Fill - Free fillable MISSOURI Advance Directive Planning for Important Health Care PDF form

MISSOURI

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. 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 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.

INTRODUCTION TO YOUR MISSOURI ADVANCE DIRECTIVE

This packet contains a legal document, a Missouri Advance Directive, that 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. You may fill out

Part I, Part II, or both depending on your advance-planning needs. You must fill out

Part IV.

Part I, Durable Power of Attorney for Health Care Choices, lets you name

someone (an agent, sometimes called an attorney in fact) to make decisions about your

health care. Depending on how you fill out your form, this part becomes effective

either immediately or when your doctor and one other doctor certify that you are

unable by reason of any physical or mental condition to receive and evaluate health

care treatment information or to communicate health care decisions. You may choose

to have one physician, instead of two, determine whether you are incapacitated (unable

to make health care decisions) by initialing the statement in Part I.

Part II is a Health Care Choices Directive. This is similar to a living will, although

this form—which is based on the form created by the Missouri Attorney General—allows

you to make a broader range of decisions than allowed by Missouri’s statutory living

will. Part II lets you state your wishes about health care in the event that you can no

longer speak for yourself. Specifically, Part II allows you to choose specific treatments

that you wish to be withheld or withdrawn in the event you have a terminal illness or

are persistently unconscious. Part II also allows you to make choices regarding organ

donation and includes space for you to add additional instructions and describe your

feelings regarding what constitutes an acceptable quality of life. Your Health Care

Choices Directive becomes effective when you can no longer make or communicate

your health care decisions.

Part III describes the relationship between Part I and Part II.

Part IV contains the signature and witnessing provisions so that your document will be

effective.

This form does not expressly address mental illness. If you would like to make advance

care plans regarding mental illness, you should talk to your physician and an attorney

about a durable power of attorney tailored to your needs.

Note: These

documents

will be legally

binding

only if the

person completing

them is a

competent

adult (at least 18 years old).

COMPLETING YOUR MISSOURI ADVANCE DIRECTIVE

How do I make my Missouri Advance Directive Legal?

In order for Part I to be effective, you must have your signature notarized.

In order for Part II to be effective, you must sign and date your Missouri Advance

Directive in the presence of two witnesses who are 18 years or older, neither of whom

can be a person signing on your behalf if you are physically unable to sign for yourself.

If you fill out both Part I and Part II, you will need to have your signature both

witnessed and notarized.

Who should I pick as my Agent?

Your agent is the person you appoint to make decisions about your health care if you

become unable to make those decisions yourself. Your agent may be a family member

or a close friend whom you trust to make serious decisions. The person you name as

your agent should clearly understand your wishes and be willing to accept the

responsibility of making health care decisions for you.

Your agent may not be your physician or an employee of your physician, or an owner,

operator, or employee of the health care facility in which you reside, unless the person

is your spouse, parent, child, grandparent, sibling, or grandchild.

You can appoint a second person as your alternate agent. The alternate will step in if

the first person you name as an agent is unable, unwilling, or unavailable to act for you.

Should I add other instructions to my Missouri Advance Directive?

One of the strongest reasons for naming an agent is to have someone who can respond

flexibly as your health care situation changes and deal with situations that you did not

foresee. If you add instructions to this document it may help your agent 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 agent 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

Missouri Advance Directive

at any time and in any manner that

reflects your intent to revoke. Examples of revocation include tearing your document,

orally stating your intent to revoke, or executing a written revocation.

Part II is revoked automatically when you revoke, but revocation of your agent’s powers

(Part I) becomes effective only once you notify your agent or your physician or treating

health care provider. In any event, it is a good idea to tell your agent and your

physician or other treating health care provider about your decision to revoke.

Executing a new advance directive that appoints an agent will automatically revoke your

agent's authority.

Unless your

Missouri Advance Directive

expressly provides otherwise, if you have

appointed your spouse as your agent, filing of any action for divorce or dissolution of

your marriage automatically terminates your spouse’s authority as your agent.

What other important facts should I know?

Your agent can refuse or withdraw artificial nutrition and hydration on your behalf only

if you specifically grant such authority. In order to grant this authority, you must initial

the line next to this treatment in Part II.

Before your agent may authorize withdrawal of artificial nutrition or hydration, your

physician must:

•

Attempt to explain the intent to withdraw artificial nutrition or hydration and the

consequences of withdrawal to you and give you an opportunity to refuse

withdrawal; or

•

Certify that you are comatose or consistently in a condition which makes it

impossible for you to understand the intent to withdraw artificial nutrition and

hydration and the consequences of withdrawal.

Any directions you give to withhold or withdraw treatments will not be given effect in the

event you are pregnant.

MISSOURI ADVANCE DIRECTIVE – PAGE 1 OF 6

Part I. Durable Power of Attorney for Health Care Choices

PRINT YOUR NAME

PRINT YOUR

AGENT'S NAME AND

ADDRESS

PRINT YOUR

ALTERNATE

AGENT'S NAME AND

ADDRESS

INITIAL

HERE IF

YOU WANT TO

ALLOW ONLY ONE

PHYSICIAN TO

DETERMINE

WHETHER YOU ARE

INCAPACITATED

Hospice and

Palliative Care

Organization

2020 Revised.

I, , appoint

Name:

Address:

as my agent for health care choices when I am unable to make decisions

or communicate my wishes. In the case the person above cannot serve as

my agent, or if I am divorced from or legally separated from the agent

above, I appoint the person below:

Name: Address:

This alternate agent may make health care decisions for me when I am

unable to do so or to communicate my wishes.

This durable power of attorney becomes effective when two physicians

certify that I am incapacitated and unable to make and communicate

health care choices.

You may choose to have one physician, instead of two, determine

whether you are incapacitated. If you want to exercise this option —

allowing one physician to determine whether you are incapacitated —

initial here.

MISSOURI ADVANCE DIRECTIVE – PAGE 2 OF 6

By completing this durable power of attorney, I authorize my agent to

make all decisions for me regarding my health care. This includes the

power to:

IF YOU DON'T

WANT YOUR AGENT

TO HAVE ANY OF

THESE POWERS

DRAW A LINE

THROUGH THE

PROVISION AND

INITIAL NEXT TO IT

YOUR AGENT MAY

AVE A CLAIM

AGAINST YOUR

ESTATE FOR

REASONABLE

EXPENSES THAT

ARE PART OF YOUR

CARE

Hospice and

Palliative Care

Organization

2020 Revised.

•

Consent, refuse or withdraw consent to artificially supplied nutrition

and hydration.

•

Make all necessary arrangements for health care on my behalf.

This includes admitting me to any hospital, psychiatric treatment

facility, hospice, nursing home or other health care facility.

•

Hire or fire health care personnel on my behalf.

•

Request, receive and review my medical and hospital records.

•

Take legal action if necessary to do what I have directed.

•

Carry out my wishes regarding autopsy and organ donation, and

decide what should be done with my body.

My agent under this durable power of attorney will not incur any personal

financial liability. The agent also should not be compensated for services

performed for me. However, the agent shall be reimbursed for reasonable

expenses that are part of my care.

THIS IS A DURABLE POWER OF ATTORNEY AND THE AUTHORITY OF MY

ATTORNEY IN FACT, WHEN EFFECTIVE, SHALL NOT TERMINATE OR BE

VOID OR VOIDABLE IF I AM OR BECOME DISABLED OR INCAPACITATED

OR IN THE EVENT OF LATER UNCERTAINTY AS TO WHETHER I AM DEAD

OR ALIVE.

MISSOURI ADVANCE DIRECTIVE – PAGE 3 OF 6

Part II. Health Care Choices Directive

I want those involved in my health care to understand my wishes if I

cannot communicate or make decisions on my own. I make this directive to

provide clear and convincing proof of my wishes and instructions about my

health care and treatment. If my doctor believes medical treatment will

lead to my recovery, I want to have the treatment. I also want to have

care and treatment for pain or discomfort even if this treatment might

shorten my life, affect my appetite, slow my breathing or be habit-forming.

If I have a terminal illness or condition and there is no reasonable hope I

will recover, or if I am persistently unconscious, I direct all of the life-

prolonging procedures I have initialed below to be withheld or withdrawn. I

direct the following treatments to be withheld or withdrawn: (initial all that

apply)

Surgery or other invasive procedures

Cardiopulmonary resuscitation (CPR) to restart my heart or

breathing

Antibiotics

Dialysis

Mechanical ventilator (respirator)

INITIAL ALL

TREATMENTS THAT

YOU WANT TO BE

WITHHELD OR

WITHDRAWN IN

THE EVENT YOU

ARE TERMINALLY

ILL OR

PERMANENTLY

ONSCIOUS

INITIAL YOUR

ORGAN DONATION

PREFERENCE

@ 2005 National

Hospice and

Palliative Care

Organization 2020

Revised.

Artificially supplied nutrition and hydration (including tube feeding)

Chemotherapy

Radiation therapy

All other “life-prolonging” medical treatments or surgeries that are

merely intended to keep me alive without reasonable hope of

making me better or curing my illness or injury.

Organ Donation Choices (initial only one)

I consent to the donation of my organs or tissues. I realize my

body may need to be maintained artificially after my death until my

organs can be removed.

I refuse to make anatomical gifts of part or all of my body. I prohibit

my agent from consenting to such gifts before or after my death.

MISSOURI ADVANCE DIRECTIVE – PAGE 4 OF 6

I also give the following directions regarding my health care:

Attach extra pages if necessary. Sign and date the attached pages.

Optional: Describe what you consider an acceptable quality of life. For

example, being able to recognize my loved ones, make decisions,

communicate or feed yourself.

Attach extra pages if necessary. Sign and date the attached pages.

ADD OTHER

INSTRUCTIONS, IF

ANY, REGARDING

YOUR ADVANCE

CARE PLANS

THESE

INSTRUCTIONS CAN

FURTHER ADDRESS

YOUR HEALTH CARE

PLANS, SUCH

YOUR

WISHES

REGARDING

HOSPICE

TREATMENT, BUT

CAN ALSO ADDRESS

OTHER ADVANCE

PLANNING ISSUES,

SUCH AS YOUR

BURIAL WISHES

ATTACH

ADDITIONAL PAGES

IF NEEDED

OPTIONAL

DESCRIBE YOUR

IDEA OF

ACCEPTABLE

QUALITY OF LIFE

Hospice and

Palliative Care

Organization

2020 Revised.

Make sure to talk about this directive and your wishes with your agent,

your doctors, family, friends and clergy. Give each of them a copy of the

directive. Bring a copy with you when you go to a hospital or other health

care facility. Keep the original with your important papers.

MISSOURI ADVANCE DIRECTIVE – PAGE 5 OF 6

Part III. Relationship Between Health Care Choices Directive and

Durable Power of Attorney for Health Care Choices

This Part is effective only if I have completed Part I and Part II.

THIS PART

DESCRIBES THE

RELATIONSHIP

BETWEEN PARTS I

AND II IN THE

EVENT YOU FILL

OUT BOTH PARTS

IF YOU DISAGREE

WITH THIS

RELATIONSHIP,

YOU MAY WANT TO

ONLY FILL OUT ONE

PART OR TALK TO

AN ATTORNEY

ABOUT AN

ADVANCE

DIRECTIVE

TAILORED TO YOUR

NEEDS

Hospice and

Palliative Care

Organization

2020 Revised.

As I have executed the health care choices directive and durable power of

attorney for health care choices, I trust and encourage my agent to:

•

First, follow my wishes as expressed in the directive or otherwise

from knowledge about me or having had discussions with me about

making choices regarding life-prolonging medical treatment.

•

Second, if my agent does not know my wishes for a specific

decision, but my agent has evidence of what I might want, my

agent can try to figure out how I would decide. This is called

substituted judgment and requires my agent imagining himself or

herself in my position. My agent should consider my values,

religious beliefs, past choices and past statements I have made.

The aim is to choose as I probably would choose, even if it is not

what my agent would choose for himself or herself.

•

Third, if my agent has very little or no knowledge of what I would

want, then my agent and the doctors will have to make a decision

based on what a reasonable person in the same situation would

decide. This is called making decisions in my best interest. I have

confidence in my agent’s ability to make decisions in my best

interest if my agent does not have enough information to follow my

preferences or use substituted judgment, and if this is the case, I

authorize my agent to make decisions that might even be contrary

to my directive in his or her best judgment.

•

Finally, if the durable power of attorney for health care choices is

determined to be ineffective, or if my agent is unable to serve, the

health care choices directive is intended to be used on its own as

firm instructions to my health care providers regarding life-

prolonging procedures.

MISSOURI ADVANCE DIRECTIVE – PAGE 6 OF 6

DATE YOUR

DOCUMENT

SIGN HERE AND

PRINT YOUR NAME

AND ADDRESS

Part IV. Execution

IN WITNESS THEREOF, I have executed this document on this day of

, in the year of .

Signature:

Print name:

Address:

If you filled out Part II, you must have your

signature witnessed

by two people

who are at least 18 years of age.

The person who signed this document is of sound mind and voluntarily signed

this document in our presence. Each of the undersigned witnesses is at least 18

years of age.

Witness #1

Signature:

Print name:

Address:

Witness #2

Signature:

Print name:

Address:

If you filled out Part I, you must

have

your

advance directive

notarized.

STATE OF MISSOURI )

) SS

COUNTY OF )

On this day of , in the year of ,

personally appeared before me the person signing, known by me to be the

person who completed this document and acknowledged it as his/her free act

and deed.

IN WITNESS WHEREOF, I have set my hand and affixed my official seal in the

County

of , State of Missouri, the day and year first above

written.

IF YOU FILLED OUT

PART II, YOUR

WITNESSES MUST

SIGN AND PRINT

THEIR NAMES AND

ADDRESSES HERE

A NOTARY MUST

FILL OUT THIS

SECTION IF YOU

FILLED OUT PART I

NOTE: YOU MUST

HAVE YOUR

DOCUMENT BOTH

NOTARIZED AND

SIGNED BY TWO

WITNESSES IF YOU

FILLED OUT PARTS

I AND II

Hospice

and

Palliative Care

Organization

2020

Revised.

Notary public’s signature Notary seal

Courtesy

CaringInfo

1731 King St., Suite 100,

Alexandria,

22314

www.caringinfo.org, 800

658-8898

You Have Filled Out Your Health Care Directive, Now What?

1. Your

Missouri 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 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 Missouri document.

7. Be aware that your Missouri 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 these 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.

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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

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