"Advance Directive Form for Health Care With Special Provisions for Mental Health Conditions" - Virginia

Advance Directive Form for Health Care With Special Provisions for Mental Health Conditions is a legal document that was released by the Virginia Department of Health - a government authority operating within Virginia.

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VIRGINIA ADVANCE DIRECTIVE FOR HEALTH CARE
WITH SPECIAL PROVISIONS FOR MENTAL HEALTH CONDITIONS
I, ____________________________________________________________________________________, willingly and
voluntarily make known my wishes in the event that I am incapable of making an informed decision about my health
care, as follows:
(YOU MAY INCLUDE ANY OR ALL OF THE PROVISIONS IN SECTIONS I AND II BELOW.)
SECTION I: APPOINTMENT AND POWERS OF MY AGENT
(CROSS THROUGH THIS SECTION I IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE
HEALTH CARE DECISIONS FOR YOU.)
A. Appointment of My Agent
I hereby appoint _________________________________________________________________________________________
Name of Primary Agent
E-mail Address
________________________________________________________________________________________________________
Home Address
Telephone Number
as my agent to make health care decisions on my behalf as authorized in this document.
If the primary agent named above is not reasonably available or is unable or unwilling to act as my agent, then I appoint
as successor agent to serve in that capacity:
Name of Successor Agent
E-mail Address
Home Address
Telephone Number
I grant to my agent full authority to make health care decisions on my behalf as described below. My agent shall have
this authority whenever and for as long as I have been determined to be incapable of making an informed decision.
In making health care decisions on my behalf, I want my agent to follow my desires and preferences as stated in this
document or as otherwise known to him or her. If my agent cannot determine what health care choice I would have
made on my own behalf, then I want my agent to make a choice for me based upon what he or she believes to be in my
best interests.
B. Powers of My Agent
[IF YOU APPOINTED AN AGENT ABOVE, YOU MAY GIVE HIM/HER THE POWERS LISTED BELOW.
YOU MAY CROSS THROUGH ANY POWERS LISTED BELOW THAT YOU DO NOT WANT TO GIVE
YOUR AGENT AND ADD ANY ADDITIONAL POWERS YOU DO WANT TO GIVE YOUR AGENT.]
The powers of my agent shall include the following:
1. To consent to or refuse or withdraw consent to any type of health care, including, but not limited to, artificial
respiration (breathing machine), artificially administered nutrition (tube feeding) and hydration (IV fluids), and
cardiopulmonary resuscitation (CPR). This authorization specifically includes the power to consent to dosages of
pain-relieving medication in excess of recommended dosages in an amount sufficient to relieve pain. This applies
even if this medication carries the risk of addiction or of inadvertently hastening my death.
2. To request, receive and review any oral or written information regarding my physical or mental health, including but
not limited to medical and hospital records, and to consent to the disclosure of this information as necessary to carry
out my directions as stated in this advance directive.
3. To employ and discharge my health care providers.
—page 1 of 4—
VIRGINIA ADVANCE DIRECTIVE FOR HEALTH CARE
WITH SPECIAL PROVISIONS FOR MENTAL HEALTH CONDITIONS
I, ____________________________________________________________________________________, willingly and
voluntarily make known my wishes in the event that I am incapable of making an informed decision about my health
care, as follows:
(YOU MAY INCLUDE ANY OR ALL OF THE PROVISIONS IN SECTIONS I AND II BELOW.)
SECTION I: APPOINTMENT AND POWERS OF MY AGENT
(CROSS THROUGH THIS SECTION I IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE
HEALTH CARE DECISIONS FOR YOU.)
A. Appointment of My Agent
I hereby appoint _________________________________________________________________________________________
Name of Primary Agent
E-mail Address
________________________________________________________________________________________________________
Home Address
Telephone Number
as my agent to make health care decisions on my behalf as authorized in this document.
If the primary agent named above is not reasonably available or is unable or unwilling to act as my agent, then I appoint
as successor agent to serve in that capacity:
Name of Successor Agent
E-mail Address
Home Address
Telephone Number
I grant to my agent full authority to make health care decisions on my behalf as described below. My agent shall have
this authority whenever and for as long as I have been determined to be incapable of making an informed decision.
In making health care decisions on my behalf, I want my agent to follow my desires and preferences as stated in this
document or as otherwise known to him or her. If my agent cannot determine what health care choice I would have
made on my own behalf, then I want my agent to make a choice for me based upon what he or she believes to be in my
best interests.
B. Powers of My Agent
[IF YOU APPOINTED AN AGENT ABOVE, YOU MAY GIVE HIM/HER THE POWERS LISTED BELOW.
YOU MAY CROSS THROUGH ANY POWERS LISTED BELOW THAT YOU DO NOT WANT TO GIVE
YOUR AGENT AND ADD ANY ADDITIONAL POWERS YOU DO WANT TO GIVE YOUR AGENT.]
The powers of my agent shall include the following:
1. To consent to or refuse or withdraw consent to any type of health care, including, but not limited to, artificial
respiration (breathing machine), artificially administered nutrition (tube feeding) and hydration (IV fluids), and
cardiopulmonary resuscitation (CPR). This authorization specifically includes the power to consent to dosages of
pain-relieving medication in excess of recommended dosages in an amount sufficient to relieve pain. This applies
even if this medication carries the risk of addiction or of inadvertently hastening my death.
2. To request, receive and review any oral or written information regarding my physical or mental health, including but
not limited to medical and hospital records, and to consent to the disclosure of this information as necessary to carry
out my directions as stated in this advance directive.
3. To employ and discharge my health care providers.
—page 1 of 4—
4. To authorize my admission, transfer, or discharge to or from a hospital, hospice, nursing home, assisted living facility or
other medical care facility.
5. To authorize my admission to a health care facility for treatment of mental illness as permitted by law.
6. To continue to serve as my agent if I object to the agent’s authority after I have been determined to be incapable of making
an informed decision.
7. To authorize my participation in any health care study approved by an institutional review board or research review
committee according to applicable federal or state law if the study offers the prospect of direct therapeutic benefit to me.
8. To authorize my participation in any health care study approved by an institutional review board or research review
committee according to applicable federal or state law that aims to increase scientific understanding of any condition that I
may have or otherwise to promote human well-being, even though it offers no prospect of direct benefit to me.
9. To make decisions regarding visitation during any time that I am admitted to any health care facility, consistent with the
following directions:
________________________________________________________________________________________________________
10. To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability
to medical providers.
ADDITIONAL POWERS OR LIMITATIONS, IF ANY: __________________________________________________________
___________________________________________________________________________________________________________
C. Special Powers of My Agent to Authorize Health Care Over My Objection
This section includes my specific instructions about my health care if I am objecting to health care that my health care
agent and my physician believe I need.
(CROSS THROUGH ANY POWERS YOU DO NOT WANT TO GIVE YOUR AGENT.)
The powers of my agent shall include the following:
1. To authorize my admission to a health care facility for the treatment of mental illness as permitted by law, even if I
object.
2. To authorize other health care that is permitted by law and that my health care agent and my physician believe I
need, even if I object. This would include any type of health care unless I have indicated otherwise by my specific
instructions written elsewhere in this document or in the space below.
p I do not authorize these specific types of health care:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
[TO GIVE YOUR AGENT ANY OF THE POWERS SET FORTH IN THIS SUBSECTION C, YOUR PHYSICIAN
OR LICENSED CLINICAL PSYCHOLOGIST MUST SIGN THE STATEMENT IN THE BOX BELOW.]
I am a physician or licensed clinical psychologist familiar with the person who has made this advance directive for health
care. I attest that he or she is presently capable of making an informed decision and that he or she understands the
consequences of the special powers given to his/her agent by this Subsection C of this advance directive.
_________________________________________________________________________________________________________
Physician or Licensed Clinical Psychologist Signature
Date
_________________________________________________________________________________________________________
Physician or Licensed Clinical Psychologist Printed Name and Address
—page 2 of 4—
SECTION II: MY HEALTH CARE INSTRUCTIONS
[YOU MAY USE ANY OR ALL OF PARTS 1, 2 OR 3 IN THIS SECTION TO DIRECT YOUR HEALTH
CARE EVEN IF YOU DO NOT HAVE AN AGENT. IF YOU CHOOSE NOT TO PROVIDE WRITTEN
INSTRUCTIONS, DECISIONS WILL BE BASED ON YOUR VALUES AND WISHES, IF KNOWN, AND
OTHERWISE ON YOUR BEST INTERESTS. IF YOU ARE AN ORGAN, EYE OR TISSUE DONOR, YOUR
INSTRUCTIONS WILL BE APPLIED SO AS TO ENSURE THE MEDICAL SUITABILITY OF YOUR ORGANS,
EYES AND TISSUES FOR DONATION.]
1. I provide the following instructions in the event my attending physician determines that my death is imminent (very
close) and medical treatment will not help me recover:
[CHECK ONLY 1 BOX IN THIS PART 1.]
p I do not want any treatments to prolong my life. This includes tube feeding, IV fluids, cardiopulmonary
resuscitation (CPR), ventilator/respirator (breathing machine), kidney dialysis or antibiotics. I understand that I
still will receive treatment to relieve pain and make me comfortable. (OR)
p I want all treatments to prolong my life as long as possible within the limits of generally accepted health care
standards. I understand that I will receive treatment to relieve pain and make me comfortable. (OR)
p [YOU MAY WRITE HERE YOUR OWN INSTRUCTIONS ABOUT YOUR CARE WHEN YOU ARE
DYING, INCLUDING SPECIFIC INSTRUCTIONS ABOUT TREATMENTS THAT YOU DO WANT, IF
MEDICALLY APPROPRIATE, OR DON’T WANT. IT IS IMPORTANT THAT YOUR INSTRUCTIONS
HERE DO NOT CONFLICT WITH OTHER INSTRUCTIONS YOU HAVE GIVEN IN THIS ADVANCE
DIRECTIVE.]:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
2. I provide the following instructions if my condition makes me unaware of myself or my surroundings or unable to
interact with others, and it is reasonably certain that I will never recover this awareness or ability even with medical
treatment:
[CHECK ONLY 1 BOX IN THIS PART 2.]
p I do not want any treatments to prolong my life. This includes tube feeding, IV fluids, cardiopulmonary
resuscitation (CPR), ventilator/respirator (breathing machine), kidney dialysis or antibiotics. I understand that I
still will receive treatment to relieve pain and make me comfortable. (OR)
p I want all treatments to prolong my life as long as possible within the limits of generally accepted health care
standards. I understand that I will receive treatment to relieve pain and make me comfortable. (OR)
p I want to try treatments for a period of time in the hope of some improvement of my condition. I suggest
__________________________ as the period of time after which such treatment should be stopped if my condition
has not improved. Any agent or surrogate may specify the exact time period in consultation with my physician. I
understand that I still will receive treatment to relieve pain and make me comfortable. (OR)
p [YOU MAY WRITE HERE YOUR INSTRUCTIONS ABOUT YOUR CARE WHEN YOU ARE UNABLE
TO INTERACT WITH OTHERS AND ARE NOT EXPECTED TO RECOVER THIS ABILITY. THIS
INCLUDES SPECIFIC INSTRUCTIONS ABOUT TREATMENTS YOU DO WANT, IF MEDICALLY
APPROPRIATE, OR DO NOT WANT. IT IS IMPORTANT THAT YOUR INSTRUCTIONS HERE DO
NOT CONFLICT WITH OTHER INSTRUCTIONS YOU HAVE GIVEN IN THIS ADVANCE DIRECTIVE.]
______________________________________________________________________________________________________
______________________________________________________________________________________________________
—page 3 of 4—
3. I provide the following other instructions concerning my health care:
[YOU MAY WRITE HERE STATEMENTS AND INSTRUCTIONS ABOUT TREATMENTS THAT YOU
DO WANT, IF MEDICALLY APPROPRIATE, OR ABOUT TREATMENTS YOU DO NOT WANT
UNDER SPECIFIC CIRCUMSTANCES OR ANY CIRCUMSTANCES. IT IS IMPORTANT THAT YOUR
INSTRUCTIONS HERE DO NOT CONFLICT WITH OTHER INSTRUCTIONS YOU HAVE GIVEN IN THIS
ADVANCE DIRECTIVE.]
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4. [INSTEAD OF WRITING INSTRUCTIONS ON THIS FORM, YOU MAY DIRECT THAT YOUR MENTAL
HEALTH CARE BE PROVIDED IN ACCORDANCE WITH A CRISIS PLAN. IF YOU HAVE PREPARED A
CRISIS PLAN, CHECK THE FOLLOWING BOX AND ATTACH THE CRISIS PLAN TO THIS DOCUMENT.]
p I direct that my mental health care be provided in conformity with the preferences I have expressed in the
accompanying crisis plan to the extent authorized by law.
SECTION III: ANATOMICAL GIFTS
(YOU MAY USE THIS DOCUMENT TO RECORD YOUR DECISION TO DONATE YOUR ORGANS, EYES
AND TISSUES OR YOUR WHOLE BODY AFTER YOUR DEATH. IF YOU DO NOT MAKE THIS DECISION
HERE OR IN ANY OTHER DOCUMENT, YOUR AGENT CAN MAKE THE DECISION FOR YOU UNLESS
YOU SPECIFICALLY PROHIBIT HIM/HER FROM DOING SO, WHICH YOU MAY DO IN THIS OR SOME
OTHER DOCUMENT. CHECK ONE OF THE BOXES BELOW IF YOU WISH TO USE THIS SECTION TO
MAKE YOUR DONATION DECISION.)
p I donate my organs, eyes and tissues for use in transplantation, therapy, research and education. I direct that all
necessary measures be taken to ensure the medical suitability of my organs, eyes or tissues for donation. I understand
that I may register my directions at the Department of Motor Vehicles or directly on the donor registry, www.
DonateLifeVirginia.org, and that I may use the donor registry to amend or revoke my directions; OR
p I donate my whole body for research and education.
[Write here any specific instructions you wish to give about anatomical gifts.]
______________________________________________________________________________________________________
______________________________________________________________________________________________________
AFFIRMATION AND RIGHT TO REVOKE:
By signing below, I indicate that I understand this document and that
I am willingly and voluntarily executing it. I also understand that I may revoke all or any part of it at any time as provided by
law.
___________________________________________________________________________________________________________
Date
Signature of Declarant
The declarant signed the foregoing advance directive in my presence. [TWO ADULT WITNESSES NEEDED]
______________________________________________________ ____________________________________________________
Witness Signature
Witness Printed
______________________________________________________ ____________________________________________________
Witness Signature
Witness Printed
This form satisfies the requirements of Virginia's Health Care Decisions Act. If you have legal questions about this form or would like to develop a
different form to meet your particular needs, you should talk with an attorney. It is your responsibility to provide a copy of your advance directive to
your treating physician. You also should provide copies to your agent, close relatives and/or friends. For information on storing this advance directive in
the free Virginia Advance Health Directive Registry, go to http://www.VirginiaRegistry.org. This form is provided by the Virginia Hospital & Healthcare
Association as a service to its members and the public. (June 2012, www.vhha.com) seg
—page 4 of 4—
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