Fill - Free fillable Utah Advance Health Care Directive PDF form

Part I: Allows you to name another person to make health care decisions for you when you

cannot make decisions or speak for yourself.

Part II: Allows you to record your wishes about health care in writing.

Part III: Tells you how to revoke or change this directive.

Part IV: Makes your directive legal.

C. My Alternate Agent

This person will serve as your agent if your agent, named above, is unable or unwilling to serve.

Alternate Agent’s Name: _______________________________________________________________

Street Address: _______________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________

Work Phone: (_______) _____________________

Part I: My Agent (Health Care Power of Attorney)

Page 1 of 4

My Personal Information

Utah Advance Health Care Directive

(

Pursuant to Utah Code Section 75-2a-117

ective 2009

)

Name: ______________________________________________________________________________

Street Address: _______________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Telephone: (_______) _____________________ Cell Phone: (_______) _____________________

Birth Date: ____________________________

B. My Agent

Agent’s Name: _______________________________________________________________________

Street Address: _______________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________

Work Phone: (_______) _____________________

A. No Agent

If you do not want to name an agent, initial the box below, then go to Part II; do not name an agent in B

or C below. No one can force you to name an agent.

I do not want to choose an agent.

D. Agent’s Authority

If I cannot make decisions or speak for myself (in other words, after my physician or another authorized provider

finds that I lack health care decision making capacity under Section 75-2a-104 of the Advance Health Care

Directive Act), my agent has the power to make any health care decision I could have made such as, but not

limited to:

 Consent to, refuse, or withdraw any health care. This may include care to prolong my life such as food and

fluids by tube, use of antibiotics, CPR (cardiopulmonary resuscitation), and dialysis, and mental health care,

such as convulsive therapy and psychoactive medications. This authority is subject to any limits in

paragraph F of Part I or in Part II of this directive.

 Hire and fire health care providers.

 Ask questions and get answers from health care providers.

 Consent to admission or transfer to a health care provider or health care facility, including a mental health

facility, subject to any limits in paragraphs E or F of Part I.

 Get copies of my medical records.

 Ask for consultations or second opinions.

My agent cannot force health care against my will, even if a physician has found that I lack health care decision

making capacity.

E. Other Authority

My agent has the powers below only if I initial the “yes” option that precedes the statement. I authorize my agent to:

____YES ____ NO Get copies of my medical records at any time, even when I can speak for myself.

____YES ____ NO Admit me to a licensed health care facility, such as a hospital, nursing home, assisted living,

or other facility for long-term placement other than convalescent or recuperative care.

F. Limits/Expansion of Authority

I wish to limit or expand the powers of my health care agent as follows:

_____________________________________________________________________________________________________

G. Nomination of Guardian

Even though appointing an agent should help you avoid a guardianship, a guardianship may still be necessary.

Initial the "YES" option if you want the court to appoint your agent or, if your agent is unable or unwilling to

serve, your alternate agent, to serve as your guardian, if a guardianship is ever necessary.

____YES ____ NO I, being of sound mind and not acting under duress, fraud, or other undue influence, do hereby

nominate my agent, or if my agent is unable or unwilling to serve, I hereby nominate my

alternate agent, to serve as my guardian in the event that, after the date of this instrument, I

ecome inca

acitated.

Name: ______________________________________________ Page 2 of 4

Part I: My Agent (continued)

I. Organ Donation

____YES ____ NO If I have not otherwise agreed to organ donation, my agent may consent to the donation of my

organs for the purpose of organ transplantation.

H. Consent to Participate in Medical Research

____YES ____ NO I authorize my agent to consent to my participation in medical research or clinical trials, even

if I may not benefit from the results.

Part II: My Health Care Wishes (Living Will)

I want my health care providers to follow the instructions I give them when I am being treated, even if my instructions conflict

with these or other advance directives. My health care providers should always provide health care to keep me as comfortable

and functional as possible.

Choose only one of the following options, numbered Option 1 through Option 4, by placing your initials before the numbered

statement. Do not initial more than one option. If you do not wish to document end-of-life wishes, initial Option 4. You may

choose to draw a line through the options that you are not choosing.

Option 3

Initial

I choose not to receive care for the purpose of prolonging life, including food and fluids by tube, antibiotics

CPR, or dialysis being used to prolong my life. I always want comfort care and routine medical care that will

keep me as comfortable and functional as possible, even if that care may prolong my life.

If you choose this option, you must also choose either (a) or (b), below

Initial

(a) I put no limit on the ability of my health care provider or agent to withhold or withdraw life-

sustaining care.

Initial

(b) My health care provider should withhold or withdraw life-sustaining care if at least one of the

initialed conditions is met:

If you

selected

(a), above,

do not

choose any

options

under (b).

I have a progressive illness that will cause death

I am close to death and am unlikely to recover

I cannot communicate and it is unlikely that my condition will improve

I do not recognize my friends or family and it is unlikely that my condition will improve

I am in a persistent vegetative state

Additional comments:

Option 4

Initial

I do not wish to express preferences about health care wishes in this directive.

Additional comments

Name: ______________________________________________ Page 3 of 4

Option 2

Initial

I choose to prolong life. Regardless of my condition or prognosis, I want my health care team to try to

prolong my life as long as possible within the limits of generally accepted health care standards.

Additional comments:

Option 1

Initial

I choose to let my agent decide. I have chosen my agent carefully. I have talked with my agent about my

health care wishes. I trust my agent to make the health care decisions for me that I would make under the

circumstances.

Additional comments:

Name: ______________________________________________ Page 4 of 4

Part II: My Health Care Wishes (continued)

Additional instructions about your health care wishes:

________________________________________________________________________________________________________

If you do not want emergency medical service providers to provide CPR or other life sustaining measures, you must work with a

physician or APRN to complete an order that reflects your wishes on a form approved by the Utah Department of Health.

Part III: Revoking or Changing a Directive

I may revoke or change this directive by:

 Writing “void” across the form, burning, tearing, or otherwise destroying or defacing this document or directing another

person to do the same on my behalf;

 Signing a written revocation of the directive, or directing another person to sign a revocation on my behalf;

 Stating that I wish to revoke the directive in the presence of a witness who: is 18 years of age or older; will not be

appointed as my agent in a substitute directive; will not become a default surrogate if the directive is revoked; and signs

and dates a written document confirming my statement; or

 Signing a new directive. (If you sign more than one Advance Health Care Directive, the most recent one applies.)

Part IV: Making My Directive Legal

I sign this directive voluntarily. I understand the choices I have made and declare that I am emotionally and mentally competent

to make this directive. My signature on this form revokes any living will or power of attorney form naming a health care agent

that I have completed in the past.

______________________________ __________________________________________________________________

Date Signature

________________________________________________

City, County, and State of Residence

I have witnessed the signing of this directive, I am 18 years of age or older, and I am not:

1. Related to the declarant by blood or marriage;

2. Entitled to any portion of the declarant's estate according to the laws of intestate succession of any state or jurisdiction or

under any will or codicil of the declarant,

3. A beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transfer or death deed that is held,

owned, made, or established by, or on behalf of, the declarant;

4. Entitled to benefit financially upon the death of the declarant;

5. Entitled to a right to, or interest in, real or personal property upon the death of the declarant;

6. Directly financially responsible for the declarant's medical care;

7. A health care provider who is providing care to the declarant or an administrator at a health care facility in which the

declarant is receiving care; or

8. The appointed agent or alternate agent.

_________________________________________________ _________________________________________________

Signature of Witness Printed Name of Witness

_________________________________________________ ______________________ _________ _____________

Street Address City State Zip

If the witness is signing to confirm an oral directive, describe below the circumstances under which the directive was made.

________________________________________________________________________________________________________

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