MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 1 OF 11
© 2005 National
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;
(c) Approve or disapprove diagnostic tests, surgical procedures,
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
Part 3 of this form lets you designate a physician to have primary
responsibility for your health care.