Fill - Free fillable 44. MS Advance Directive For Healthcare MISSISSIPPI PDF form

MISSISSIPPI

Advance

Directive

Planning for Important Healthcare Decisions

CaringInfo

1731 King St., Suite 100,

Alexandria,

22314

www.caringinfo.org

800/658-8898

CaringInfo, a program of the National Hospice and Palliative Care Organization (NHPCO), is

a national consumer engagement initiative to improve care at the end of life.

It’s About How You LIVE

It’s About How You LIVE is a national community engagement campaign encouraging

individuals to make informed decisions about end-of-life care and services. The campaign

encourages people to:

Learn about options for end-of-life services and care

Implement plans to ensure wishes are honored

Voice decisions to family, friends and healthcare providers

Engage in personal or community efforts to improve end-of-life care

Note: The following is not a substitute for legal advice. While CaringInfo updates the

following information and form to keep them up-to-date, changes in the underlying law can

affect how the form will operate in the event you lose the ability to make decisions for

yourself. If you have any questions about how the form will help ensure your wishes are

carried out, or if your wishes do not seem to fit with the form, you may wish to talk to your

health-care provider or an attorney with experience in drafting advance directives. If you

have other questions regarding these documents, we recommend contacting

your state attorney general's office.

Reproduction and distribution by an organization or organized group without the written permission of the

National Hospice and Palliative Care Organization is expressly forbidden.

Using these Materials

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may receive

healthcare

2. These materials include:

•

Instructions for preparing your advance directive, please read all the instructions.

•

Your state-specific advance directive forms, which are the pages with the gray

instruction bar on the left side.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so you

will have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide

you through the process.

3. Talk with your family, friends, and physicians about your advance directive. Be sure the

person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy the form and give it to the person

you have appointed to make decisions on your behalf, your family, friends, health-care

providers and/or faith leaders so that the form is available in the event of an emergency.

5. You may also want to save a copy of your form in an online personal health records

application, program, or service that allows you to share your medical documents with

your physicians, family, and others who you want to take an active role in your advance

care planning.

INTRODUCTION TO YOUR MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

This packet contains a legal document, a Mississippi Advance Health-Care Directive,

that protects your right to refuse medical treatment you do not want, or to request

treatment you do want, in the event you lose the ability to make decisions yourself. You

may complete any or all of the first four parts, depending on your advance planning needs.

You must complete part 5.

Part 1 is a Power of Attorney for Health Care. This part lets you name someone (an

agent) to make decisions about your health care in the event that you can no longer speak

for yourself. The power of attorney for health care becomes effective when your doctor

determines that you can no longer make or communicate your health-care decisions, unless

you elect for it to be effective immediately.

Part 2 includes your Individual Instructions. This is your state’s living will. It lets you

state your wishes about health care in the event that you can no longer speak for yourself

and

•

are terminally ill,

•

are permanently unconscious, or

•

the likely risks and burdens of the proposed treatment would outweigh the

expected benefits.

Your individual instructions go into effect when your physician determines that you can no

longer communicate your wishes and one of the conditions listed above exists.

Part 3 allows you to express your wishes regarding organ donation.

Part 4 of this form lets you designate a physician to have primary responsibility for your

health care.

Part 5 contains the signature and witnessing provisions so that your document will be

effective.

This form does not expressly address mental illness. If you would like to make advance

care plans regarding mental illness, you should talk to your physician and an attorney about

an advance directive tailored to your needs.

Note: These documents

will be

legally binding

only if the

person completing

them is a

competent

adult who is 18

years

of age or older or an

emancipated

minor.

Instructions for Completing Your Mississippi Advance Health-Care Directive

How do I make my Advance Health-Care Directive legal?

In order to make your Advance Health-Care Directive legally binding you have two options:

1. Sign your document in the presence of two witnesses. Your witnesses must be at least

18 years of age. Neither of your witnesses can be:

•

the person you appointed as your agent,

•

a health-care provider, or

•

an employee of a health-care provider or facility.

In addition, one of your witnesses cannot be:

•

related to you by blood or marriage or adoption,

•

entitled to any part of your estate either under your last will and testament or by

operation of law.

2. Sign your document in the presence of a notary public.

Who should I appoint as my agent?

Your agent is the person you appoint to make decisions about your health care if you

become unable to make those decisions yourself. Your agent may be a family member or a

close friend whom you trust to make serious decisions. The person you name as your agent

should clearly understand your wishes and be willing to accept the responsibility of making

health-care decisions for you.

You can appoint a second person as your alternate agent. The alternate will step in if the

first person you name as an agent is unable, unwilling, or unavailable to act for you.

Unless related by blood, marriage, or adoption, your agent cannot be an owner, operator,

or employee of a residential long-term health-care institution at which you are receiving

care.

Should I add personal instructions to my Advance Health-Care Directive?

One of the strongest reasons for naming an agent is to have someone who can respond

flexibly as your health-care situation changes and deal with situations that you did not

foresee. If you add instructions to this document it may help your agent carry out your

wishes, but be careful that you do not unintentionally restrict your agent’s power to act in

your best interest. In any event, be sure to talk with your agent about your future medical

care and describe what you consider to be an acceptable “quality of life.”

What if I change my mind?

To revoke the designation of an agent in Part 1 of your Mississippi Advance Health-Care

Directive, you must do so in a signed writing or by personally informing your primary

physician or the provider who has undertaken primary responsibility for your healthcare.

Unless you provide otherwise, a decree of annulment, divorce, dissolution of marriage, or

legal separation automatically revokes a previous designation of your spouse as your agent.

You make revoke all or part of your advance health-care directive, other than the

designation of an agent, at any time and in any manner that communicates an intent to

revoke by, for example, destroying the advance health-care directive.

A later advance directive that conflicts with an earlier advance directive will revoke the

earlier advance directive to the extent of the conflict.

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 1 OF 11

EXPLANATION

Hospice and

Palliative Care

Organization

2018 Revised.

Explanation

You have the right to give instructions about your own health care. You

also have the right to name someone else to make health-care

decisions for you. This form lets you do either or both of these things.

It also lets you express your wishes regarding the designation of your

primary physician. If you use this form, you may complete or modify all

or any part of it. You are free to use a different form.

Part 1 of this form is a power of attorney for health care. Part 1 lets

you name another individual as agent to make health-care decisions for

you if you become incapable of making your own decisions or if you

want someone else to make those decisions for you now even though

you are still capable. You may name an alternate agent to act for you if

your first choice is not willing, able, or reasonably available to make

decisions for you. Unless related to you, your agent may not be an

owner, operator, or employee of a residential long-term health-care

institution at which you are receiving care.

Unless the form you sign limits the authority of your agent, your agent

may make all health-care decisions for you. This form has a place for

you to limit the authority of your agent. You need not limit the authority

of your agent if you wish to rely on your agent for all health-care

decisions that may have to be made. If you choose not to limit the

authority of your agent, your agent will have the right to:

(a) Consent or refuse consent to any care, treatment, service,

or procedure to maintain, diagnose, or otherwise affect a

physical or mental condition;

(b) Select or discharge health-care providers and institutions;

programs of medication, and orders not to resuscitate; and

(d) Direct the provision, withholding, or withdrawal of artificial

nutrition and hydration and all other forms of health care.

Part 2 of this form lets you give specific instructions about any aspect

of your health care. Choices are provided for you to express your

wishes regarding the provision, withholding, or withdrawal of treatment

to keep you alive, including the provision of artificial nutrition and

hydration, as well as the provision of pain relief. Space is provided for

you to add to the choices you have made or for you to write out any

additional wishes.

Part 3 of this form lets you designate a physician to have primary

responsibility for your health care.

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 2 OF 11

Part 4 of this form lets you authorize your agent to make an

anatomical gift on your behalf in accordance with your wishes if you

have not done so yourself.

EXPLANATION

CONTINUED

Hospice and

Palliative Care

Organization

2018 Revised.

After completing this form, sign and date the form at the end in Part

5 and have the form witnessed by one of the two alternative

methods listed below. Give a copy of the signed and completed form

to your physician, to any other health-care providers you may have,

to any health-care institution at which you are receiving care, and to

any health-care agents you have named. You should talk to the

person you have named as agent to make sure that he or she

understands your wishes and is willing to take the responsibility.

You have the right to revoke this Advance Health-Care Directive or

replace this form at any time.

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 3 OF 11

PART 1

POWER OF ATTORNEY FOR HEALTH CARE

PRINT YOUR NAME

PRINT THE NAME,

HOME ADDRESS

AND HOME AND

WORK TELEPHONE

NUMBERS OF YOUR

PRIMARY

AGENT

(1) DESIGNATION OF AGENT:

I, , designate the

(your name)

following individual as my agent to make health-care decisions for me:

(Name of individual you choose as agent)

(address) (city) (state) (zip code)

(home phone) (work phone)

PRINT THE NAME,

HOME ADDRESS

AND HOME AND

WORK TELEPHONE

NUMBERS OF YOUR

OPTIONAL: If I revoke my agent’s authority or if my agent is not willing,

able, or reasonably available to make a health-care decision for me, I

designate as my first alternate agent:

(Name of individual you choose as first alternate agent)

FIRST

ALTERNATE

AGENT

PRINT THE NAME,

HOME ADDRESS

AND HOME AND

WORK TELEPHONE

NUMBERS OF YOUR

SECOND

ALTERNATE AGENT

Hospice and

Palliative Care

Organization

2018 Revised.

(address) (city) (state) (zip code)

(home phone) (work phone)

OPTIONAL: If I revoke the authority of my agent and first alternate agent

or if neither is willing, able, or reasonably available to make a health-care

decision for me, I designate as my second alternate agent:

(Name of individual you choose as second alternate agent)

(address) (city) (state) (zip code)

(home phone) (work phone)

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 4 OF 11

2) AGENT’S AUTHORITY: My agent is authorized to make all health-care

decisions for me, including decisions to provide, withhold, or withdraw

artificial nutrition and hydration, and all other forms of health care to keep

me alive, except as I state here:

ADD PERSONAL

INSTRUCTIONS

ONLY IF YOU WANT

TO LIMIT

THE POWER OF

YOUR

AGENT

(Add

additional sheets

if needed.)

INITIAL THE BOX

ONLY IF YOU WISH

YOUR AGENT’S

AUTHORITY TO

BECOME EFFECTIVE

IMMEDIATELY

CROSS OUT AND

INITIAL ANY

STATEMENTS IN

PARAGRAPHS

3, 4 OR 5 THAT

DO NOT REFLECT

YOUR WISHES

Hospice and

Palliative Care

Organization

2018 Revised.

(3) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s

authority becomes effective when my primary physician determines that I

am unable to make my own health-care decisions unless I mark the

following box. If I mark this box [ ], my agent’s authority to make

health-care decisions for me takes effect immediately.

(4) AGENT’S OBLIGATION: My agent shall make health-care decisions

for me in accordance with this power of attorney for health care, any

instructions I give in Part 2 of this form, and my other wishes to the extent

known to my agent. To the extent my wishes are unknown, my agent shall

make health-care decisions for me in accordance with what my agent

determines to be in my best interest. In determining my best interest, my

agent shall consider my personal values to the extent known to my agent.

(5) NOMINATION OF GUARDIAN: If a guardian of my person needs to

be appointed for me by a court, I nominate the agent designated in this

form. If that agent is not willing, able, or reasonably available to act as

guardian, I nominate the alternate agents whom I have named, in the

order designated.

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 5 OF 11

PART 2

INSTRUCTIONS FOR HEALTH CARE

If you are satisfied to allow your agent to determine what is best for you in

making end-of-life decisions, you need not fill out this part of the form. If

you do fill out this part of the form, you may strike any wording you do not

want.

INITIAL THE

PARAGRAPH THAT

BEST REFLECTS

YOUR WISHES

REGARDING

LIFE-SUPPORT

MEASURES

INITIAL ONLY ONE

BOX

INITIAL THE BOX

ONLY IF YOU WANT

ARTIFICIAL

NUTRITION AND

HYDRATION

REGARDLESS OF

YOUR MEDICAL

CONDITION

ADD PERSONAL

INSTRUCTIONS

ONLY IF YOU WANT

(6) END-OF-LIFE DECISIONS: I direct that my health-care providers

and others involved in my care provide, withhold or withdraw treatment in

accordance with the choice I have marked below:

[ ] (a) Choice NOT To Prolong Life

I do not want my life to be prolonged if (i) I have an incurable and

irreversible condition that will result in my death within a relatively short

time, (ii) I become unconscious and, to a reasonable degree of medical

certainty, I will not regain consciousness, or (iii) the likely risks and

burdens of treatment would outweigh the expected benefits, or

[ ] (b) Choice To Prolong Life

I want my life to be prolonged as long as possible within the limits of

generally accepted health-care standards.

(7) ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutrition and

hydration must be provided, withheld or withdrawn in accordance with the

choice I have made in paragraph (6) unless I mark the following box.

If I mark this box [ ], artificial nutrition and hydration must be provided

regardless of my condition and regardless of the choice I have made in

paragraph (6).

(8) RELIEF FROM PAIN: Except as I state in the following space, I direct

that treatment for alleviation of pain or discomfort be provided at all times,

even if it hastens my death:

TO LIMIT

COMFORT

TREATMENT

Hospice

and

Palliative

Care

Organization

2018 Revised.

(Add

additional sheets

if needed.)

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 6 OF 11

ADD OTHER

INSTRUCTIONS, IF

ANY, REGARDING

YOUR ADVANCE

CARE PLANS

THESE

INSTRUCTIONS CAN

FURTHER ADDRESS

YOUR HEALTH-CARE

PLANS, SUCH AS

YOUR WISHES

REGARDING

HOSPICE

(9) OTHER WISHES: (If you do not agree with any of the optional

choices above and wish to write your own, or if you wish to add to the

instructions you have given above, you may do so here.) I direct that:

TREATMENT,

BUT

CAN

ALSO ADDRESS

OTHER ADVANCE

PLANNING ISSUES,

SUCH AS YOUR

BURIAL WISHES

ATTACH

ADDITIONAL PAGES

IF NEEDED

(Add

additional sheets

if needed.)

Hospice and

Palliative Care

Organization

2018 Revised.

(10) EFFECT OF COPY: A copy of this form has the same effect as the

original.

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 7 OF 11

PRINT THE NAME,

ADDRESS AND

TELEPHONE

NUMBER OF YOUR

PRIMARY

PHYSICIAN

PART 3

PRIMARY PHYSICIAN

(OPTIONAL)

(11) I designate the following physician as my primary physician:

(name of physician)

(address) (city) (state) (zip code)

PRINT THE NAME,

ADDRESS AND

TELEPHONE

NUMBER OF YOUR

ALTERNATE

PRIMARY

PHYSICIAN

(phone)

If the physician I have designated above is not willing, able, or reasonably

available to act as my primary physician, I designate the following

physician as my primary physician:

(name of physician)

(address) (city) (state) (zip code)

(phone)

Hospice and

Palliative Care

Organization

2018 Revised.

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 8 OF 11

CROSS OUT AND

INITIAL THIS

STATEMENT IF YOU

DO NOT

AUTHORIZE YOUR

PART 4

AUTHORIZATION FOR ORGAN DONATION

(OPTIONAL)

(12) I authorize my agent to make this anatomical gift, if medically acceptable, to

take effect upon my death. The words and marks below indicate my desires.

Upon my death, I wish to donate:

My body for anatomical study if needed.

AGENT TO MAKE AN

Any needed organs, tissues, or eyes.

ANATOMICAL GIFT

OF YOUR ORGANS

OR PHYSICAL

PARTS

OTHERWISE,

INITIAL YOUR

ORGAN DONATION

WISHES

ADD INSTRUCTIONS

HERE ONLY IF YOU

WANT TO LIMIT

YOUR ANATOMICAL

GIFT

Only the following organs, tissues, or eyes:

I authorize the use of my organs, tissues, or eyes:

For transplantation

For therapy

For research

For medical education

For any purpose authorized by law.

This authority granted to my patient advocate to make an anatomical gift

is limited as follows (here list

limitations

special wishes,

if any):

Hospice and

Palliative Care

Organization

2018 Revised.

(Add

additional sheets

if needed.)

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 9 OF 11

PART 5: EXECUTION

This advance directive will not be valid unless it is EITHER:

IF YOU CHOOSE TO

SIGN WITH

WITNESSES, USE

ALTERNATIVE 1,

BELOW (P. 15)

IF YOU CHOOSE TO

HAVE YOUR

SIGNATURE

NOTARIZED, USE

ALTERNATIVE 2,

BELOW (P. 16)

Hospice and

Palliative Care

Organization

2018 Revised.

(A) Signed in the presence of two adult witnesses, at least 18 years of

age, who must also sign the document to show that they personally know

you and believe you to be of sound mind and under no duress, fraud, or

undue influence.

Neither of your witnesses can be:

• the person you appointed as your agent,

• a health-care provider, or an employee of a health-

care provider or facility.

In addition, one of your witnesses cannot be:

• related to you by blood or marriage or adoption,

• entitled to any part of your estate either under your

last will and testament or by operation of law.

(If you choose to sign with witnesses, use alternative 1 below).

(B) Witnessed by a notary.

(If you choose to have your signature notarized, use alternative 2,

below).

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 10 OF 11

SIGN AND DATE

YOUR ADVANCE

DIRECTIVE

PRINT YOUR NAME

Alternative No. 1: Sign Before Witnesses

(signature) (date)

(printed name)

AND

ADDRESS

(address)

YOUR WITNESSES

MUST SIGN, DATE,

AND PRINT THEIR

NAMES HERE

Witness No. 1

DECLARATION OF WITNESSES

WITNESS NO. 1

MUST BE

UNRELATED TO YOU

AND NOT HAVE ANY

INTEREST IN YOUR

ESTATE

I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code

of 1972, that the principal is personally known to me, that the principal signed

or acknowledged this advance directive in my presence, that the principal

appears to be of sound mind and under no duress, fraud or undue influence,

that I am not the person appointed as agent by this document, and that I am

not a health-care provider, nor an employee of a health-care provider or facility.

I am not related to the principal by blood, marriage or adoption, and to the best

of my knowledge, I am not entitled to any part of the estate of the principal

upon the death of the principal under a will now existing or by operation of law.

(signature of witness) (date)

(printed name of witness)

Witness No. 2

I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code

of 1972, that the principal is personally known to me, that the principal signed

or acknowledged this advance directive in my presence, that the principal

appears to be of sound mind and under no duress, fraud or undue influence,

that I am not the person appointed as agent by this document, and that I am

not a health-care provider, nor an employee of a health-care provider or facility.

Hospice and

Palliative Care

Organization

2018 Revised.

(signature of witness) (date)

(printed name of witness)

MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

PAGE 11 OF 11

Alternative No. 2: Sign Before a Notary Public

SIGN AND DATE

YOUR ADVANCE

DIRECTIVE

PRINT YOUR NAME

AND ADDRESS

(signature) (date)

(printed name)

(address)

Notary Public

A NOTARY PUBLIC

SHOULD

COMPLETE

THIS

SECTION OF YOUR

DOCUMENT

State of

County of

On this day of , in the year ,

before me, (insert name of notary

public)

appeared , personally known to me

(or proved to me on the basis of satisfactory evidence) to be the person

whose name is subscribed to this instrument, and acknowledged that he or

she executed it. I declare under the penalty of perjury that the person

whose name is subscribed to this instrument appears to be of sound mind

and under no duress, fraud or undue influence.

Notary Seal

(Signature of Notary Public)

Hospice and

Palliative Care

Organization

2018 Revised.

Courtesy

Cari

Info

1731 King St., Suite 100,

Alexandria,

22314

www.caringinfo.org, 800/

-8898

You Have Filled Out Your Health-Care Directive, Now What?

1. Your Mississippi Advance Health-Care Directive is an important legal document. Keep the

original signed document in a secure but accessible place. Do not put the original

document in a safe deposit box or any other security box that would keep others from

having access to it.

2. Give photocopies of the signed original to your agent and alternate agents, doctor(s),

family, close friends, clergy, and anyone else who might become involved in your health-

care. If you enter a nursing home or hospital, have photocopies of your document placed in

your medical records.

3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes

concerning medical treatment. Discuss your wishes with them often, particularly if your

medical condition changes.

4. You may also want to save a copy of your form in an online personal health records

application, program, or service that allows you to share your medical documents with your

physicians, family, and others who you want to take an active role in your advance care

planning.

5. If you want to make changes to your documents after they have been signed and

witnessed, you must complete a new document.

6. Remember, you can always revoke your Mississippi document.

7. Be aware that your Mississippi document will not be effective in the event of a medical

emergency. Ambulance and hospital emergency department personnel are required to

provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive that

states otherwise. These directives called “prehospital medical care directives” or “do not

resuscitate orders” are designed for people whose poor health gives them little chance of

benefiting from CPR. These directives instruct ambulance and hospital emergency personnel

not to attempt CPR if your heart or breathing should stop.

Currently not all states have laws authorizing these orders. We suggest you speak to your

physician if you are interested in obtaining one. CaringInfo does not distribute these

forms.

Congratulations!

You’ve downloaded your free, state specific advance directive.

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