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Advance Directives

Important information on health care decision-

making: You Have the Right to Decide

The documents provided in this package are being presented to

you in accordance with the Federal Patient Self-determination

Act, the Health Care Advance Directives Statute of Florida, and

as a public service of Lee Health.

Name:

Date of Birth:

Revised April, 2018

120134218-5732

Frequently Asked Questions Concerning Advance Directives

WHO NEEDS TO BE CONCERNED ABOUT ADVANCE DIRECTIVES?

All adult patients (age 18 years and older) should understand advance directives. Federal law

requires certain facilities, including hospitals, nursing homes and home health agencies provide

written information about an individual’s rights under State law to make decisions concerning

medical care, including the right to accept or refuse medical or surgical treatment and the right

to formulate advance directives. Further, those facilities must document in a prominent part of

the individual’s current medical record whether or not the individual has executed an advance

directive. Every adult person who becomes a patient in Lee Memorial Health System facilities

should be asked whether they have written an advance directive. Advance directives are not

required to receive care in Lee Memorial Health System, but are provided to you to be able to

document your wishes concerning treatment.

WHY DOES LEE MEMORIAL PROVIDE THIS INFORMATION?

e United States Congress passed a law in 1990 called the “Patient Self-Determination Act”.

is law requires that all health care organizations provide written information to patients

regarding their rights to make decisions about their own medical care. is includes the right to

accept or refuse medical or surgical treatment.

WHAT IS AN ADVANCE DIRECTIVE?

An advance directive is a set of instructions you have prepared regarding your medical care.

ey may describe what treatment you do or do not want and serve to convey your wishes to the

medical team in the event you are not able to give directions yourself.

WHO CAN BE A WITNESS TO A LIVING WILL?

Generally, any adult can be, but a spouse or blood relative can be only ONE of the witnesses; the

second witness should be someone who is not related to you. e person you have named as

your surrogate should not be one of the witnesses.

WHAT IS A LIVING WILL?

A living will contains specic instructions about what you want done regarding withholding or

withdrawing life-prolonging procedures in the event you have a terminal condition, an end-

stage condition, or are in a persistent vegetative state.

WHAT IS A DESIGNATION OF HEALTH CARE SURROGATE (DHCS)?

A DHCS is a document you sign appointing a person (surrogate) you trust to make

health care decisions for you if you are temporarily or permanently unable to make

health care decisions for yourself. It is important you talk with your surrogate and let

the surrogate know your wishes about your medical care and treatment, so that your

surrogate will make the decisions based upon your desires.

WHO CAN BE A WITNESS TO A HEALTH CARE SURROGATE DESIGNATION?

A spouse or blood relative can be one of the witnesses, the second witness should be

someone who is not related to you. e person designated as your surrogate cannot be

a witness.

WHEN DOES MY LIVING WILL OR OTHER ADVANCE DIRECTIVE ACTUALLY GO

INTO EFFECT?

Your physician, aer evaluating your condition, will call in another physician for a

second opinion. If both determine that you have a terminal condition, an end-stage

condition, or a persistent vegetative state, your living will goes into eect. If you have

designated a surrogate and it is determined by your physician that you do not have the

“capacity”, or ability, to make your own decisions, then your surrogate would be asked

to provide consent for you.

WHAT IF I HAVE NOT MADE AN ADVANCE DIRECTIVE OR CANNOT SIGN MY NAME

ON A LIVING WILL?

You can give verbal instructions to your physician and family. However, it is more

helpful for you to put your wishes in writing.

WHAT IF I CHANGE MY MIND AND WANT TO DELETE ALL OR PART OF MY LIVING

WILL?

Your advance directive can be revoked at any time by doing any of the following

things: a) signing a written statement saying that you revoke it; b) physically tearing

up the directive or have someone else tear it up in your presence; c) orally expressing

that you revoke it; d) executing another advance directive that is dierent than the

previous one. e most important thing to remember is to tell your doctor, family or

friends what you want.

CAN MY LIFE INSURANCE COMPANY CANCEL MY LIFE INSURANCE FOR SAYING I

WANT LIFE SUPPORT WITHHELD OR WITHDRAWN?

No. Florida law states that no policy of life insurance will be invalidated by you

making these choices. Also, you cannot be required to make an advance directive as a

condition for getting insurance or being admitted to a hospital.

I SIGNED A LIVING WILL IN ANOTHER STATE. IS IT VALID HERE?

Normally, yes! Florida will recognize an advance directive executed in another state

provided that it meets Florida’s state requirements.

WHERE SHOULD I KEEP MY ADVANCE DIRECTIVE?

Your advance directive is your “voice” and should serve to give your instructions if you

cannot. It is important that it be in an accessible place and that your surrogate, family

and physician all have a copy of it. You should also bring a copy with you each time

you are admitted to the hospital, or ask someone to bring it for you.

WHERE CAN I GET AN ADVANCE DIRECTIVE?

ere is a form included in this booklet that you are free to use. ere are other

versions of living wills available. is one is the example provided in Florida Statutes.

You may use another version of a living will, but it may be advisable to make sure that

it meets Florida law requirements.

DO I NEED A LAWYER TO MAKE A LIVING WILL OR DESIGNATE A HEALTH CARE

SURROGATE?

No. You can execute a living will or health care surrogate designation without a lawyer.

However, if you need to prepare documents related to nancial decision-making,

such as a Durable Power of Attorney, you would be wise to ask for the assistance of an

attorney. e information in this packet is related to health care decision-making.

Lee Health hopes that this booklet has helped answer questions about living wills and

advance directives. However, if you have further questions and would like more

assistance, please feel free to call us at:

343-2940—Medical Social Work, Department of Care Management

343-5199—Spiritual Services Department

424-3765—Older Adult Services

432-3450—HealthPark Care & Rehabilitation Center Social Services

343-2000—Guest Services

ADVANCE DIRECTIVES

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Living Will

(Please print your name)

(A life-prolonging procedure

means any medical procedure,

treatment, or intervention,

including articially provided

sustenance and hydration, which

sustains, restores or supplants a

spontaneous vital function.)

(You should give your physician,

family members or a close friend a

copy of the document.)

Declaration made this day of , 20

I, , willfully and

voluntarily make known my desire that my dying not be artiﬁcially prolonged

under the following circumstances, and I do hereby declare:

If at any time I am incapacitated and:

I have a terminal condition, or

I have an end-stage condition, or

I am in a persistent vegetative state

Initial all that apply

and if my primary physician and another consulting physician have determined

that there is no reasonable medical probability of my recovery from such

condition, I direct that life-prolonging procedures be withheld or withdrawn

when the application of such procedures would serve only to prolong artiﬁcially

the process of dying, and that I would be permitted to die naturally with only

the administration of medication or the performance of any medical procedure

deemed necessary to provide me with comfort care or to alleviate pain. It is

my intention that this declaration be honored by my family and physician as

the ﬁnal expression of my legal right to refuse medical or surgical treatment

and to accept the consequences for such refusal. In the event that I have been

determined to be unable to provide express and informed consent regarding

the withholding, withdrawal, or continuation of life-prolonging procedures,

I wish to designate the following person as my surrogate to carry out the

provisions of this declaration.

Name

Address

City State Zip Code

(You may wish to give special

consideration to cardiopulmonary

resuscitation, ventilators for

breathing, articial tube feedings

or uids given by tubes, kidney

dialysis, surgery, or antibiotics.)

I understand the full import of this declaration, and I am emotionally and

mentally competent to make this declaration.

Additional instructions (optional):

YOU SIGN HERE

(If you are unable to sign, a witness

must sign your name at your

direction and in your presence).

Signed

WITNESS SIGN HERE

(Must be signed in the presence

of two (2) witnesses, one of whom

is neither a spouse nor a blood

relative.)

Witness

Address

City State Zip Code

Phone

WITNESS SIGN HERE

Witness

Address

City State Zip Code

Phone

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ADVANCE DIRECTIVES

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Designation Of Health Care Surrogate

I, , designate as my health care surrogate under s. 765.202, Florida Statutes:

Name

Address

City State Zip Code

Phone

If my health care surrogate is not willing, able, or reasonably available to perform his or her duties, I

designate as my alternate health care surrogate:

Name

Address

City State Zip Code

Phone

INSTRUCTIONS FOR HEALTH CARE

I authorize my health care surrogate to:

Receive any of my health information, whether oral or recorded in any form or medium, that:

(Initials)

1. Is created or received by a health care provider, health care facility, health plan, public health authority,

employer, life insurer, school or university, or health care clearinghouse; and

2. Relates to my past, present, or future physical or mental health or condition; the provision of health care to

me; or the past, present, or future payment for the provision of health care to me.

I further authorize my health care surrogate to:

Make all health care decisions for me, which means he or she has the authority to:

(Initials)

1. Provide informed consent, refusal of consent, or withdrawal of consent to any and all of my health care,

including life-prolonging procedures.

2. Apply on my behalf for private, public, government, or veterans’ beneﬁts to defray the cost of health care.

3. Access my health information reasonably necessary for the health care surrogate to make decisions

involving my health care and to apply for beneﬁts for me.

4. Decide to make an anatomical gift pursuant to part V of chapter 765, Florida Statutes.

Speciﬁc instructions and restrictions:

While I have decision-making capacity, my wishes are controlling and my physicians and health care

providers must clearly communicate to me the treatment plan or any change to the treatment plan prior to its

implementation.

o the extent I am capable of understanding, my health care surrogate shall keep me reasonably informed of

all decisions that he or she has made on my behalf and matters concerning me.

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THIS HEALTH CARE SURROGATE DESIGNATION IS NOT AFFECTED BY MY SUBSEQUENT INCAPACITY EXCEPT AS

PROVIDED IN CHAPTER 765, FLORIDA STATUTES.

PURSUANT TO SECTION 765.104, FLORIDA STATUTES, I UNDERSTAND THAT I MAY, AT ANY TIME WHILE I RETAIN MY

CAPACITY, REVOKE OR AMEND THIS DESIGNATION BY:

(1) SIGNING A WRITTEN AND DATED INSTRUMENT WHICH EXPRESSES MY INTENT TO AMEND OR REVOKE THIS

DESIGNATION;

(2) PHYSICALLY DESTROYING THIS DESIGNATION THROUGH MY OWN ACTION OR BY THAT OF ANOTHER PERSON IN

MY PRESENCE AND UNDER MY DIRECTION;

(3) VERBALLY EXPRESSING MY INTENTION TO AMEND OR REVOKE THIS DESIGNATION; OR

(4) SIGNING A NEW DESIGNATION THAT IS MATERIALLY DIFFERENT FROM THIS DESIGNATION.

MY HEALTH CARE SURROGATE’S AUTHORITY BECOMES EFFECTIVE WHEN MY PRIMARY PHYSICIAN DETERMINES

THAT I AM UNABLE TO MAKE MY OWN HEALTH CARE DECISIONS UNLESS I INITIAL EITHER OR BOTH OF THE

FOLLOWING BOXES:

IF I INITIAL THIS BOX [ ], MY HEALTH CARE SURROGATE’S AUTHORITY TO RECEIVE MY HEALTH INFORMATION

TAKES EFFECT IMMEDIATELY.

IF I INITIAL THIS BOX [ ], MY HEALTH CARE SURROGATE’S AUTHORITY TO MAKE HEALTH CARE DECISIONS

FOR ME TAKES EFFECT IMMEDIATELY. PURSUANT TO SECTION 765.204(3), FLORIDA STATUTES, ANY INSTRUCTIONS

OR HEALTH CARE DECISIONS I MAKE, EITHER VERBALLY OR IN WRITING, WHILE I POSSESS CAPACITY SHALL

SUPERCEDE ANY INSTRUCTIONS OR HEALTH CARE DECISIONS MADE BY MY SURROGATE THAT ARE IN MATERIAL

CONFLICT WITH THOSE MADE BY ME.

SIGNATURES: Sign and date the form here:

Print Your Name

Sign Your Name Date

Address

City State Zip Code

SIGNATURES OF WITNESSES:

Note: A spouse or blood relative can be one of the witnesses; the second witness should be someone who is

not related to you. The person designated as your surrogate cannot be a witness.

First Witness

Print Your Name

Sign Your Name Date

Address

City State Zip Code

Second Witness

Print Your Name

Sign Your Name Date

Address

City State Zip Code

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