure to sign and date the form.

2.Attach either a copy of your advance directive, or optionally, an Advance Directive Locator form which indicates only the physical location of your advance directive so that it can be retrieved.

3.Registrations MUST include a completed and signed Registration Agreement form, and a copy of your advance

directive document.

4. MAIL to:

Vermont Advance Directive Registry (VADR)

PO Box 2789

Westfield, NJ 07091-2789

5. OR FAX to:

908- 654-1919

For additional information visit: http://healthvermont.gov/vadr/ or call 1-888-548-9455

Registrant

Name: First

Middle

Last

Suffix

Gender: Male

_

Female

Date of Birth (MM/DD/YYYY):

Primary Mailing Address:

Apt #

City/Town:

State:

Zip:

Phone: Home

Work

Other

Secondary Mailing Address:

Apt #

City/Town:

State:

Zip:

Emergency Contacts

Primary: Name

Relationship to Registrant:

Mailing Address:

City/Town:

State:

Zip:

Phone: Home

Work/Other:

Secondary: Name

Relationship to Registrant:

Phone: Home

Work/Other:

I,

(print name) request that my advance directive be registered in the

Vermont Advance Directive Registry, and authorize its access as allowed by Vermont law. By signing below, I acknowledge and affirm that: the information provided is accurate; I have read, understand, and agree to the terms of the Registry Registration Policy; I will safeguard my registrant identification number and wallet card from unauthorized access; and I will immediately notify the Registry in writing of changes to my registration information or advance directive. I execute this agreement voluntarily and without coercion, duress, or undue influence by any party. I understand that anyone who has access to my wallet card can use it to gain access to my documents and personal information. This authorization remains in effect until I revoke it.

Signature of Registrant:

Date: