Page 1. compassion & choices Care and Choice at the End of Life. Advance Directive. Planning for Important Healthcare Decisions.

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1 Page 1 cmpassin & chices Care and Chice at the End f Life. Advance Directive Planning fr Imprtant Healthcare Decisins Clrad

2 SECTION (1) INTRODUCTION TO YOUR COLORADO ADVANCE DIRECTIVES FOR HEALTHCARE Every adult needs Advance Directives fr healthcare. Regardless f age, regardless f health, nne f us knws when a future event might leave us unable t speak fr urselves. If yu becme unable t make r cmmunicate decisins abut yur medical treatment, a written recrd f yur healthcare wishes wuld prve invaluable. WHAT ARE ADVANCE DIRECTIVES FOR HEALTHCARE? Advance Directives are a generic term used fr dcuments that traditinally include a Living Will (a Clrad Declaratin as t Medical r Surgical Treatment), a Medical Durable Pwer f Attrney (MDPOA), Cardipulmnary Resuscitatin (CPR) Directives and Medical Orders fr Scpe f Treatment (MOST). The Living Will prtin f an Advance Directive is a place fr yu t specify what kinds f treatment and care yu wuld r wuld nt want if yu were unable t speak fr yurself. This dcument allws yu t prvide instructins relating t yur future healthcare, such as when yu wish t receive medical treatment r when yu wish t stp r refuse life-sustaining medical treatments. The Medical Durable Pwer f Attrney allws yu t appint smene (an Agent ) t act n yur behalf in matters cncerning yur healthcare when yu are unable t speak fr yurself due t illness r incapacitatin. CPR Directives and MOST will be described in detail later. WHY ARE THEY USEFUL? Advance Directives help yu t maintain cntrl ver healthcare decisins that are imprtant t yu when yu are unable t make r cmmunicate decisins due t any temprary r permanent injury r illness. They allw yu t express yur wishes abut any aspect f yur healthcare, including decisins abut life-sustaining treatment. They als allw yu t chse a persn t speak n yur behalf and cmmunicate yur decisins when yu are nt able t d s. Appinting an agent and making sure yur agent is aware f and understands yur wishes is ne f the mst imprtant things yu can d. If the time cmes fr a decisin t be made, yur agent can participate in relevant discussins, weighing the prs and cns f treatment decisins based n yur wishes. Yur agent can make healthcare decisins n yur behalf whenever yu cannt d s fr yurself, even if yur decisin-making capacity is nly temprarily affected. Anther imprtant cnsideratin is yur family: Advance Directives help relieve the stress and duress assciated with having t make imprtant healthcare decisins n behalf f smene they care abut. By making yur wishes knwn in advance, yu help yur 1

3 family and friends knw what yu wuld want dne. Otherwise they may struggle t decide n their wn. ARE ADVANCE DIRECTIVES FOR HEALTHCARE LEGALLY VALID IN EVERY STATE? Yes, Advance Directives are legally valid in every state. Each state (and the District f Clumbia) has laws that permit individuals t sign dcuments stating their wishes abut healthcare decisins when they cannt speak fr themselves. The specifics f these laws vary, but the basic principle f listening t the patient s wishes is the same everywhere. The law gives great weight t any frm f written directive. If the curts becme invlved, they usually try t fllw the patient s stated values and preferences, especially if they are in written frm. An Advance Directive fr healthcare may be the mst cnvincing evidence f yur wishes yu can create. It is imprtant t nte that while it is legal t have an Advance Directive in every state, n current law requires that they be strictly hnred by healthcare prfessinals. Mst states have reciprcity in their statutes regarding medical durable pwer f attrney. HOW DO I MAKE ADVANCE DIRECTIVES FOR HEALTHCARE? Yu d nt need a lawyer t cmplete yur Advance Directives. Hwever, a lawyer may be helpful if yur family situatin is cmplex r if yu expect prblems t arise. If yu wish, yu can start by making a cpy f the MDPOA and Living Will beginning n page 7. If there are prtins f this dcument with which yu disagree, it is legally acceptable fr yu t crss them ut and write yur initials in the margin. The next step wuld be t share and discuss yur Advance Directives with yur agent(s) as well as ther trusted friends r relatives. Yur primary healthcare prviders are als imprtant participants t include in the creatin f yur Advance Directive. Based n yur medical histry and yur current health, discuss the types f medical prblems yu may face. Yur prvider can help yu t better understand ptential treatment ptins. Make sure yur prvider clearly understands yur treatment wishes and gals. Cmpassin & Chices prvides up-t-date state-specific infrmatin abut Advance Directives. Take the time t cnsider what is imprtant t yu and seek advice s that yur Advance Directive reflects yur beliefs. If yu wuld like help cmpleting yur Advance Directive fr healthcare, call Cmpassin & Chices at Clrad law requires that yu sign yur Living Will in the presence f tw witnesses. These witnesses must als sign yur Living Will. In Clrad, yur MDPOA des nt have t be signed, but sme ther states require signatures. We have thus cmbined the Living Will with the MDPOA s that yu need nly ne set f signatures fr bth 2

4 dcuments. Yur witnesses must be at least 18 years ld and cannt be any f the fllwing: entitled t any prtin f yur estate under yur last will and testament r by peratin f law, yur attending healthcare prfessinal r any ther treating healthcare prfessinal, r an emplyee f yur attending healthcare prfessinal r treating healthcare facility. At this time, it is nt required t have these dcuments ntarized in Clrad. Hwever, ntarizatin will assist in interstate reciprcity, as well as emphasizing the legality f the dcuments. IF I CHANGE MY MIND, CAN I CHANGE OR CANCEL MY ADVANCE DIRECTIVE FOR HEALTHCARE? Yes, yu can change r cancel yur Advance Directives at any time. Yu can d this by ntifying yur agent and/r healthcare prvider in writing f yur decisin t d s. It is best t destry all cpies f yur ld Advance Directive and create a new ne. Make sure t prvide cpies f yur new frm t the apprpriate individuals. Cmpassin & Chices recmmends that yu peridically review yur Advance Directives and re-sign and date them t indicate that this dcuments cntinues t reflect yur wishes. WHO SHOULD BE MY AGENT? One f the mst imprtant things yu can d is t appint an agent t speak fr yu if and when yu are ever unable t d s fr yurself. An agent has great pwer ver yur healthcare and shuld be carefully chsen. In nrmal circumstances, n ne will be mnitring yur agent and his/her decisins. T help avid disagreements, we recmmend selecting ne primary agent and at least ne alternate agent. Yur alternate agent wuld speak n yur behalf if yur primary agent were unwilling r unable t speak fr yu. Yur agent must agree t serve in this rle. It might be imprtant t specify that yur healthcare agent bears n financial burden r liability if he/she agrees. Agents must be 18 r lder, and have decisinal capacity. If the agent is a spuse and the cuple later divrces, legally separates r annuls the marriage, the agent is autmatically remved unless therwise expressly stated in the dcument. Befre deciding n an agent (and alternatives), ask yurself: Are they assertive? Will they be able t make difficult and pssibly emtinal decisins? D they live nearby? Are they cmfrtable talking abut death? Will they respect my values and wishes? Then, talk t them. Share yur wishes and make sure they clearly understand what is imprtant t yu. G ver the medical-directive sectin f yur Living Will with them. Cnfirm their willingness t speak n yur behalf. Take int cnsideratin that yur children r yur parents may nt necessarily be the best chices t be yur agents. It is ften very emtinally difficult fr intimate relatives t allw their clse nes t die, even thugh they intellectually may agree with yur Living Will. In Clrad, because we have n default surrgate decisin-makers, it really is essential t appint an agent. In additin t family, think abut friends, clleagues, clergy, r 3

5 prfessinal advisrs. If yu cannt think f anyne, cntact Cmpassin & Chices at fr help in lcating an agent. If yu d nt appint an agent, and yur healthcare prvider (r a curt) determines that yu lack decisinal capacity, then a prxy fr healthcare will be appinted. In rder t accmplish this, a search will be cnducted t lcate an interested party such as a family member, friend, r advisr. Again, if yu cannt think f anyne t appint, cntact Cmpassin & Chices at fr help in lcating an agent. HOW CAN I MAKE SURE HEALTHCARE PROVIDERS WILL FOLLOW MY ADVANCE DIRECTIVES? Currently, there are n state laws that blige medical persnnel t hnr yur Advance Directives. Sme healthcare prviders have values and pinins that d nt agree with the wishes yu have expressed n either ethical r medical grunds. Because f this, they may nt want t fllw the directins yu have prvided. Clrad law allws dctrs r healthcare facilities t refuse t hnr yur Advance Directive n cnscience grunds. Hwever, they must help yu find anther healthcare prfessinal, r facility, willing t hnr yur wishes. While this is rare, it is imprtant t be aware f its ptential. T help avid this situatin, talk t yur healthcare prviders ahead f time. Make sure they understand yur wishes and are familiar with yur Advance Directive dcuments. And make sure they are willing t hnr them. If they bject, wrk ut the issues r find anther healthcare prvider. Once yur Advance Directives are cmpleted and signed, prvide a cpy t yur agent, all healthcare prviders, clse friends and relatives, and anyne else wh may be invlved with yur care. DEVELOPING YOUR OWN PHILOSOPHY ABOUT LIVING AND DYING: Because death is a part f every life, there are several reasns fr giving thught t death befre having t face the near apprach f it. One reasn is that yu will handle it better if it is n yur wn terms as much as pssible. Anther is that it will be very helpful t thse wh care abut yu if they knw definitely what yur preferences are. Here are sme questins abut life as well as death, which may be helpful in thinking things thrugh. Have yu accepted the fact that yu are ging t die ne day? Is it death r the prcess f dying that is f mst cncern? Have yu thught abut decisins and cnsequences f a terminal cnditin if that ccurs? Have yu had a friend r relative whse dying was a prlnged prcess, wh lingered n lng after he r she wanted nly the release f death? 4

6 Are yu able t savr the small things in daily life, things that yu perhaps used t take fr granted? What are sme f the things in life that bring yu warm satisfactin t recall? Have yu given thught t the meaning f life? If yes, d yu cnsider a meaning in general, r the specific meaning f yur wn life at any given mment? D yu think it is imprtant t establish a meaning f life? What wuld yu think if at sme pint yu felt that yur life had lst all meaning? Examples: the death f smene dear t yu, a terminal illness, when yu have n cntrl ver yur life, r feel that yu have becme "useless." Des death, then, have a cnnectin with the meaningfulness f life? Des this qutatin make sense t yu? D yu want t amend it in sme way? Is there nt a certain satisfactin in the fact that natural limits are set t the life f the individual, s that at its cnclusin it may appear as a wrk f art? - Albert Einstein If yu had a terminal illness, at what pint wuld yu want the release f death? Intractable symptms: pain, nausea, fatigue, anrexia, anxiety, cnfusin, incntinence, difficulty swallwing r breathing, sleeplessness r sleepiness Unacceptable indignities such as helplessness and lss f bwel and bladder cntrl, inability t wash, dress, eat, walk, transfer t a tilet r cmmde Dementia: lss f self / memry / cmmunicatins capacity / radical persnality changes such as repeated angry utbursts fr n reasn Unwillingness t prlng the anguish f thse yu lve as they watch yu deterirate and linger t n purpse Unwillingness t see yur life savings g t the dying industry rather than t thse yu lve r t causes yu believe in Simple inability t enjy living any lnger under the given cnditins f life and health Yu may rate what is imprtant t yu by marking each blank with either 1, 2, 3, 4, r 5, 1 being the least imprtant and 5 being the mst. Wanting t knw the truth abut my cnditin. Wanting t take part in decisin-making invlving my healthcare. Wanting my healthcare agent t participate in my healthcare decisin-making if I am unable t decide fr myself. Letting nature take its curse." Maintaining my quality f life. Maintaining my dignity. Maintaining my privacy. Living as lng as pssible, regardless f quality f life. 5

7 Having physical mbility. Having gd eyesight. Having gd hearing. Having reasnable mental capacity. Being able t speak. Being able t cmmunicate with thers nnverbally writing, tuching, blinking. Having independence and cntrl in my life. Aviding being a burden n thers. Being cmfrtable and pain-free, even if it may hasten my death. Leaving gd memries fr friends and family. Leaving assets fr family, friends, charities, etc. Dying in a shrt while, as ppsed t a lingering prcess. Managing financial aspects. Other thughts and feelings regarding medical treatments: Signature Date 6

8 SECTION (2) ADVANCE DIRECTIVES 2(a) MEDICAL DURABLE POWER OF ATTORNEY By this dcument, I intend t create a Medical Durable Pwer f Attrney, prvide an Advance Directive fr treatment when I am in a terminal state, and make a Declaratin as t Medical r Surgical Treatment (a Living Will). Third parties may rely n the representatins f my Agent wh is designated t serve my interest. I, (name), f (city and state), the Principal, hereby appint (name f Agent, with city and state), t serve as my Agent and t exercise the pwers set frth belw. If my Agent ceases t act due t inability r unwillingness t cntinue t serve, I hereby designate (name f first substitute Agent, with city and state) as my first substitute Agent. If my substitute ceases t act due t inability r unwillingness t cntinue t serve, I designate (name f secnd substitute Agent, with city and state). ACTIVE DATE AND DURABILITY: By this dcument I intend t create a Medical Durable Pwer f Attrney effective upn, and nly during, any perid f disability r incapacity in which, in the pinin f my attending healthcare prfessinal, I am unable t make r cmmunicate respnsible decisins regarding medical treatment r healthcare fr myself. AGENT POWERS: I grant t my Agent full authrity t make decisins fr me regarding my medical and psychlgical treatment and healthcare. In exercising this authrity, my Agent shall fllw my desires as stated in my Declaratin as t Medical r Surgical treatment. In making decisins, my Agent shall attempt t discuss the prpsed decisin with me t determine my desires if I am able t cmmunicate in any way. If my Agent cannt determine the chice I wuld want made, then my Agent shall make a chice fr me based upn what my Agent believes t be in my best interests. My Agent's authrity t interpret my desires is intended t be as brad as pssible, except fr any limitatins I may state belw. Accrdingly, my Agent is authrized as fllws: (a) T cnsent, refuse, r withdraw cnsent t any and all types f psychiatric and medical care, treatment, surgical prcedures, diagnstic prcedures, medicatin, and the use f mechanical r ther prcedures that affect bdily functin, including (but nt 7

9 limited t) artificial respiratin, artificial nurishment and hydratin, and cardipulmnary resuscitatin; (b) T have access t my medical recrds and infrmatin t the same extent that I am entitled, including the right t disclse the cntents t thers; (c) T authrize my admissin t r discharge frm (even against medical advice) any hspital, nursing hme, residential care, assisted living, r similar care facility r service; (d) T cntract n my behalf fr any healthcare-related service r facility, withut my Agent's incurring persnal financial liability fr such cntracts; (e) T retain and discharge medical, scial service and ther supprt persnnel respnsible fr my care; (f) T authrize any medicatin r prcedure intended t relieve pain fr me, even thugh such use may lead t physical damage r addictin, r may hasten the mment f (but nt intentinally cause) my death; (g) T make anatmical gifts as fllws. (Initial thse that apply) I authrize my agent t make anatmical gifts n my behalf fr the limited purpse f transplantatin, which shall take effect upn my death, t such persns and rganizatins as my agent shall deem apprpriate, and t execute such papers and d such acts as shall be necessary, apprpriate, incidental, r cnvenient with such gifts. I authrize my agent t make tissue gifts nly n my behalf fr the limited purpse f transplantatin, which shall take effect upn my death, t such persns and rganizatins as my agent shall deem apprpriate, and t execute such papers and d such acts as shall be necessary, apprpriate, incidental, r cnvenient with such gifts. I authrize my agent t make anatmical gifts n my behalf fr the purpses f medical research, and t execute such papers and d such acts as shall be necessary, apprpriate, incidental, r cnvenient in cnnectin with such gifts. I d nt authrize my agent t make any anatmical gifts n my behalf fllwing my death. (h) T take any ther actin necessary t implement my preference as t my healthcare as expressed herein r elsewhere, including (but nt limited t) granting any waiver r release frm liability required by any hspital, healthcare prfessinal, r ther healthcare prvider; signing any dcuments relating t a refusal f treatment r the discharge frm a facility against medical advice; and pursuing any legal actin in my name and at my r my estate s expense t frce cmpliance with my wishes as determined by my Agent, including claims fr actual r punitive damages fr any such failure t cmply. ACCESS TO MY MEDICAL RECORDS AND OTHER PERSONAL INFORMATION: My Agent shall have the pwer t request, receive, review and release any infrmatin, including drug-and-alchl treatment infrmatin, mental health infrmatin, medical and hspital recrds and ther data having special prtectins under the law, specifically including the Health Insurance Prtability and Authrizatin Act f 1996 (HIPAA), regarding my physical r mental health; and t execute any releases, waivers, insurance frms, r ther dcuments that may be requested in rder t btain such 8

10 infrmatin; r t btain gvernment assistance r insurance payment fr any service rendered t me r fr my benefit. Each persn nminated t be my Agent shall specifically be authrized t receive all persnal health infrmatin and dcuments necessary t determine my incapacity as if such persn were already acting as my Agent. GRANTING RELEASES: My Agent, n behalf f me, my heirs, and my estate, shall have the pwer t grant waivers r releases frm liability t healthcare prviders and ther persns r cvered entities (as defined under HIPAA) invlved in prviding healthcare services fr me r maintaining my prtected health infrmatin and ther healthcare recrds wh act in reliance n instructins given by my Agent fr the purpse f carrying ut the prvisins f this dcument. RELEASE OF INFORMATION: I hereby authrize all cvered entities as defined under the Health Insurance Prtability and Authrizatin Act f 1996 (HIPAA) (including healthcare prfessinals and all ther prviders f healthcare services, mental healthcare, drug and alchl treatment, hspitals, residential care facilities, insurance prviders and medicalinfrmatin prcessrs) t release t my Agent, r t my Agent s designee, all individually identifiable prtected health infrmatin r phtcpies f any recrds which my Agent may request in rder t carry ut my Agent s respnsibilities hereunder. I hereby waive all privileges which may be applicable t such infrmatin and recrds and t any cmmunicatin pertaining t my health and made in the curse f any cnfidential relatinship recgnized by the law, specifically including the Health Insurance Prtability and Authrizatin Act f 1996 (HIPAA). I understand that any prtected health infrmatin released t my Agent r nminee is nt prtected frm further disclsure, as my Agent deems necessary r advisable. This release shall terminate upn revcatin f this Pwer f Attrney. SIGNATURES: As previusly stated, signatures fr the cmbined MDPOA and the Living Will are at the end f Sectin 2(b) belw. 9

11 2(b) LIVING WILL AND DECLARATION AS TO MEDICAL / SURGICAL TREATMENT (a) If I shuld either: 1) have an terminal injury, illness r disease; 2) be in a prlnged, and/r irreversible cmatse r persistent vegetative state; r 3) be in an advanced stage f prgressive dementia in which I am unable t cherently cmmunicate, swallw fd and water safely, care fr myself, and recgnize my family and ther peple, and if tw healthcare prfessinals* certify in writing that there is n reasnable prbability f recvery frm these cnditins, then I direct that such prcedures listed belw, where I have written and initialed yes, be withheld r withdrawn and that I be permitted t die naturally. Such life-sustaining prcedures include, but are nt limited t, the fllwing: (1) Surgery, unless it is abslutely necessary t cntrl pain (2) Antibitics (using drugs t fight infectin), when they will nt significantly imprve my cmfrt (3) Cardipulmnary resuscitatin including electrnic shck in the event f cardiac arrest (4) Invasive diagnstic tests (5) Intubatin (insertin f a tube t admit air r administer gases) (6) Respiratr supprt (breathing by machine) (7) Bld r bld prducts (such as transfusins) (8) Kidney dialysis (9) Heart-regulating drugs, including electrlyte replacement, if my heartbeat becmes irregular (10) Crtisne r ther sterid therapy, if tissue swelling threatens vital centers in my brain (11) Stimulants, diuretics r any ther treatment fr heart failure, if the strength and functin f my heart is impaired (12) The withhlding f administratin f pneumnia vaccine (13) Artificial hydratin and nutritin (giving fd and fluid thrugh a tube in the veins, nse r stmach), except as my healthcare prfessinal determines t be necessary t prvide cmfrt nly, but nt t maintain life. (14) Eating and drinking by muth (b) It being understd that life-sustaining prcedures shall nt include any medical prcedure r interventin fr nurishment cnsidered necessary by the attending physician t prvide cmfrt r alleviate pain, I direct that, in accrdance with Clrad law and pursuant t the terms f this declaratin, life-sustaining prcedures shall be (initial nly the ptin that applies): withdrawn; r withheld; r cntinued fr a perid f nt less than days, and if there be n change in my cnditin which wuld indicate t my healthcare prfessinal that my prgnsis 10

12 has imprved, then I direct that life-sustaining prcedures shall be withdrawn and/r withheld; r cntinued indefinitely, regardless f my cnditin r prgnsis * Please nte that healthcare prfessinal" is a current term used in medical dcuments t reflect that, in sme rural areas, there is n healthcare prfessinal available and either a licensed physician's assistant r nurse practitiner is the nly attending health prvider. I am aware that withhlding r withdrawing any f these prcedures may hasten my death, but I cnsider it against my interests and the interests f my survivrs t have my bdy artificially maintained after the pssibilities f reasnable physical and/r mental recvery is gne (initial yes r n ). (c) Such persn as I appint with this Medical Durable Pwer f Attrney fr healthcare, after cnsultatin with my healthcare prfessinal, may use such persn's best judgment t distinguish between treatments that are humane and thse that nly pstpne the mment f death. (d) Specifically in regard t NOURISHMENT AND HYDRATION, I have checked and initialed the fllwing items I agree with: (1) If I am incmpetent but cnscius, and unable r unwilling t eat r t be fed in the usual manner, I declare my wish t vluntarily stp eating and drinking by muth and t refuse tube feeding thrugh my nse and/r thrat and/r thrugh any surgical insertin f a tube, r thrugh intravenus feeding except insfar as is necessary t prvide cmfrt nly, but nt t maintain life, as determined by my physician and apprved by my Agent. (2) If I am uncnscius and the prcedure being administered t me is tube r intravenus feeding, nce my physician and physician cnsultant have established that there is nt a reasnable likelihd that I will ever return t a cnscius state with the ability t be riented and t interact in a reasnably unimpaired way with my envirnment (such as the cnditin smetimes called the Permanent r Persistent Vegetative State), I declare my wish t have such artificial feeding withheld r withdrawn. I am aware that this may hasten my death, but I cnsider it against my interests and the interests f my survivrs t have my bdy artificially maintained after reasnable hpe f mental recvery is gne. EXCULPATION: (a) My Agent and my Agent s estate, heirs, successrs, and assigns are hereby released and frever discharged by me, my estate, heirs, successrs, and assigns frm all liability and frm all claims r demands f all kinds arising ut f the acts r missins 11

13 f my Agent. N persn wh relies in gd faith upn any representatins by my Agent r Successr Agent shall be liable t me, my estate, my heirs r my successrs r assigns fr recgnizing the Agent s authrity. (b) Any healthcare prfessinal, nurse, r ther individual acting n my behalf is authrized and directed t fllw these instructins. N healthcare prfessinal signing a certificate f terminal cnditin and n healthcare prfessinal, hspital r hspital persnnel withhlding r withdrawing life-sustaining prcedures in cmpliance with this declaratin, in the absence f actual knwledge f revcatin r fraud, misrepresentatin, r imprper executin, shall be subject t civil liability, criminal penalty, r licensing sanctins therefr. On behalf f myself, my Agent, my family and my heirs and devisees, I hereby release any persn wh acts in reliance n the freging sentence frm any claim r liability fr any injury t me r arising by reasn f my death. NOMINATION OF GUARDIAN: If a guardian f my persn shuld fr any reasn be appinted, I nminate my Agent (r successr) named abve. ADMINISTRATIVE PROVISIONS: (a) I revke all prir pwers f attrney r Advance Directives fr healthcare. (b) This Medical Durable Pwer f Attrney and Living Will is intended t be valid in any jurisdictin in which it is presented. (c) The pwers delegated under these dcuments are separable, s that the invalidity f ne r mre pwers shall nt affect any thers. (d) Phtcpies f these dcuments shall be as effective as the riginal. I specifically direct my Agent t have phtcpies f these dcuments placed in my medical recrds. (e) This dcument shall be gverned by the laws f the State f Clrad in all respects, including its validity, cnstructin, interpretatin, and terminatin. I intend fr these dcuments t be hnred in any jurisdictin where it may be presented and fr any such jurisdictin t refer t Clrad law t interpret and determine the validity f these dcuments and any f the pwers granted under these dcuments. REVOCATION AND RESIGNATION: I reserve the right t revke r amend these dcuments and t substitute ther agents in place f thse designated herein. Amendments r revcatin shall be made in writing by me persnally, nt by any agent f mine, and shall be attached t the riginal f these dcuments. My agent and any alternate agent may resign by the executin f a written resignatin delivered t me r, if I am mentally incapacitated, by delivery t any persn in charge f my care and custdy. 12

14 SEVERABLITY: If any part f any prvisin f this dcument shall be invalid r unenfrceable under applicable law, such part shall be ineffective t the extent f such invalidity nly, withut in any way affecting the remaining prvisins f this dcument. RESOLUTION WITH THESE DOCUMENTS AND MY AGENT S WISHES: I have executed this Directive fr Medical / Surgical Treatment (Living Will) declaring my wishes regarding the cntinued use f life-sustaining prcedures r artificial nutritin and hydratin in the event I am in a terminal cnditin r persistent vegetative state and I am unable t make medical decisins fr myself. I have als named my agent in this Medical Durable Pwer f Attrney. In the event that the decisins f my agent shall cnflict with this Directive: (Initial One) My preferences in this Directive shall prevail ver the wishes f my agent. My agent under this Directive shall have authrity t verride my preferences as stated in this Directive. BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE CONTENTS OF THESE DOCUMENTS AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT. I AM OF SOUND MIND AND WILLFULLY AND VOLUNTARILY EXECUTE THIS DOCUMENT. I sign my name t this Medical Durable Pwer f Attrney and Directive fr Medical / Surgical Treatment n this day f, 20. Signature f Principal Principal's hme address:. Witnesses are named belw, alng with the Acceptance f Appintment. 13

15 2(c) WITNESSES' STATEMENT I d hereby declare that the Principal (the persn wh has signed r acknwledged this dcument),, has signed r acknwledged this Medical Durable Pwer f Attrney Dcument in my presence, and that he/she appears t be f sund mind and under n duress, fraud, r undue influence. T the best f my knwledge, I am nt a creditr f the Principal nr entitled t any part f his r her estate under a will nw existing r by peratin f law. Witness N. 1 Signature: Date: Print Name: Phne(s): Address: Witness N. 2 Signature: Date: Print Name: Phne(s): Address: 14

16 2(d) AGENTS' ACCEPTANCE OF APPOINTMENT The undersigned accept appintment as Agent(s) under this Medical Durable Pwer f Attrney. Print Name f Agent: Hme Phne: Signature: Other Phne: Address: Print Name f 1st Substitute Agent: Hme Phne: Signature: Other Phne: Address: Yu may have a secnd Substitute Agent shuld yu wish: Print Name f 2nd Substitute Agent Hme Phne: Signature: Other Phne: Address: Ntarizatin is ptinal. If yu wish t have this Living Will ntarized, use the fllwing frm: STATE OF COLORADO CITY COUNTY Subscribed and swrn t befre me by, the Principal, and and and, as witnesses, as the vluntary act and deed f the Principal, this day f, 20. Ntary Public Address f Ntary Public: My cmmissin expires 15

17 2(e) MEDICAL ORDERS FOR SCOPE OF TREATMENT (MOST) The Medical Orders fr Scpe f Treatment (MOST) dcument fr Clrad is nw a legally binding dcument. In sme ther states, it is smetimes referred t as Physician Orders fr Life-Sustaining Treatment (POLST). In general, this frm is intended fr use by thse with serius, chrnic, r terminal illness and/r wh are in treatment facilities. It is a ne-page, tw-sided frm that summarizes a persn's wishes regarding specific treatment and scpe f treatment. It des nt replace yur Living Will, but rather, when signed by a physician, physician's assistant, r nurse practitiner, serves as a medical rder which must be accepted and fllwed in any healthcare facility in the state. The frm may be dwnladed by ging t Ggle and typing "MOST Frm fr Clrad" int the "search" bx. Cpies, faxes, r scans f the MOST are just as valid as the riginal. 2(f) DIRECTIVE TO WITHHOLD CARDIOPULMONARY RESUSCITATION If yur heart r breathing shuld malfunctin r stp, emergency medical service persnnel must, by law, attempt cardipulmnary resuscitatin (CPR); yur cnsent is assumed. Fewer than 10% f elderly persns will survive a resuscitatin prcedure. If they d recver, he r she ften sustains brken ribs and irreversible brain damage. If yu wish t refuse CPR, yu will need t execute a Ntice f Patient r Authrized Agent's Directive t Withhld Cardipulmnary Resuscitatin (r "CPR Directive"). A template frm may be dwnladed frm the Clrad Department f Health and Envirnment Web site ( HVHz8 ), r yu can use the frm prvided here. This frm must have a physician's signature, as well as yur r yur Agent's, but ther frms (such as the MOST) are acceptable as CPR directives as well. In fact, any clear, written statement refusing CPR which is "apparent and immediately available" t respnding emergency persnnel shuld be hnred. T be extra certain that it will be hnred, using the template frm is strngly advised. "N CPR" bracelets r necklaces may be purchased frm Awards and Signs, Ltd, 6801 S. Daytn, Greenwd Village, CO 80112, fr $27.95 (2013 price). Orders must include bth a check and a phtcpy r fax f the signed CPR Directive. 16

18 COLORADO DIRECTIVE FOR WITHHOLDING CPR NOTICE OF PATIENT OR AUTHORIZED AGENT'S DIRECTIVE TO WITHHOLD CARDIOPULMONARY RESUSCITATION (CPR) Patient's name: Name f authrized agent, prxy, guardian/parent(s) f minr child (if this shuld be applicable): Patient's Date f Birth: / / Gender: Male Female Eye Clr: Hair Clr: Race/Ethnicity: Asian r Pacific Islander Black, Nn- Hispanic White, nn-hispanic American Indian r Alaska Native Hispanic Other Name f Hspice Prgram (if applicable): Attending Healthcare Prfessinal: Attending Healthcare Prfessinal's Address Attending Healthcare Prfessinal's Phne ( ) License # Directive made n this date:, pursuant t Clrad Revised Statute Check nly ne f the fllwing (as apprpriate): Patient: I am ver the age f 18 years, f sund mind and acting vluntarily. It is my desire t initiate this directive n my behalf, and I have been advised that the expected result f executing this directive is my death, in the event that my heart r breathing stps r malfunctins. Authrized agent/prxy/legally authrized guardian/parent(s) f minr child: I am ver the age f 18 years, f sund mind, and I am legally authrized t act n behalf f the patient named abve in the issuance f this directive. I have been advised that the expected result f executing this directive is the death f the patient, in the event the patient's heart r breathing stps r malfunctins. I hereby direct emergency medical services persnnel, healthcare prviders, and any ther persn t withhld cardipulmnary resuscitatin in the event that my/the patient's heart r breathing stps r malfunctins. I understand that this directive des nt apply t ther medical interventins fr cmfrt care. If I/the patient am/is admitted t a healthcare facility, this directive shall be implemented as a healthcare prfessinal's rder, pending further healthcare prfessinals' rders. Use f riginal signatures n each page f this frm makes each page an riginal dcument. Signature (Signature f : Patient r authrized agent/prxy/legally authrized guardian/parent(s) f minr child) Signature f Attending Healthcare Prfessinal 17

19 Cnsent t the fllwing tissue dnatin is ptinal. These tissue dnatins d nt require resuscitatin: I hereby make an anatmical gift, t be effective upn my death, f: Any needed tissues, r the fllwing tissues: skin crnea bne related tissues and tendns. Dnr/Agent Signature: Again, this page is included fr infrmatinal purpses nly. 18

20 (3) MY LAST WISHES** An Addendum t My Advance Directives I, as a persn f clear and sund mind and under n cercin, endrse the items INITIALED n this directive. I d s with the understanding that there is a chance that nne f these eventualities will befall me r that they all might. My wishes stated here have been carefully cnsidered. They have been discussed with persns whm I have appinted as my healthcare agents. My agents agree with my wishes. This addendum is a supplement t and des nthing t negate my Advance Directives and my Medical Durable Pwer f Attrney but is appended t ensure that my additinal wishes will be knwn by all wh may care fr me. This cannt cver all pssibilities, but it particularly applies t irreversible brain cnditins where there is a strng likelihd that cgitative functin cannt be restred, where I cannt speak fr myself and where there is n life supprt t discnnect s that death culd ccur easily. I wish t die with dignity and in peace. It is imprtant fr me t knw that I will nt have t die a lingering and/r demeaning death r endure a hpeless and severely disabling cnditin which wuld invlve great suffering fr myself and/r thse I lve. I wuld like t chse when and hw I die and t seek help in carrying ut that decisin. T further indicate that this is an enduring request, I have been a member f the Hemlck Sciety, which is nw called Cmpassin & Chices, since. It shuld be clear that despite my wish t chse death, I want the best pssible medical care, including life-sustaining measures when the prgnsis appears t be favrable and if there is a reasnable chance that I will be restred t independent living that has meaning and ffers enjyment, with my pre-crisis level f cgnitin intact. TO THOSE WHO CARE ABOUT ME: If I am ill and hmebund r in a hspital r nursing hme, I wuld ask thse persns wh are clse t me nt t abandn me but t visit as much as I r they can tlerate, and t insure that I have adequate care and that my wishes are carried ut. I ask that yu respect my view f dying and death and nt try t impse yur philsphy r beliefs n me, n matter hw well-meaning. Quality f life and autnmus decisin-making are high pririties fr me. STATEMENT OF DESIRES: I want all the prvisins f my Advance Directives t be implemented. My preference wuld be t die (circle ne): at hme with (r withut) hspice care; in a hspital; ther (specify). I desire (circle ne): crematin, burial, dnatin t medical facility (specify) 19

21 I wuld like (circle ne): memrial service; funeral; neither; ther. BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE CONTENTS OF THIS DOCUMENT AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT. I AM OF SOUND MIND AND WILLFULLY AND VOLUNTARILY EXECUTE THIS DOCUMENT. Signature Date, 20 ** My Last Wishes is nt fficially a legal dcument, but rather a statement f persnal desires. 20

22 (4) CONSENT FOR RELEASE OF MEDICAL RECORDS A. Patient requesting release f Medical Recrds: B. Medical Recrds requested frm all thse wh hld such medical recrds, including but nt limited t: and any ther persn in the medical field wh hlds my recrds C. Wh is t receive the Medical Recrds: I, the patient ("A" abve) hereby authrize the hlder(s) ("B" abve) f my cnfidential medical recrds and infrmatin named abve t share and discuss any and all medical, mental health, scial wrk, legal, r ther treatment and cnfidential infrmatin cncerning me, and t prvide cpies f same t the persns named in (C) abve. I r my estate will cver the csts incurred. Signature Date PURPOSES AND EFFECTS OF THIS CONSENT: I have asked the advcacy prgram f Cmpassin & Chices f Clrad and specifically thse named in "C" abve t intervene regarding my care, treatment, and supprt in the event I cannt speak fr myself. This Cnsent will assist my patient advcate(s) t cmmunicate with the hlders f my cnfidential medical recrds regarding my needs fr cnsenting t r refusing healthcare. I intend fr any agent serving hereunder t be treated as my persnal representtative as defined in 45 CFR (g) f the Health Insurance Prtability and Accuntability Act f 1996 ( HIPAA ), s as t have all authrity and rights that I wuld persnally have with respect t the use and disclsure f my individually identifiable prtected health infrmatin r ther medical recrds. I recgnize that infrmatin disclsed by a cvered entity pursuant t this authrizatin is subject t further disclsure and may n lnger be prtected by the HIPAA privacy rules. This release shall expire ne year after my death unless earlier revked in writing. Effective Date: This Cnsent is effective frm the date f signature. Patient Signature Date 21

23 Ntarizatin is ptinal. Yu may use this frm if yu wish: STATE OF COLORADO CITY COUNTY Subscribed and swrn t befre me by, the Principal, as the vluntary act and deed f the Principal, this day f, 20. Ntary Public Address f Ntary Public My cmmissin expires: 22

24 (5) MEDICAL INFORMATION FORM Patient's Name Date Date f Birth Phne(s) Address City State Zip Belw are the names and phne numbers f the advcacy persns I have designated t be my agents if I am unable t make r versee the executin f healthcare decisins fr myself. Advcate s Name Phne(s) Address Alternate Phne(s) Address Prvide yur Advance Directives with this frm. If yur lawyer has a cpy, give his/her name and phne number (belw). Give a cpy f this frm t yur attrney. Dctr s name and phne Other dctr s name and phne Have yu discussed yur wishes with yur dctr(s)? With yur family? With anyne else? Name Name Are there peple wh may disagree with yur wishes? If s, wh? Name Name What might these persns d? Are there any ther cncerns? Cntact infrmatin fr attrney, if any 23

25 (6) QUESTIONS TO ASK YOUR HEALTHCARE PROVIDER It is imprtant fr yu and yur Healthcare Prvider (HCP) t understand each ther. The fllwing list f questins shuld prvide bth f yu with the infrmatin necessary fr such an understanding. If yur HCP intimidates yu r belittles yur questins, cnsider finding a mre sympathetic HCP. T facilitate the sessin between yu and yur HCP, bring the fllwing with yu: 1) This list f questins 2) A list f yur vitamins, herbs, supplements, prescriptin and nnprescriptin drugs and their dsages 3) A list f yur vital statistics, such as allergies, ther cnditins, surgeries 4) A friend r family member 5) Cpies f yur Advance Directives, Last Wishes and ther pertinent dcuments abve. Make sure yur HCP is aware that yur dcuments include HIPAA authrizatin t release yur recrds t yur agents and ther necessary persns. Questins regarding tests: 1) What tests will be perfrmed fr diagnsis? 2) What are the risks and reliability f these tests? 3) Hw lng will it take t get results? 4) Will I need t take time ff frm wrk fr these tests? Questins regarding yur cnditin 1) What is the diagnsis? 2) Are there alternate diagnses? 3) What is the prgnsis? 4) Hw lng will I need this treatment? 5) If the treatment is unsuccessful, will yu accept the terms f my Advance Directives? Questins regarding medicatin 1) Hw will the medicatin help my cnditin? 2) What are the side effects f this treatment? 3) Hw lng will I need t take the medicatin? 4) Will this medicatin interfere with ther medicatins I am taking? Questins befre surgery 1) What are the gals f surgery? 2) What are the alternatives t surgery? 3) What is the surgical prcedure? 4) What are the chices f anesthesia? 5) What are the risks f surgery? 6) Hw lng will it take t recver frm surgery? 7) If treatment is unsuccessful and there is NO hpe f recvery, wuld yu explre with me and my agent ptins n dying? If my cnditin is hpeless, wuld yu be willing t help me t die? If family members disagree, wuld yu cntinue t be my advcate? 24

26 (8) IMPORTANT THINGS TO DO AND REMEMBER 1) D NOT put the riginals f yur signed, witnessed, and ntarized Advance Directives and ther imprtant dcuments in a safe-depsit bx r any place that wuld keep thers frm having access t them. Tell yur agent and family where these vitally imprtant papers can readily be fund. (Again, in Clrad, at this time, ntarizatin is recmmended but nt required.) 2. The "Last Wishes," althugh nt strictly a legal dcument, shuld be attached as an addendum t the ther dcuments. 3. Give phtcpies f the signed riginals t yur agent and t yur substitute agents, dctrs, family, clse friends, clergy and anyne else wh might becme invlved in yur healthcare. If yu enter a nursing hme, hspital r lng-term residential-care facility, have phtcpies made and placed in yur medical recrds. 4. Be sure t talk t yur agent, substitute agent (smetimes referred t as "the alternate"), clergy, family, and friends abut yur wishes cncerning medical treatment. Discuss yur wishes ften, especially if yur medical cnditin changes. 5. If yu want t make any changes t yur dcuments after they have been signed and witnessed, yu shuld cmplete new dcuments, and gather in and destry frmer dcuments. 6. Remember, yu can always revke ne r mre f yur Clrad dcuments. 7. Shuld death ccur at hme, the cunty crner r yur dctr shuld be called, as a qualified medical prfessinal needs t be ntified t make the fficial prnuncement f death. If hspice is being used, they will als help with this ntificatin. If the patient des nt have a NO CPR Directive r is nt wearing the bracelet r necklace, caretakers need t be aware that the paramedics will try t resuscitate. If the patient and family have been expecting death and d nt want CPR administered, d nt call The initial chice f a funeral hme t remve the bdy is a crucial decisin made at the time f death, as it can have serius financial impact. A family member r clse friend shuld accmpany the bereaved next f kin t the mrtuary t advise and supprt that individual in making arrangements fr the service. (This infrmatin is prvided by Funeral Cnsumer Sciety f Clrad, ) 9. If direct crematin is planned, the crematry may be able t cllect the bdy directly. If yu wish t make an anatmical gift, please call Family and clse friends als need t be ntified and asked t help the next f kin with the ntificatin f ther family, friends, clse neighbrs, the church, and the rganizatins the deceased was a member f, and help with ther immediate tasks. 11. It is imprtant that the crucial papers and infrmatin regarding prepaid funeral plicies and instructins fr a service, etc., are kept where the family members can find them easily. If the deceased was receiving public assistance r was a member f the military, financial assistance may be available t help cver funeral expenses. Scial Services shuld be ntified regarding anyne receiving public assistance, and the V.A. shuld be cntacted regarding anyne wh is currently r was previusly in the military. 25

27 12. It is imprtant that smene be respnsible fr answering the phne, cllecting mail, caring fr pets, keeping track f gifts f fd r flwers and nting wh the dnrs are; and fr finding smene t stay in the hme during the service and having refreshments available if a receptin is t be held in the hme fllwing the service. We hpe this infrmatin has been helpful t yu. If yu have questins yu can cntact either Cmpassin & Chices f Clrad r the natinal Cmpassin & Chices ffice. Cntact infrmatin is belw. Cmpassin & Chices f Clrad Natinal Cmpassin & Chices PO Bx PO Bx Denver, CO Denver, CO cmpassinandchicesfclrad.rg inf@cmpassinandchices.rg 26