Cover page. Not part of document. Do not scan.
Advance Directive
including Power of Attorney for Health Care
Overview
This legal document meets the requirements for Wisconsin, Minnesota and Iowa.* It lets you
Name another person to make your health care decisions if you cannot make them for yourself.
Write down your goals and preferences for future medical care in specific situations.
The person you name is called your health care agent. You can also name alternate health care agents who can
make decisions if the person you named first or second cannot or is not willing to make those decisions. This
document gives your agent author
ity to make health care decisions on your behalf only after doctors have
determined you are incapable of making health care decisions for yourself.
This document does not give your agent authority to:
Make financial or other business decisions.
Make certain decisions about your mental health treatment.
Read this advance directive carefully before you complete and sign it. You should discuss your goals,
values, and this advance directive with your health care agent(s
). Unless y
ou talk with your
health care agent(s), they may not know your goals and be able to follow your instructions.
Recommendation: make an appointment with an advance care planning facilitator for help. If this advance
directive does not meet your needs, ask your health organization or attorney about other options.
To complete this advance directive
This advance directive is divided into four parts:
Part 1 – My health care agent
Part 2 – General authority of the health care agent
Part 3 – Statement of desires, care instructions or limits
Part 4 – Making the document legal
Follow the instructions in each of the four parts.
After you complete your advance directive
Take these steps:
Talk to the person(s) you named as your agent(s) about your goals and preferences for future medical
care, if you have not already. Make sure they feel able to do this important job for you in the future.
Give your agent(s) a copy of this advance directive.
Talk to the rest of your family and close friends who might be involved if you have a serious illness or
injury. Make sure they know who your agent(s) is, and what your preferences are.
Give a copy to your doctor and/or you
r health
care facility. Make sure your preferences are understood.
*As of June 1, 2017 The name Honoring Choices Wisconsin is used under license from the Twin Cities Medical Foundation.
9-78725-01 (08/17)
Cover page. Not part of document. Do not scan.
Keep a copy of this advance directive where it can be easily found.
If you go to a hospital or nursing home, take a copy of this advance directive and ask that it be placed in
your medical record.
Review and update this advance directive whenever any of the “Five D’s” occur:
Decade when you start each new decade of your life.
Death (or Dispute) when a loved one or a health care agent dies (or disagrees with your
preferences).
Divorce when divorce (or annulment) happens. If your spouse or domestic partner is your
agent, your advance directive is no longer valid. You must complete a new advance
directive, even if you want your ex-spouse or ex-partner to remain your agent.
Diagnosis when you are diagnosed with a serious illness.
Decline when your health gets worse, especially when you are unable to live on your own.
If your goals and preferences change:
o Talk to your agent(s), your family, your doctor, and everyone who has copies of this advance
directive.
o Then, complete a new advance directive.
Cut out the card below, fill it in, fold it and put it in your wallet.
Need help?
If you need help to complete this advance directive, contact:
Marshfield Clinic Health System
Advance Care Planning
Toll Free: 1-844-853-4106
Local: 715-221-7132
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Advance Directive including Power of Attorney for Health Care
For:
Name _______________________________________ Date of Birth _____________________
Telephone (Cell) ______________________________ (Work) __________________________
(Home)________________________
Address____________________________________________________________________
City ______________________________________ State/ZIP _________________________
Copies of this document have been given to:
Name ____________________________________________________________________
Name ____________________________________________________________________
Name ____________________________________________________________________
Name ____________________________________________________________________
Name ____________________________________________________________________
Name ____________________________________________________________________
Name ____________________________________________________________________
Health care professional/health care facility:
Name ___________________________________________________________________
Name ___________________________________________________________________
Name ___________________________________________________________________
The name Honoring Choices Wisconsin is used under license from the Twin Cities Medical Foundation. June 2017
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Notice to Person Making this Document
You have the right to make decisions about your health care. No health care may be given to you
over your objection, and necessary health care may not be stopped or withheld if you object.
Because your health care providers in some cases may not have had the opportunity to
establish a long-term relationship with you, they are often unfamiliar with your beliefs and
values and the details of your family relationships. This poses a problem if you become
physically or mentally unable to make decisions about your health care.
In order to avoid this problem, you may sign this legal document to specify the person whom
you want to make health care decisions for you if you are unable to make those decisions
personally. That person is known as your health care agent. You should take some time to
discuss your thoughts and beliefs about medical treatment with the person or persons whom
you have specified. You may state in this document any types of health care that you do or do
not desire, and you may limit the authority of your health care agent. If your health care agent
is unaware of your desires with respect to a particular health care decision, he or she is
required to determine what would be in your best interests in making the decision.
This is an important legal document. It gives your agent broad powers to make health care
decisions for you. It revokes any prior power of attorney for health care that you may have
made. If you wish to change your power of attorney for health care, you may revoke this
document at any time by destroying it, by directing another person to destroy it in your
presence, by signing a written and dated statement or by stating that it is revoked in the
presence of two witnesses. If you revoke, you should notify your agent, your health care
providers, and any other person to whom you have given a copy. If your agent is your spouse or
domestic partner and your marriage is annulled or you are divorced or the domestic
partnership is terminated after signing this document, the document is invalid.
You may also use this document to make or refuse to make an anatomical gift upon your death.
If you use this document to make or refuse to make an anatomical gift, this document revokes
any prior record of gift that you may have made. You may revoke or change any anatomical gift
that you make by this document by crossing out the anatomical gifts provision in this
document.
Do not sign this document unless you clearly understand it. It is suggested that you keep the
original of this document on file with your doctor.
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Part 1: My health care agent
If you can no longer make your own health care decisions, this advance directive names the person you
authorize to make these choices for you. This person will be your health care agent. State law says he or she will
make your health care choices for you only after doctors have determined you are incapable of making health
care decisions. Your agent will make decisions about your medical care as you would if you were able. You and
your health care agent(s) should have ongoing talks about your health and health care choices.
Choose someone who knows you well. It should be someone you trust and who respects your goals and values.
This person should be able to make difficult decisions under stress. Often family members are good choices,
but not always. Choose someone who will closely follow what you want and will be a good advocate for you.
Discuss this document and your views with the person(s) you choose to be your health care agent(s).
A health care agent must be at least 18 years old. Your health care agent may not be one of your health care
providers or an employee of your health care provider, unless he or she is a relative.
The person I choose as my health care agent is:
Name ________________________________ Relationship ____________________________
Telephone (Cell)__________________ (Work) _________________ (Home) ________________
Address ____________________________________________________________________
City ______________________________________ State/ZIP _________________________
If that person is unable or unwilling to make decisions for me, then my next choice is:
Second choice:
Name ________________________________ Relationship ____________________________
Telephone (Cell)__________________ (Work) _________________ (Home) ________________
Address ____________________________________________________________________
City ______________________________________ State/ZIP _________________________
If that person is unable or unwilling to make decisions for me, then my next choice is:
Third choice:
Name ________________________________ Relationship ____________________________
Telephone (Cell)__________________ (Work) _________________ (Home) ________________
Address ____________________________________________________________________
City ______________________________________ State/ZIP _________________________
I do not have a health care agent. Instead, I want Part 3 of this document to
guide my health care.
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Part 2: General authority of the health care agent
To complete this part:
Draw a line through anything in the box below you do not want your health care agent to do. For example, it
should look like this: Decide on
I want my health care agent to be able to:
Decide on tests, medicine, surgery and other medical care. If treatment has started, my agent can keep
it going or stop it, based on my instructions or my best interests.
Interpret my instructions based on what he or she knows of my preferences and values.
Review and release my medical records and personal files as needed for my medical care.
Arrange for my medical care and treatment in Wisconsin or any other state.
Decide whether organs or tissues (anatomical gifts) can be donated after my death according to my
preferences and values.
Limits on mental health treatment in Wisconsin
Wisconsin law says my health care agent may not admit or commit me to an inpatient facility for mental health
treatment. This means that in Wisconsin, my agent cannot admit me to:
an institution for mental diseases
an intermediate care facility for people with an intellectual disability, or
a state treatment facility for mental health.
My health care agent may not agree to any drastic mental health treatments for me. These treatments include
experimental mental health research, brain surgery, or electroshock therapy.
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To complete the next three questions:
Initial or check the box beside the one statement in each section you agree with.
In Wisconsin, if you do not mark any box in a section, or you choose “no,” only a court can
make the decision and not your health care agent.
1. Agent authority to make the decision to admit me to a nursing home or
community-based residential facility for long-term care.
Note: Your health care agent has the authority to admit you to a nursing home or care facility (community-
based residential facility) for a short-term stay. For example, you might need care to recover after surgery
and you expect to go home.
If I need long-term care for any reason, then:
Yes, my agent can make the decision to admit me to a nursing home or community-based
residential facility for a long-term stay.
No, my agent cannot make the decision to admit me to a nursing home or community-based
residential facility for a long-term stay.
In Wisconsin, choosing “no” or leaving this section blank means I cannot be admitted to a Wisconsin
long-term care facility without a court order.
2. Agent authority to make the decision to refuse or have removed a feeding tube
and/or IV fluids.
Yes, my agent can make the decision to refuse or stop tube feedings and/or IV fluids.
No, my agent cannot make the decision to refuse or stop tube feedings and/or IV fluids.
In Wisconsin, choosing “no” or leaving this section blank means feeding tubes and IV fluids cannot be
refused or stopped without a court order.
3. Agent authority to make health care decisions during pregnancy.
Yes, my agent can make health care decisions for me if I am pregnant.
No, my agent cannot make health care decisions if I am pregnant.
This does not apply to me.
In Wisconsin, choosing “no” or leaving this section blank means health care decisions cannot be made
for me while I am pregnant without a court order.
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Part 3: Statement of desires, care instructions or limits
Part 3 allows you to make your preferences clear. Your health care agent and your doctors will refer to this
section as they care for you. If you did not name a health care agent or if your health care agent cannot be
reached, you can direct your care with the choices you make below. You should talk with your health care agent
about the kind of care you want, even if you don’t make choices in this section.
You are not required to complete this part of the document.
___ ___________ _ __ _ ___ ___________ _ __ _ ___________ _ ___ _ __________ _ __ _ ___ _ ________ _ __ _ ___ ________ ___ _ __ _ ____ _ _ __ _ ________ _ __ _ ___ ________ ___ _ __ _ _ ___ ___________ _ ___________ __ _
To complete this part:
Initial or check the box beside the one statement you agree with.
You may add other specific care instructions on page 7.
1. Treatments that may prolong life if I am in this situation.
If I am sick or injured and my doctors believe there is little chance I will recover the ability to know who I am,
who my family and friends are, or where I am, this is my choice:
I want to refuse or stop all treatments. Some examples are a machine that breathes for me
(respirator/ventilator), feeding tubes, blood products, antibiotics, or fluids given to me through an IV,
treatments for chronic medical conditions, or other medications.
I want to receive all treatments to keep me alive, unless my doctor determines the treatments
would harm me more than help me.
With either choice, I understand I will be kept clean and comfortable. I will continue to receive pain and
comfort medicines, and food and fluids by mouth if I can swallow safely.
2. Cardiopulmonary resuscitation (CPR).
Based on my current health, this is my choice about CPR if my heart or breathing stops.
I want CPR attempted unless my doctor determines:
I have a medical condition and no reasonable chance of survival with CPR,
OR
CPR would harm me more than help me.
I do not want CPR. Let me die a natural death.
If you do not want emergency personnel to give you CPR, you will need to talk to your doctor about other
documents you need.
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Specific care instructions to meet my goals and preferences in certain situations:
Comfort preferences: These things are important to me for comfort (for example, favorite music, warm
blankets, best positioning in bed).
Including others when making decisions about my care: (If there is time, try to include these
people in my care decisions.)
If I am near death and cannot communicate, I want to give my friends and family these
personal messages:
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To complete this part:
Initial or check the box beside the statement you agree with.
After my death, these are some of my preferences:
1. Donation of my organs or tissue (anatomical gifts)
Examples of organs are kidney, liver, heart, and lungs. Examples of tissue are eyes, skin, bones, and heart
valves.
A. I do not wish to donate any part of my body.
B. After I die, I wish to donate any parts of my body that may help others.*
C. After I die, I wish to donate only these organs and tissue:* _______________________
_______________________________________________________________________
*If you checked B or C, register in your state at www.DonateLife.net to make your preferences legal.
2. Autopsy preference
Initial or check one box OR both B and C.
A. I do not wish to have an autopsy.
B. I would accept an autopsy if it can help my relatives and/or loved ones understand the
cause of my death or if the findings may help them make their own health care choices.
C. I would accept an autopsy if it can help advance medical knowledge or medical
education.
If I am near death, things I would want: (For example, favorite music, rituals, dim lighting, a visit
from the hospital chaplain or someone from my faith community.)
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Part 4: Making the document legal
In Wisconsin: This document must be signed and dated in the presence of two witnesses who meet the
qualifications explained below. A notary public cannot be used instead of the two witnesses.
In Minnesota or Iowa: This document must be signed and dated either in the presence of two
witnesses who meet the qualifications explained below OR in the presence of a notary public.
My signature and date
I am of sound mind. I agree with everything written in this document.
I have completed this document of my free will.
My signature _________________________________________________ Date _____________________________
If I cannot sign my name, I ask (print name) ______________________________________________ to sign for me.
Signature of the person I asked to sign for me _________________________________________
Statement of witnesses
A. By signing this document as a witness, I certify I am:
At least 18 years old.
Not related by blood, marriage, domestic partnership, or adoption to the person signing this document.
Not a health care agent appointed by the person signing this document.
Not directly financially responsible for this person’s health care.
Not a health care provider directly serving the person at this time.
Not an employee of a health care provider directly serving the person at this time.
In Wisconsin, social workers and chaplains may serve as witnesses even if employed by the health
care provider.
Not aware that I am entitled to or have a claim against the person’s estate.
B. I know this to be the person identified in the document. I believe this person to be of sound mind and at
least 18 years old. I personally witnessed this person sign this document, and I believe that this person did
so voluntarily.
Witness Number One:
Signature ________________________________________Date _______________________
Print name_________________________________________________________________
Address ___________________________________________________________________
City______________________________________State/ZIP__________________________
Witness Number Two:
Signature ________________________________________Date _______________________
Print name__________________________________________________________________
Address ___________________________________________________________________
City______________________________________State/ZIP__________________________
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