Fillable GEORGIA Advance Directive Planning for Important Health Care

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1
GEORGIA
Advance Directive
Planning for Important Health Care Decisions
CaringI
nfo
1731 King St., Suite 100,
Alexandria,
VA 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 health care 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.
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Revised 2019.
Reproduction and distribution by an organization or organized group without the written permission of the
National Hospice and Palliative Care Organization is expressly forbidden.
2
Using these Materials
BEFORE YOU BEGIN
1. Check to be sure that you have the materials for each state in which you could receive
health care.
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.
3
INTRODUCTION TO YOUR GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE
This packet contains the Georgia Advance Directive for Health Care, which protects
your right to refuse medical treatment that you do not want or to request treatment you
do want, in the event you lose the ability to make decisions yourself. The form contains
three parts, any number of which may be filled out, and a fourth signature page that must
be filled out for any of the three other parts to be effective.
Part One: Health Care Agent. This allows you to choose someone to make health care
decisions for you if you cannot (or do not want to) make health care decisions for yourself.
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.
Your health care agent’s power becomes effective when your doctor determines that you
are no longer able to make or communicate your health care decisions or when you decide
to have your health care agent make decisions for you.
Part Two: Treatment Preferences. This part allows you to state your treatment
preferences if you are (1) unable to communicate your treatment preferences, and (2)
your physician and one other physician determine that you either have a terminal
condition or are in a state of permanent unconsciousness. If you also have a health care
agent, then your agent is authorized to make all decisions discussed in Part Two, but will
be guided by your written Treatment Preferences as well as any other factors you may
have listed in section 4 of Part One.
Part Three: Guardianship. This part allows you to nominate a person to be your
guardian should one ever be needed.
Part Four: Signatures. This part needs to be filled out in order to make any of the three
other parts effective. All three preceding parts are optional. You are free to fill out any or
all of them.
These forms do not expressly address mental illness. If you would like to make advance
care plans involving mental illness, you should talk to your physician and an attorney
about a durable power of attorney for mental health care.
Note: These documents
will be
legally binding
only if the
person completing
them is a
competent
adult, at least 18 years old, or an
emancipated
youth.
4
COMPLETING YOUR GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE
How do I make my Advance Directive for Health Care legal?
The law requires that you sign your document, or another person signs it in your presence
and at your express direction, in the presence of two witnesses who must be at least 18
years of age and of sound mind.
Your witnesses cannot be your health care agent, someone who will knowingly inherit
anything from you or otherwise gain a financial benefit from your death, or someone who
is directly involved in your health care.
Only one witness can be an employee, agent, or medical staff member of the facility in
which you are receiving health care.
Note:
You do not need to
notarize
your
Georgia Advance Directive
for
Health
Care.
Whom should I appoint as my agent?
Your health care agent is the person you appoint to make decisions about your medical
care if you become unable to make those decisions yourself. Your health care agent may
be a family member or a close friend whom you trust to make serious decisions. The
person you name as your health care agent should clearly understand your wishes and be
willing to accept the responsibility of making medical decisions for you.
No physician or health care provider may act as your health care agent if he or she is
directly involved in your health care.
You can appoint a second and third person as your alternate health care agent(s). The
alternate(s) will step in if the first person you name as agent is unable, unwilling, or
unavailable to act for you.
Should I add personal instructions to my Advance Directive for Health Care?
One of the strongest reasons for naming a health care agent is to have someone who can
respond flexibly as your medical situation changes and deal with situations that you did
not foresee. If you add instructions to this document it may help your health care agent
carry out your wishes, but be careful that you do not unintentionally restrict your health
care agent’s power to act in your best interest. In any event, be sure to talk with your
health care agent about your future medical care and describe what you consider to be an
acceptable “quality of life.”
5
COMPLETING YOUR GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE
(CONTINUED)
What if I change my mind?
Revocation
You may revoke your Georgia advance directive for health care at any time, regardless of
your mental or physical condition, by:
•
obliterating, burning, tearing, or otherwise destroying your document,
•
signing and dating a written revocation or directing another person to do so (if you
are receiving health care in a health care facility, the revocation must be
communicated to your attending physician) , or
•
orally revoking your document in the presence of a witness, at least 18 years of
age, who must sign and date a written confirmation of your revocation within 30
days (if you are receiving health care in a health care facility, the revocation must
be communicated to your attending physician).
•
by completing a new advance directive for health care. A new advance directive
will revoke an older advance directive to the extent that they are inconsistent with
each other.
Change
in
Marital
Status
If you get married after completing your advance directive for health care and you have
not named your spouse as your health care agent, your marriage automatically revokes
the power of your health care agent. If you have appointed your spouse as your health
care agent and you divorce or the marriage is annulled, your health care agent’s power is
automatically revoked. You can, however, specify that you do not want these changes to
occur in section 8 in PART TWO of your advance directive for health care.
What other important facts should I know?
Pregnancy
If you are a woman and would like your treatment preferences regarding withholding or
withdrawal of life-sustaining procedures, nourishment, or hydration to be honored even if you
are pregnant, you must initial the statement in section 9 in PART TWO of the advance directive
for health care form.
State law requires that, before honoring a pregnant patient’s Treatment Preferences, the
attending physician must first determine whether the fetus is viable. If the fetus is viable, your
treatment preferences will not be honored, even if you initial section 9.
Guardianship
Part III of your advance directive for health care provides space where you can nominate
someone to serve as your guardian if there should come a time when you need a court-
appointed guardian. Unless a court specifies otherwise, your guardian has no power to
make any personal or health care decisions granted to your agent under your advance
directive for health care.
6
INSTRUCTIONS
PRINT YOUR NAME
AND BIRTH DATE
INTRODUCTION
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 1 OF 12
By:
(Print Name)
Date of Birth:
(Month/Day/Year)
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.
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.
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.
You should give a copy of this completed form to people who might need
it, such as your health care agent, your family, and your physician. Keep a
copy of this completed form at home in a place where it can easily be
found if it is needed. Review this completed form periodically to make sure
it still reflects your preferences. If your preferences change, complete a
new advance directive for health care.
7
INSTRUCTIONS
INTRODUCTION
CONTINUED
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 2 OF 12
Using this form of advance directive for health care is completely
optional. Other forms of advance directives for health care may be used in
Georgia.
You may revoke this completed form at any time.
Once completed, this form will replace any advance directive for health
care, durable power of attorney for health care, health care proxy, or living
will that you have completed before completing this form.
INSTRUCTIONS
PRINT THE NAME
AND ADDRESS OF
YOUR HEALTH CARE
AGENT
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 3 OF 12
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. Unless
you
specify otherwise
in
section
8 of PART TWO,
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. Unless
you
specify otherwise
in
section
8 of
PART TWO,
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, and Mobile)
(2) BACK-UP HEALTH CARE AGENT
[Th
is
sect
ion is
opt
i
on
al. 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):
PRINT NAMES,
ADDRESSES, AND
TELEPHONE
NUMBERS OF
YOUR ALTERNATE
HEALTH CARE
AGENTS
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
Name:
Address:
Telephone Numbers:
(Home, Work, and Mobile)
Name:
Address:
Telephone Numbers:
(Home, Work, and Mobile)
8
INSTRUCTIONS
DESCRIPTION OF
POWERS OF
HEALTH CARE
AGENT
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 4 OF 12
(3) GENERAL POWERS OF HEALTH CARE AGENT
My health care agent will make health care decisions for me when I am unable to
make my health care decisions or I choose to have my health care agent make
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, for example, the power to:
•
Admit me to or discharge me from any hospital, skilled nursing facility,
hospice, or other health care facility or service;
•
Request, consent to, withhold, or withdraw any type of health care; and
•
Contract for any health care facility or service for me, and to obligate me
to pay for these services (and my health care agent 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 (including the Health
Insurance Portability and Accountability Act of 1996) and 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 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, mental
retardation, 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.
9
10
INSTRUCTIONS
INITIAL IF YOU DO
NOT WANT YOUR
HEALTH CARE
AGENT TO HAVE
POWER TO
AUTHORIZE AN
AUTOPSY
INITIAL
STATEMENTS THAT
YOU WANT TO
APPLY, IF ANY
INITIAL HERE IF
YOU WANT
SOMEONE OTHER
THAN YOUR
HEALTH CARE
AGENT TO MAKE
FINAL DISPOSITION
DECISIONS
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 5 OF 12
(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 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:
Name:
Address:
Telephone Numbers:
(Home, Work, and Mobile)
INITIAL THE ONE
STATEMENT THAT
REFLECTS YOUR
WISH
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
I wish for my body to be:
(Initials) Buried
OR
(Initials) Cremated
11
INSTRUCTIONS
INITIAL THE
STATEMENTS THAT
REFLECT YOUR
WISH
YOU MAY INITIAL
BOTH STATEMENTS
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 6 OF 12
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.]
(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 certified in writing after personal examination by my
attending physician and a second physician in accordance with currently
accepted medical standards.
12
INSTRUCTIONS
INITIAL ONE
STATEMENT THAT
REFLECTS YOUR
WISH
INITIAL ONLY ONE
(A, B, OR C)
IF YOU INITIAL (C),
INITIAL EACH
STATEMENT THAT
YOU WANT TO
APPLY
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 7 OF 12
(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,
regardless
of which choice you
make,
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:
(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.
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
(Initials) If I need assistance to breathe, I want to have a
ventilator used.
(Initials) If my heart or pulse has stopped, I want to have
cardiopulmonary resuscitation (CPR) used.
13
INSTRUCTIONS
OPTIONAL SECTION
ADD OTHER
INSTRUCTIONS, IF
ANY, REGARDING
YOUR ADVANCE
CARE PLANS
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 8 OF 12
(8) ADDITIONAL STATEMENTS
[Th
is
sect
ion is
opt
ion
al. 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.]
THESE
INSTRUCTIONS CAN
FURTHER ADDRESS
YOUR HEALTH CARE
PLANS, SUCH AS
YOUR WISHES
REGARDING
HOSPICE
TREATMENT, BUT
CAN ALSO
ADDRESS
OTHER
ADVANCE
PLANNING ISSUES,
SUCH AS YOUR
BURIAL WISHES
ATTACH
ADDITIONAL PAGES
IF NEEDED
© 2005 National
Hospice
and
Palliative
Care
Organization.
2019 Revised.
14
INSTRUCTIONS
INITIAL HERE IF
YOU WANT PART
TWO TO BE
CARRIED OUT IF
YOU ARE PREGNANT
AND YOUR FETUS IS
NOT VIABLE
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 9 OF 12
(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.
15
INSTRUCTIONS
INITIAL YOUR
PREFERENCE
REGARDING
NOMINATION OF
YOUR GUARDIAN,
IN THE EVENT YOU
NEED TO HAVE ONE
APPOINTED BY A
COURT
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 10 OF 12
PART THREE: GUARDIANSHIP
(10) GUARDIANSHIP
[P
AR
T
TH
R
EE is
opt
ion
al. 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:
(Home, Work, and Mobile)
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
16
INSTRUCTIONS
INITIAL HERE IF
YOU WANT TO
LIMIT WHEN THIS
ADVANCE
DIRECTIVE IS
EFFECTIVE
SIGN AND DATE
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 11 OF 12
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.
This form revokes 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 .
[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;
•
A
person
who will
knowingly inherit anything
from you or otherwise
knowingly
gain a
financial benefit
from your
death;
or
•
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)
17
INSTRUCTIONS
HAVE YOUR
WITNESSES SIGN,
DATE AND PRINT
THEIR ADDRESSES
HERE
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 12 OF 12
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 witness) (Date)
Print Name:
Address:
(Signature of witness) (Date)
Print Name:
Address:
[This form does not
need
to be notarized.]
© 2005 National
Hospice and
Palliative Care
Organization.
2019 Revised.
Courtesy
of
C
a
r
i
ngInfo
1731 King St., Suite 100,
Alexandria,
VA
22314
www.caringinfo.org,
800/6
5
8-
88
98
18
You Have Filled Out Your Health Care Directive, Now What?
1. Your
Georgia Advance Directive
for
Health
Care 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 agent, 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 Georgia document.
7. Be aware that your Georgia 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 non-hospital do-not-resuscitate orders. We
suggest you speak to your physician if you are interested in obtaining one. CaringInfo
does not distribute these forms.
OR donate online today: www.NationalHospiceFoundation.org/donate
Congratulations!
You’ve downloaded your free, state specific advance directive.
You are taking important steps to make sure your wishes are known. Please consider helping us
keep this resource free.
Your generous support to the National Hospice Foundation allows us to continue to provide FREE
resources, tools, and information to educate and empower individuals to access advance care
planning, caregiving, hospice and grief services.
Please show your support for our mission and consider making a tax-deductible gift
to the National Hospice Foundation today.
Since 1992, the National Hospice Foundation has been dedicated to creating FREE resources for
individuals and families facing a life-limiting illness, raising awareness for the need for hospice
and palliative care, and providing ongoing professional education and skills development to
hospice and palliative care professionals across the nation. To learn more, please visit
www.NationalHospiceFoundation.org
You may wonder if a gift of $35, $50 or $100 to the National Hospice Foundation would make a
difference, but it is only because of the generosity of others like you that these FREE resources
are made available.
Please consider supporting our mission by returning a generous tax-deductible donation.
Every gift makes a difference! Your gift strengthens the Foundation’s ability to provide FREE
caregiver and family resources.
Cut along the dotted line and use the coupon below to return a check contribution of
the most generous amount you can send. Thank you.
YES! I want to support the important work of the National Hospice Foundation.
$35
helps us provide webinars to hospice professionals
$50
helps us provide free advance directives
$100 helps us maintain our free InfoLine
$________ to support the mission of the National Hospice Foundation.
Return to:
National Hospice Foundation
PO Box 824401
Philadelphia, PA 19182-4401
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GEORGIA Advance Directive Planning for Important Health Care

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Completed 24 October 2020

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