Fillable INDIANA Advance Directive Planning for Important Health Care (NHPCO)

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INDIANA Advance Directive Planning for Important Health Care (NHPCO)

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INDIANA

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 healthcare 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. If you have other questions regarding these documents, we

recommend contacting your state attorney general's office.

Reproduction and distribution by an organization or organized group without the written permission of

the National Hospice and Palliative Care Organization is expressly forbidden.

Using these Materials

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may receive

healthcare.

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.

INTRODUCTION TO YOUR INDIANA ADVANCE DIRECTIVE

This packet contains the Indiana Advance Directive for Health Care, which protects your

right to refuse medical treatment 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.

Part One. The Appointment of Health-Care Representative and Power of

Attorney lets you name someone, called your health-care representative, to make

decisions about your medical care — including decisions about life support — if you can no

longer speak for yourself. This document is especially useful because it allows you to

appoint someone to speak for you any time you are unable to make your own medical

decisions, not only at the end of life. If you have it witnessed by a notary, Part One also

empowers your health-care representative as your attorney-in-fact to make other advance

planning decisions, such as those regarding organ donation and final disposition of your

body.

Your appointment of health-care representation and power of attorney becomes effective

when your doctor determines that you are no longer able to make or communicate

decisions about your health care.

Part Two. The Indiana Declaration lets you state your wishes with regard to life-

prolonging procedures in the event you develop a terminal condition and can no longer

make your own decisions. The Declaration allows you to choose between Indiana’s Living

Will Declaration, which allows you to state your preference for the withdrawal or

withholding of life-prolonging procedures, and Indiana’s Life-Prolonging Procedures

Declaration, which allows you to state your preference for receiving life-prolonging

procedures if you are terminally ill.

Part Three contains the signature and witness provisions so that your document will be

effective.

Following the advance directive form is an Indiana Organ Donation Form.

This form does 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 tailored to your needs.

Note: The Power of

Attorney

and

Indiana Declaration documents

will be

legally

binding

only if the

person completing

them is a

competent

adult (at least 18 years old).

COMPLETING YOUR INDIANA ADVANCE DIRECTIVE

How do I make my Indiana Advance Directive legal?

Indiana law requires that you have your signature witnessed in different ways, depending

on the powers you are granting to your health-care representative and/or the declarations

you make.

If you fill out Part One, appointment of health-care representative and power of attorney,

you must sign this form in the presence of one adult, age 18 or older, who is not your

health-care representative.

In order for you to grant your health-care representative the additional powers listed on

page 3 of the form, your witness must be a notary public.

Part Two requires that you sign in the presence of two competent witnesses, 18 years of

age or older, who must also sign the document and state that they personally know you

and believe you to be of sound mind. If you choose in your declaration to have life-

prolonging procedures withheld or withdrawn, your witnesses cannot be:

•

a person signing the Declaration on your behalf if you are unable to sign it yourself,

•

your parent, spouse, or child,

•

a person entitled to any part of your estate, or

•

a person directly financially responsible for your medical care.

If you are fill out both parts, you must sign your form in the presence of two competent

witnesses, 18 years of age or older, who must also sign the document and state that they

personally know you and believe you to be of sound mind. If you choose in your

declaration to have life-prolonging procedures withheld or withdrawn, your witnesses

cannot be:

•

a person signing the Declaration on your behalf if you are unable to sign it yourself,

•

your parent, spouse, or child,

•

a person entitled to any part of your estate, or

•

a person directly financially responsible for your medical care.

If you fill out both parts, and want to grant your health care representative the additional

powers listed on page 3 of the form, you should have your form notarized in addition to

having it witnessed.

Whom should I appoint as my health-care representative?

Your health-care representative — who is also your attorney-in-fact for purposes of your

power of attorney — is the person you appoint to make decisions about your medical care

if you become unable to make those decisions yourself. Your health-care representative

may be a family member or a close friend whom you trust to make serious decisions. The

person you name as your health-care representative should clearly understand your

wishes and be willing to accept the responsibility of making medical decisions for you.

You can appoint a second person as your successor health-care representative. The

successor will step in if the first person you name as a health-care representative is

unable, unwilling, or unavailable to act for you.

Should I add personal instructions to my Indiana Advance Directive

One of the strongest reasons for naming a health-care representative 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

representative carry out your wishes, but be careful that you do not unintentionally restrict

your agent’s power to act in your best interest. In any event, be sure to talk with your

representative about your future medical care and describe what you consider to be an

acceptable “quality of life.”

What if I change my mind?

You may revoke your health-care representative’s powers under Part One by telling your

representative or your health-care provider, either orally or in writing, that you are

revoking those powers.

You may revoke the instructions you have set out in Part Two at any time by:

•

signing and dating a written revocation,

•

orally expressing your intent to revoke your declaration, or

•

physically canceling or destroying the declaration or directing another to do so in

your presence.

Your revocation of Part Two becomes effective once you notify your doctor.

What other important facts should I know?

A pregnant patient’s wishes to have life-prolonging procedures withheld or withdrawn will

not be honored due to restrictions in state law.

INDIANA ADVANCE DIRECTIVE – PAGE 1 OF 8

PART ONE: APPOINTMENT OF HEALTH-CARE REPRESENTATIVE

AND POWER OF ATTORNEY

(name)

(address)

hereby appoint

(name of health-care representative)

(address)

(home telephone number) (work telephone number)

INSTRUCTIONS

PRINT YOUR NAME

AND ADDRESS

PRINT THE NAME,

ADDRESS AND

TELEPHONE

NUMBERS OF YOUR

HEALTH-CARE

REPRESENTATIVE

PRINT THE NAME,

ADDRESS AND

TELEPHONE

NUMBERS OF YOUR

SUCCESSOR

HEALTH-CARE

REPRESENTATIVE

Hospice and

Palliative Care

Organization. 2020

Revised.

as my health-care representative — and attorney-in-fact, if I have had this

document notarized on page 7 — (“health-care representative”) to make

health-care decisions on my behalf whenever I am incapable of making my

own health-care decisions.

In the event the person I appoint above is unable, unwilling or unavailable

to act as my health-care representative, I hereby appoint:

(name of successor health-care representative)

(address)

(home telephone number) (work telephone number)

as my successor health-care representative.

INDIANA ADVANCE DIRECTIVE – PAGE 2 OF 8

PART ONE: APPOINTMENT OF HEALTH-CARE REPRESENTATIVE

AND POWER OF ATTORNEY (Continued)

Powers Granted to my Health-Care Representative

I grant my health-care representative all powers available under Indiana

Code, Title 16, Article 36, Chapter 1 to make health-care decisions for me

in the event I am unable to make such decisions myself. These powers

include, but are not limited:

(1) to consent to or refuse health care for me;

(2) to admit or release me from a hospital or health-care facility; and

(3) to have access to my records, including medical records,

concerning my condition.

THESE POWERS

CAN BE GRANTED

TO YOUR HEALTH-

CARE

REPRESENTATIVE

WITHOUT HAVING

A NOTARY PUBLIC

WITNESS YOUR

SIGNATURE

Hospice and

Palliative Care

Organization.

2020 Revised.

I understand health care to include any medical care, treatment, service, or

procedure to maintain, diagnose, treat, or provide for my physical or

mental well-being. Health care also includes the providing of nutrition and

hydration through intravenous, gastrostomy, or nasogastric tubes.

I authorize my health-care representative to make decisions in my best

interest concerning withdrawal or withholding of health care. If at any time

based on my previously expressed preferences and the diagnosis and

prognosis, my health-care representative is satisfied that certain health care

is not or would not be beneficial or that such health care is or would be

excessively burdensome, then my health-care representative may express

my will that such health care be withheld or withdrawn and may consent on

my behalf that any or all health care be discontinued or not instituted, even

if death may result.

My health-care representative must try to discuss this decision with me.

However, if I am unable to communicate, my health-care representative

may make such a decision for me, after consultation with my physician or

physicians and other relevant health-care givers. To the extent appropriate,

my health-care representative may also discuss this decision with my family

and others to the extent they are available.

INDIANA ADVANCE DIRECTIVE - PAGE 3 OF 8

PART ONE: APPOINTMENT OF HEALTH-CARE REPRESENTATIVE

AND POWER OF ATTORNEY (Continued)

Additional Powers Granted to my Health-Care Representative as

my Attorney-in-Fact (Notary Required)

IN ORDER TO

GRANT YOUR

HEALTH-CARE

REPRESENTATIVE

THESE ADDITIONAL

POWERS TO SERVE

AS YOUR

ATTORNEY-IN-FACT,

YOU MUST HAVE

YOUR SIGNATURE

WITNESSED BY A

NOTARY PUBLIC ON

PAGE 7 OF THIS

FORM

REVOCATION

OPTIONS

YOU MAY REVOKE

ALL POWERS

GRANTED TO YOUR

HEALTH-CARE

REPRESENTATIVE

IN THIS FORM,

INCLUDING THOSE

AS YOUR

ATT

ORNEY-IN-FACT,

AS DESCRIBED

HERE

Hospice and

Palliative Care

Organization.

2020 Revised.

If my signature of this document is witnessed by a notary public, I further

grant my health-care representative all powers available as my attorney-in-

fact under Indiana Code §§ 30-5-5-16 and 30-5-5-17 to make health-care

decisions for me in the event I am unable to make such decisions myself,

including, but not limited to:

(1) to employ or contract with servants, companions, or health care

providers involved in my health care;

(1) to make anatomical gifts on my behalf;

(3) to request an autopsy; and

(4) to make plans for the disposition of my body.

Revocation of Health-Care Representative’s Power and

Appointment

I may revoke the authority of my health-care representative, including any

powers granted to my health-care representative as my attorney-in-fact,

and all of the powers granted in this document, whenever I am capable of

consenting to health care by notifying my health-care provider or my

health-care representative orally or in writing.

I may revoke the appointment of my health-care representative, and all of

the powers granted in this document, whenever I am capable of consenting

to health care by notifying my health-care representative orally or in

writing.

INDIANA ADVANCE DIRECTIVE - PAGE 4 OF 8

PART ONE: APPOINTMENT OF HEALTH-CARE REPRESENTATIVE

AND POWER OF ATTORNEY (Continued)

Guidance for my Health-Care Representative

When making health-care decisions for me, my health-care representative

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 representative should

make decisions for me that my health-care representative believes are in

my best interest, considering the benefits, burdens, and risks of my current

circumstances and treatment options.

In addition, my health-care representative should consider the following

instructions in making health-care decisions on my behalf: (attach

additional pages if needed.)

ADD OTHER

INSTRUCTIONS, IF

ANY, REGARDING

YOUR

ADVANCE

CARE

PLANS

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

Hospice and

Palliative Care

Organization. 2020

Revised.

INDIANA ADVANCE DIRECTI0VE – PAGE 5 OF 8

PART TWO: DECLARATION

PRINT THE DATE

PRINT YOUR NAME

INITIAL ONLY ONE

OF THE FOLLOWING

TWO CHOICES

INITIAL HERE IF

YOU WANT LIFE-

PROLONGING

PROCEDURES

UNDER ALL

CIRCUMSTANCES

INITIAL HERE IF

YOU WANT LIFE-

PROLONGING

PROCEDURES

WITHHELD OR

WITHDRAWN

UNDER THE

CONDITIONS

LISTED

IF YOU INITIALED

THE LIVING WILL

DECLARATION

ABOVE, INITIAL THE

STATEMENT

THAT REFLECTS

YOUR WISHES

ABOUT ARTIFICIAL

NUTRITION

(FEEDING) AND

HYDRATION

(FLUIDS)

Hospice and

Palliative Care

Organization.

2020 Revised.

Declaration made this day of .

(day) (month, year)

I, ,

(name)

being at least eighteen (18) years old and of sound mind, willfully and

voluntarily exercise my right to determine the course of my health care and

to provide clear and convincing proof of my treatment decisions. If at any

time I have an incurable injury, disease, or illness determined to be a

terminal condition and am unable to make decisions, I declare that:

(Life-Prolonging Procedures Declaration) I want the use of life-

prolonging procedures that would extend my life under all circumstances.

This includes appropriate nutrition and hydration, the administration of

medication, and the performance of all other medical procedures necessary

to extend my life, to provide comfort care, or to alleviate pain.

(Living Will Declaration) I request that my dying shall not be

artificially prolonged. If my death will occur within a short time and the

use of life prolonging procedures would serve only to artificially prolong the

dying process, I direct that such procedures be withheld or withdrawn, and

that I be permitted to die naturally with only the performance or provision

of any medical procedure or medication necessary to provide me with

comfort care or to alleviate pain, and, if I have so indicated below, the

provision of artificially supplied nutrition and hydration. (Indicate your

choice by initialing or making your mark before signing this declaration):

I wish to receive artificially supplied nutrition and

hydration, even if the effort to sustain life is futile or

excessively burdensome to me.

I do not wish to receive artificially supplied nutrition and

hydration, if the effort to sustain life is futile or excessively burdensome to

me.

I intentionally make no decision concerning artificially

supplied nutrition and hydration, leaving the decision to my health-

care representative appointed under Indiana Code 16-36-1-7 or my

attorney-in-fact with health-care powers under Indiana Code 30-5-5.

INDIANA ADVANCE DIRECTIVE – PAGE 6 OF 8

PART TWO: DECLARATION (Continued)

I further declare that: (add additional instructions, if any, adding

additional pages, if needed.)

ADD OTHER

INSTRUCTIONS, IF

ANY, REGARDING

YOUR ADVANCE

CARE PLANS

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

Hospice and

Palliative Care

Organization. 2020

Revised.

In the absence of my ability to give directions regarding the use of life-

prolonging procedures, 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 accept the consequences of the

refusal. My health-care representative, under Indiana Code 16-36-1-7 or

my attorney-in-fact, under Indiana Code 30-5-5, if I have appointed one, is

responsible for interpreting this declaration if there is a disagreement as to

its applicability.

INDIANA ADVANCE DIRECTIVE — PAGE 7 OF 8

PART THREE: EXECUTION

PRINT YOUR NAME

I, _, the principal and/or

declarant, sign my name or direct another person to sign my name to this

instrument this day of 20 _, and do

hereby declare to the undersigned witness(es) that I sign it willingly, and I

execute it as my free and voluntary act for the purposes herein expressed,

and that I am of sound mind, and under no constraint or undue influence. I

understand the full importance of this declaration.

Signed

City, County, and State of Residence

PRINT THE DATE

SIGN YOUR NAME

PRINT YOUR CITY,

COUNTY, AND

STATE OF

RESIDENCE

YOUR FORM MUST

BE WITNESSED BY

A NOTARY IN

ORDER TO GRANT

YOUR HEALTH-CARE

REPRESENTATIVE

THE ADDITIONAL

POWERS OF AN

ATTORNEY-IN-FACT

LISTED ON PAGE 3

IN PART ONE

(APPOINTMENT OF

HEALTH-CARE

REPRESENTATIVE)

IF SOMEONE IS

SIGNING THE FORM

FOR YOU AT YOUR

DIRECTION

BECAUSE YOU ARE

UNABLE TO SIGN,

THE NOTARY MUST

NOTE THAT HERE

Hospice and

Palliative Care

Organization. 2020

Revised.

Notary

Subscribed and acknowledged before me by ,

the principal, this day of , 20

(notary public)

My Commission expires

I further confirm that , signing on behalf of

, the principle and/or declarant, did so at

the principle and/or declarant’s direction.

(notary public)

INDIANA ADVANCE DIRECTIVE — PAGE 8 OF 8

PART THREE: EXECUTION (continued)

Witness(es)

The declarant has been personally known to me, and I believe (him/her)

to be of sound mind. I am competent and at least eighteen (18) years old.

Witness

Date

Witness

Date

I further attest that I did not sign the declarant’s signature above for or at

the direction of the declarant. I am not a parent, spouse, or child of the

declarant. I am not entitled to any part of the declarant’s estate or directly

financially responsible for the declarant’s medical care.

Witness

Date

Witness

Date

YOUR FORM MUST

BE WITNESSED

TWO WITNESSES

ARE REQUIRED IF

YOU FILLED OUT

PART TWO

(DECLARATION)

ONLY ONE WITNESS

—

WHO

MAY

NOTARY PUBLIC

SIGNING ON THE

PREVIOUS PAGE —

IS REQUIRED IF

YOU FILLED OUT

ONLY

PART

ONE

(APPOINTMENT OF

HEALTH-CARE

REPRESENTATIVE)

IF YOU CHOSE THE

LIVING WILL

DECLARATION IN

PART TWO, YOUR

TWO

WITNESSES

MUST ALSO SIGN

HERE

Hospice and

Palliative Care

Organization. 2020

Revised.

Courtesy

ingI

nfo

1731 King St., Suite 100,

Alexandria,

223

www.caringinfo.org,

8898

INDIANA ORGAN DONATION FORM — PAGE 1 OF 1

Initial the line next to the statement below that best reflects your wishes.

You do not have to initial any of the statements. If you do not initial any of

the statements, your health-care representative, attorney for health care,

proxy, or other agent, or your family may have the authority to make a gift

of all or part of your body under Indiana law.

I do not want to make an organ or tissue donation and I do not

want my attorney for health care, proxy, or other agent or family to do so.

I have already signed a written agreement or donor card regarding

organ and tissue donation with the following individual or institution:

Name of individual/institution:

Pursuant to Indiana law, I hereby give, effective on my death:

Any needed organ or parts.

The following part or organs listed below:

For (initial one):

Any legally authorized purpose.

Transplant or therapeutic purposes only.

ORGAN DONATION

(OPTIONAL)

INITIAL THE

OPTION THAT

REFLECTS YOUR

WISHES

ADD NAME OR

INSTITUTION (IF

ANY)

PRINT YOUR NAME,

SIGN, AND DATE

THE DOCUMENT

YOUR

WITNESSES

MUST SIGN AND

PRINT THEIR

ADDRESSES

AT LEAST ONE

WITNESS MUST BE

A DISINTERESTED

PARTY

Hospice and

Palliative Care

Organization 2020

Revised.

Declarant name:

Declarant signature: _ , Date:

The declarant voluntarily signed or directed another person to sign this

writing in my presence.

Witness Date

Address

I am a disinterested party with regard to the declarant and his or her

donation and estate. The declarant voluntarily signed or directed another

person to sign this writing in my presence.

Witness Date_

Address

Courtesy

Caring

nfo

1731 King St., Suite 100,

Alexandria,

223

www.caringinfo.org, 80

0/65

-88

You Have Filled Out Your Advance Directive, Now What?

1. Your Indiana Advance Directive 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 health-care representative and

successor, 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 documents placed in your medical records.

3. Be sure to talk to your health-care representative and successor, doctor(s),

clergy, and 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 change your document after it has been signed and witnessed,

you should complete a new form.

6. Remember, you can always revoke your Indiana document.

7. Be aware that your Indiana document will not be effective in the event of a

medical emergency. Ambulance personnel are required to provide

cardiopulmonary resuscitation (CPR) unless they are given a separate order that

states otherwise. These orders, commonly called “non-hospital do-not-

resuscitate orders,” are designed for people whose poor health gives them little

chance of benefiting from CPR. Indiana law provides for a “Physician Orders for

Scope of Treatment” (POST) form. A POST form includes additional information

than a standard do-not-resuscitate order relating to life-sustaining measures.

These orders must be signed by your physician and instruct ambulance

personnel not to attempt CPR if your heart or breathing should stop.

We suggest you speak to your physician for more information about the POST

form. 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.

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$________ to support the mission of the National Hospice Foundation.

Return to:

National Hospice Foundation

PO Box 824401

Philadelphia, PA 19182-4401

2020AD

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