Fillable GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE

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GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE

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Page 1 of 15
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE
By: _________________________________________Date of Birth: ______________
(Print Name) ( (Print Name) (mm/dd/yyyy)
This advance directive for health care has four parts:
PART ONE
HEALTH CARE AGENT.
This part allows you to
choose someone to make health care decisions for you
when you cannot (or do not want to) make health care
decisions for yourself. The person you choose is
called a health care agent. You may also have your
health care agent make decisions for you after your
death with respect to an autopsy, organ donation, body
donation, and final disposition of your body. You
should talk to your health care agent about this
important role.
PART TWO
TREATMENT PREFERENCES.
This part allows you to
state your treatment preferences if you have a
terminal condition or if you are in a state of permanent
unconsciousness. PART TWO will become effective
only if you are unable to communicate your treatment
preferences. Reasonable and appropriate efforts will
be made to communicate with you about your
treatment preferences before PART TWO becomes
effective. You should talk to your family and others
close to you about your treatment preferences.
PART
THREE
GUARDIANSHIP.
This part allows you to nominate a
person to be your guardian should one ever be
needed.
Page 2 of 15
PART FOUR
EFFECTIVENESS AND SIGNATURES.
This part
requires your signature and the signatures of two
witnesses. You must complete PART FOUR if you have
filled out
any other part of this form. This document
may be signed by you or signed by someone else for
you in your presence and at your express direction.
You may fill out any or all of the first three parts listed above. You must fill
out PART FOUR of this form in order for this form to be effective.
Page 3 of 15
PART ONE: HEALTH CARE AGENT
[PART ONE will be effective even if PART TWO is not completed. A
physician or health care provider who is directly involved in your health
care may not serve as your health care agent. If you are married, a future
divorce or annulment of your marriage will revoke the selection of your
current spouse as your health care agent. If you are not married, a future
marriage will revoke the selection of your health care agent unless the
person you selected as your health care agent is your new spouse.]
(1) HEALTH CARE AGENT
I select the following person as my health care agent to make health care
decisions for me:
Name: ___________________________________________________________
Address:________________________________________________________________
___________________________________________________________
_________________________________________________________________
Telephone Numbers:
_________________________________________________________________
(Home)
_________________________________________________________________
(Work)
_________________________________________________________________
(Mobile/Cell)
E-Mail Address: ____________________________________________________
Page 4 of 15
(2) BACK-UP HEALTH CARE AGENT
[This section is optional. PART ONE will be effective even if this section is
left blank.]
If my health care agent cannot be contacted in a reasonable time period and
cannot be located with reasonable efforts or for any reason my health care
agent is unavailable or unable or unwilling to act as my health care agent,
then I select the following, each to act successively in the order named, as
my back-up health care agent(s):
First Back–up Agent
Name: ___________________________________________________________
Address: _________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers: ________________________________________________
_________________________________________________________________
(Home, Work, and Mobile/Cell)
E-Mail Address: ___________________________________________________
Second Back-up Agent
Name: ___________________________________________________________
Address: _________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers:________________________________________________
_________________________________________________________________
(Home, Work, and Mobile/Cell)
E-Mail Address:____________________________________________________
Page 5 of 15
(3) GENERAL POWERS OF HEALTH CARE AGENT
My health care agent will make health care decisions for me when I am
unable to communicate my health care decisions or I choose to have my
health care agent communicate my health care decisions.
My health care agent will have the same authority to make any health care
decision that I could make. My health care agent’s authority includes the
following powers:
To authorize my admission to or discharge (including transfers) from
any hospital, skilled nursing facility, hospice, or other health care facility
or service;
To request, consent to, withhold, or withdraw any type of health care;
and to
Contract for any health care facility or service for me, and to obligate
me to pay for these services (and my health care agent, acting in this
official capacity, will not be financially liable for any services or care
contracted for me or on my behalf).
My health care agent will be my personal representative for all purposes of
federal or state law related to privacy of medical records. This includes
the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
My health care agent will have the same access to my medical records that
I have and can disclose the contents of my medical records to others for
my ongoing health care.
My health care agent may accompany me in an ambulance or air ambulance
if in the opinion of the ambulance personnel protocol permits a passenger
and my health care agent may visit or consult with me in person while I am
Page 6 of 15
in a hospital, skilled nursing facility, hospice, or other health care facility or
service if its protocol permits visitation.
My health care agent may present a copy of this advance directive for
health care in lieu of the original and the copy will have the same meaning
and effect as the original.
I understand that under Georgia law:
My health care agent may refuse to act as my health care agent;
A court can take away the powers of my health care agent if it finds
that my health care agent is not acting properly; and
My health care agent does not have the power to make health care
decisions for me regarding psychosurgery, sterilization, or treatment or
involuntary hospitalization for mental or emotional illness, developmental
disability, or addictive disease.
(4) GUIDANCE FOR HEALTH CARE AGENT
When making health care decisions for me, my health care agent should
think about what action would be consistent with past conversations we
have had, my treatment preferences as expressed in PART TWO (if I have
filled out PART TWO), my religious and other beliefs and values, and how I
have handled medical and other important issues in the past. If what I
would decide is still unclear, then my health care agent should make
decisions for me that my health care agent believes are in my best interest,
considering the benefits, burdens, and risks of my current circumstances
and treatment options.
Page 7 of 15
(5) POWERS OF HEALTH CARE AGENT AFTER DEATH
(A) AUTOPSY
My health care agent will have the power to authorize an autopsy of my
body unless I have limited my health care agent’s power by initialing below.
__________ (Initials) My health care agent will not have the power to
authorize an autopsy of my body (unless an autopsy is required by law).
(B) ORGAN DONATION AND DONATION OF BODY
My health care agent will have the power to make a disposition of any part
or all of my body for medical purposes pursuant to the Georgia Revised
Uniform Anatomical Gift Act, unless I have limited my health care agent’s
power by initialing below.
[Initial each statement that you want to apply.]
__________ (Initials) My health care agent will not have the power to make a
disposition of my body for use in a medical study program.
__________ (Initials) My health care agent will not have the power to donate
any of my organs.
(C) FINAL DISPOSITION OF BODY
My health care agent will have the power to make decisions about the final
disposition of my body unless I have initialed below.
__________ (Initials) I want the following person to make decisions about the
final disposition of my body:
Page 8 of 15
Name: ___________________________________________________________
Address: __________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers: ________________________________________________
_________________________________________________________________
(Home, Work, and Mobile/Cell)
E-Mail Address: ____________________________________________________
I wish for my body to be:
__________ (Initials) Buried OR __________ (Initials) Cremated
PART TWO: TREATMENT PREFERENCES
[PART TWO will be effective only if you are unable to communicate your
treatment preferences after reasonable and appropriate efforts have been
made to communicate with you about your treatment preferences. PART
TWO will be effective even if PART ONE is not completed. If you have not
selected a health care agent in PART ONE, or if your health care agent is
not available, then PART TWO will provide your physician and other health
care providers with your treatment preferences. If you have selected a
health care agent in PART ONE, then your health care agent will have the
authority to make all health care decisions for you regarding matters
covered by PART TWO. Your health care agent will be guided by your
treatment preferences and other factors described in Section (4) of PART
ONE.]
Page 9 of 15
(6) CONDITIONS
PART TWO will be effective if I am in any of the following conditions:
[Initial each condition in which you want PART TWO to be effective.]
_________ (Initials) A terminal condition, which means I have an incurable or
irreversible condition that will result in my death in a relatively short
period of time.
_________ (Initials) A state of permanent unconsciousness, which means I
am in an incurable or irreversible condition in which I am not aware of
myself or my environment and I show no behavioral response to my
environment.
My condition will be determined in writing after personal examination by
my attending physician and a second physician in accordance with currently
accepted medical standards.
(7) TREATMENT PREFERENCES
[State your treatment preference by initialing (A), (B), or (C). If you choose
(C), state your additional treatment preferences by initialing one or more of
the statements following (C). You may provide additional instructions about
your treatment preferences in the next section. You will be provided with
comfort care, including pain relief, but you may also want to state your
specific preferences regarding pain relief in the next section.]
If I am in any condition that I initialed in Section (6) above and I can no
longer communicate my treatment preferences after reasonable and
appropriate efforts have been made to communicate with me about my
treatment preferences, then:
Page 10 of 15
(A) _________ (Initials)
Try to extend my life for as long as possible
, using
all medications, machines, or other medical procedures that in reasonable
medical judgment could keep me alive. If I am unable to take nutrition or
fluids by mouth, then I want to receive nutrition or fluids by tube or other
medical means.
OR
(B) _________ (Initials)
Allow my natural death to occur.
I do not want any
medications, machines, or other medical procedures that in reasonable
medical judgment could keep me alive but cannot cure me. I do not want to
receive nutrition or fluids by tube or other medical means except as needed
to provide pain medication.
OR
(C) _________ (Initials) I do not want any medications, machines, or other
medical procedures that in reasonable medical judgment could keep me
alive but cannot cure me, except as follows:
[Initial each statement that you want to apply to option (C).]
_________ (Initials) If I am unable to take nutrition by mouth, I want to
receive nutrition by tube or other medical means.
_________ (Initials) If I am unable to take fluids by mouth, I want to receive
fluids by tube or other medical means.
_________ (Initials) If I need assistance to breathe, I want to have a
ventilator used.
Page 11 of 15
_________ (Initials) If my heart or pulse has stopped, I want to have
cardiopulmonary resuscitation (CPR) used.
(8) ADDITIONAL STATEMENTS
[This section is optional.
PART TWO will be effective even if this section is
left blank. This section allows you to state additional treatment
preferences, to provide additional guidance to your health care agent (if
you have selected a health care agent in PART ONE), or to provide
information about your personal and religious values about your medical
treatment. For example, you may want to state your treatment preferences
regarding medications to fight infection, surgery, amputation, blood
transfusion, or kidney dialysis. Understanding that you cannot foresee
everything that could happen to you after you can no longer communicate
your treatment preferences, you may want to provide guidance to your
health care agent (if you have selected a health care agent in PART ONE)
about following your treatment preferences. You may want to state your
specific preferences regarding pain relief.]
________________________________________________________________
________________________________________________________________
________________________________________________________________
(9) IN CASE OF PREGNANCY
[PART TWO will be effective even if this section is left blank.]
I understand that under Georgia law, PART TWO generally will have no
force and effect if I am pregnant unless the fetus is not viable and I indicate
by initialing below that I want PART TWO to be carried out.
_________ (Initials) I want PART TWO to be carried out if my fetus is not
viable.
Page 12 of 15
PART THREE: GUARDIANSHIP
(10) GUARDIANSHIP
[PART THREE is optional. This advance directive for health care will be
effective even if PART THREE is left blank. If you wish to nominate a
person to be your guardian in the event a court decides that a guardian
should be appointed, complete PART THREE. A court will appoint a
guardian for you if the court finds that you are not able to make significant
responsible decisions for yourself regarding your personal support, safety,
or welfare. A court will appoint the person nominated by you if the court
finds that the appointment will serve your best interest and welfare. If you
have selected a health care agent in PART ONE, you may (but are not
required to) nominate the same person to be your guardian. If your health
care agent and guardian are not the same person, your health care agent
will have priority over your guardian in making your health care decisions,
unless a court determines otherwise.]
[State your preference by initialing (A) or (B). Choose (A) only if you have
also completed PART ONE.]
(A) __________ (Initials) I nominate the person serving as my health care
agent under PART ONE to serve as my guardian.
OR
(B) __________ (Initials) I nominate the following person to serve as my
guardian:
Name: ___________________________________________________________
Address: _________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers: ________________________________________________
_________________________________________________________________
Page 13 of 15
(Home, Work, and Mobile/Cell)
E-Mail Address: ____________________________________________________
PART FOUR: EFFECTIVENESS AND SIGNATURES
This advance directive for health care will become effective only if I am
unable or choose not to make or communicate my own health care
decisions.
Completing this form revokes and replaces any advance directive for health
care, durable power of attorney for health care, health care proxy, or living
will that I have completed before this date.
Unless I have initialed below and have provided alternative future dates or
events, this advance directive for health care will become effective at the
time I sign it and will remain effective until my death (and after my death to
the extent authorized in Section (5) of PART ONE).
__________ (Initials) This advance directive for health care will become
effective on or upon _______________________________ and will terminate on
or upon
(
Optional: Specify a date or event
)
_______________________________________________________________.
(
Optional: Specify a date or event
)
Page 14 of 15
[You must sign and date or acknowledge signing and dating this form in the
presence of two witnesses.]
Both witnesses must be of sound mind and must be at least 18 years of
age, but the witnesses do not have to be together or present with you when
you sign this form.
A witness:
Cannot be a person who was selected to be your health care agent or
back-up health care agent in PART ONE;
Cannot be a person who will knowingly inherit anything from you or
otherwise knowingly gain a financial benefit from your death; or
Cannot be a person who is directly involved in your health care.
Only one of the witnesses may be an employee, agent, or medical staff
member of the hospital, skilled nursing facility, hospice, or other health care
facility in which you are receiving health care (but this witness cannot be
directly involved in your health care).]
By signing below, I state that I am emotionally and mentally capable of
making this advance directive for health care and that I understand its
purpose and effect.
_________________________________________ ________________
(Signature of Declarant) (Date)
Page 15 of 15
The declarant signed this form in my presence or acknowledged signing
this form to me. Based upon my personal observation, the declarant
appeared to be emotionally and mentally capable of making this advance
directive for health care and signed this form willingly and voluntarily.
______________________________________________ _______________
(Signature of First Witness) (Date)
Print Name: _______________________________________________________
Address: __________________________________________________________
_________________________________________________________________
______________________________________________ ________________
(Signature of Second Witness) (Date)
Print Name: _______________________________________________________
Address: __________________________________________________________
________________________________________________________________
[This form does not need to be notarized and a copy of a validly executed
advance directive for health care carries the same meaning and effect as the
original document.]
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GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE

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Completed 17 April 2021

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