The Utah Advance Health Care Directive is a legal document that allows individuals to outline their health care preferences and appoint someone to make medical decisions on their behalf if they become unable to do so. This directive not only empowers your chosen agent to act in your best interest but also provides a platform for you to express your specific health care wishes. Understanding and completing this form is crucial for ensuring that your medical care aligns with your values and desires.
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The Utah Advance Health Care Directive is a vital tool that empowers individuals to make their health care preferences known, particularly in situations where they may be unable to communicate their wishes. This directive is divided into four key parts, each serving a distinct purpose. The first part allows individuals to appoint an agent, someone they trust to make health care decisions on their behalf if they lose the capacity to do so. In the second part, individuals can articulate their specific health care wishes, ensuring that their values and preferences guide the care they receive. The third part outlines the process for revoking or modifying the directive, providing flexibility should circumstances change. Finally, the fourth part solidifies the legal standing of the directive, ensuring that it is recognized and respected by health care providers. By completing this form, individuals can take proactive steps to safeguard their health care choices and alleviate the burden on loved ones during difficult times.
UTAH ADVANCE HEALTH CARE DIRECTIVE
(Pursuant to Utah Code Section 75-2a-117)
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 the form.
Part IV: Makes your directive legal.
MY PERSONAL INFORMATION
Name:
Street Address:
City, State, Zip Code:
Telephone:
Cell Phone:
Birth date:
PART I: MY AGENT (HEALTH CARE POWER OF ATTORNEY)
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.
(Initial)
B.My Agent
Agent's Name:
Home phone:
Work phone:
C.Alternate Agent.
This person will serve as your agent if your agent, named above, is unable or unwilling to serve.
Alternate Agent's Name:
D.Agent's Authority
If I cannot make decisions or speak for myself (in other words, after my physician or
APRN 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 and 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.
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.
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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.
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 become
incapacitated.
H.Consent to Participate in Medical Research
I authorize my agent to consent to my participation in
medical research or clinical trials, even if I may not benefit
from the results.
I.
Organ Donation
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.
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.
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Option 1
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: ________________________________________________________
Option 2
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.
Other: _____________________________________________________________________
Option 3
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.
(a) I put no limit on the ability of my health care provider or
agent to withhold or withdraw life-sustaining care.
If you selected (a), above, do not choose any options under (b).
(b) My health care provider should withhold or withdraw
life-sustaining care if at least one of the following initialed
conditions is met:
_____
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
(Initial) unlikely that my condition will improve.
I am in a persistent vegetative state.
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Option 4
_______ I do not wish to express preferences about health care wishes in this
(Initial) directive.
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:
1.Writing "void" across the form, or burning, tearing, or otherwise destroying or defacing this document or directing another person to do the same on my behalf;
2.Signing a written revocation of the directive, or directing another person to sign a revocation on my behalf;
3.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
4.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
Print name: ________________________
___________________________________________________________________________
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;
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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 Code
If the witness is signing to confirm an oral directive, describe below the circumstances under which the directive was made.
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