Idaho Advance Care Planning Document (Living Will and Health Care Power of Attorney)

IDAHO ADVANCE CARE PLANNING DOCUMENT

Living Will and Durable Power of Attorney for Health Care

(Prepared under the Idaho Medical Consent and Natural Death Act, Idaho Code §§ 39-4501 to 39-4515 — an independently prepared form, not an official state publication)

About this document: Idaho law lets any competent adult make an advance care planning document (Idaho Code § 39-4510). This document combines the two parts of an Idaho advance directive: a Living Will (your treatment wishes, Part 3) and a Durable Power of Attorney for Health Care (your health care agent, Part 2). Only Part 1 (your information) and Part 4 (your signature and date) are required by Idaho law — every other part is optional, and anything you leave blank is treated as intentional and does not affect the rest. Idaho does not require witnesses or notarization; optional witness and notary blocks are included in Part 4 for added formality. See “Completing This Document” at the end for guidance.

PART 1 — MY INFORMATION

Idaho Code § 39-4510(1) requires your name, date of birth, telephone number, and mailing address.

My full legal name: _________________________________________________________________

My date of birth: __________________ My telephone number: _______________________

My mailing address: ________________________________________________________________

My email address (optional): _________________________________________________________

PART 2 — MY HEALTH CARE AGENT

Durable Power of Attorney for Health Care — optional under Idaho law. Complete this Part to appoint the person who is authorized to make health care decisions for you when you cannot, subject to applicable law and any court order. If you leave this Part blank, your wishes in Part 3 still speak for you.

2.1 My agent

I appoint the following person as my health care agent (attorney in fact) to make health care decisions for me:

Agent’s full name: ______________________ Relationship to me: _________________________

Agent’s mailing address: ______________________________________________________________

Agent’s telephone: _________________________ Agent’s email: __________________________

2.2 Alternate agents

If my agent is not available, not able, or not willing to act, I appoint the following alternates, in the order listed:

First alternate’s name: _________________________ Relationship: ___________________

Telephone: _________________________ Email or address: ____________________________

PART 2 — MY HEALTH CARE AGENT — CONTINUED

Second alternate’s name: _______________________ Relationship: ___________________

Telephone: _________________________ Email or address: ____________________________

2.3 When my agent’s authority operates

This document takes effect when I sign it (Part 4). My agent’s authority to make a health care decision for me operates only when I cannot make or communicate that decision myself, for as long as that inability lasts.

2.4 What my agent may do

My agent may consent to, refuse, or withdraw consent to any health care service, treatment, or procedure for me, to the same extent I could decide for myself, subject to applicable law. My agent must follow the instructions in this document and my wishes made known in any other way. If my wishes about a particular decision are not known and cannot reasonably be determined, my agent must act in my best interests, considering my values, beliefs, prognosis, the burdens and benefits of treatment, and information from my care team. This document gives no authority over my money or property. Any health care agent or court-appointed guardian must follow this document and my known wishes, subject to applicable Idaho law and any court order; their respective authority and priority are determined by the law in effect when a decision is made.

Limits on my agent’s authority (if none, write “none”):

__________________________________________________________________________________

__________________________________________________________________________________

2.5 If my agent or alternate is my spouse

Check one:

☐ If my marriage is later dissolved or annulled, my spouse’s appointment as my agent or alternate ends at that time.

☐ If my marriage is later dissolved or annulled, my spouse’s appointment continues.

If neither box is marked, the appointment continues unless I later revoke or replace it.

2.6 My earlier documents

I revoke my earlier nominations of health care agents. This document replaces my earlier living will and health care power of attorney instructions about the same subjects. This document does not itself amend or revoke any existing Physician Orders for Scope of Treatment (POST) form, practitioner-issued do-not-resuscitate order, declaration for mental health treatment, or anatomical-gift document; I should review and change each such document separately under the law and procedures governing that document.

2.7 My medical records

When and to the extent my agent has authority to make health care decisions for me, my agent is my personal representative under 45 C.F.R. § 164.502(g) with respect to health information relevant to that authority, subject to applicable law. I authorize my health care providers to disclose my health and medical records — including records protected by HIPAA — to my agent, and my agent to receive and share them and sign the releases needed, as needed to carry out this document.

Choosing your agent: current Idaho Code § 39-4510 states no categorical exclusions for health care agents.

Nevertheless, choosing your treating health care provider, a care-facility operator, or their employee may create conflicts of interest or provider-acceptance problems; consider choosing another competent adult who understands your wishes and can make informed decisions.

PART 3 — MY TREATMENT WISHES

Living Will — optional under Idaho law. These directions speak for me when I cannot make or communicate my own health care decisions. Initialing is not required; mark one box in each section you want to complete. A section left unmarked gives no instruction on that subject. Sections 3.3 and 3.4 give specific instructions; if one conflicts with a more general instruction in section 3.1 or 3.2, the specific instruction controls. As used here, “artificial life-sustaining treatment” means an intervention that uses mechanical means to sustain or supplant a vital function (Idaho Code § 39-4502(3)).

3.1 If my death is imminent

If a licensed independent practitioner who has examined me determines that I have an incurable or irreversible injury, disease, illness, or condition and that my death is imminent — expected within hours or, at most, a few days — whether or not treatment is provided, I direct (check one):

☐ Withhold or withdraw artificial life-sustaining treatment and let me die naturally, while keeping me comfortable (see section 3.6).

☐ Continue artificial life-sustaining treatment.

☐ Other instructions:

____________________________________________________________________________

3.2 If I am in a persistent vegetative state

If my attending licensed independent practitioner determines that I am in a persistent vegetative state — a condition in which I am in partial arousal rather than true awareness, am completely unresponsive to psychological or physical stimuli, and display no sign of higher brain function (Idaho Code § 39-4502(15)) — I direct (check one):

☐ Withhold or withdraw artificial life-sustaining treatment and let me die naturally, while keeping me comfortable (see section 3.6).

☐ Continue artificial life-sustaining treatment.

☐ Other instructions:

____________________________________________________________________________

3.3 Artificial nutrition and hydration

In a situation I marked in section 3.1 or 3.2, my direction about artificially administered nutrition and hydration (food and fluids through tubes or IV lines) is (check one):

☐ Withhold or withdraw artificial nutrition and hydration.

☐ Continue artificial nutrition and hydration.

☐ My health care agent decides, after consulting my care team.

Oral or assisted feeding (such as spoon or bottle feeding) for my comfort continues unless I direct otherwise in section 3.7.

3.4 Cardiopulmonary resuscitation (CPR)

If my heart stops beating or I stop breathing in a situation I marked in section 3.1 or 3.2 (check one):

☐ Attempt CPR.

☐ Do not attempt CPR — allow natural death.

☐ No instruction in this document — the decision follows Idaho’s default rule (CPR is attempted unless a contrary direction applies).

Important: a CPR direction in this document is legally relevant under Idaho Code § 39-4514(5), but a POST form or practitioner-issued do-not-resuscitate order is a medical order specifically designed for immediate use (Idaho Code §§ 39-4512A, 39-4512B). Do not rely on this document alone for rapid out-of-hospital implementation; ask a licensed independent practitioner whether an Idaho POST or DNR order is appropriate, and keep it with this document.

3.5 Pregnancy (optional)

If I am pregnant when this document operates (check one, or leave blank for no instruction):

☐ Apply this document as written during my pregnancy.

☐ During my pregnancy, follow these instructions instead:

____________________________________________________________________________

____________________________________________________________________________

3.6 Comfort care when treatment is withheld or withdrawn — required by law

Whenever artificial life-sustaining treatment or artificially administered nutrition or hydration is withheld or withdrawn from me, I am to receive comfort care as defined in Idaho Code § 39-4502(7), as Idaho Code § 39-4514(4) requires; that legal requirement cannot be waived in those circumstances. I also request appropriate pain and symptom relief, consistent with applicable law, to keep me clean, comfortable, and free of pain as much as reasonably possible.

3.7 My other treatment objectives and instructions

Anything else I want known about my care — for example, where I prefer to receive end-of-life care, treatments I do or do not want, or who may receive my medical information or visit me:

__________________________________________________________________________________

__________________________________________________________________________________

Each page I attach to this document is identified as mine, dated, and signed or initialed by me.

PART 4 — MY SIGNATURE (REQUIRED)

Idaho Code § 39-4510(1) requires only your information (Part 1), a signature, and the date. This form is designed for you to sign yourself; Idaho law also recognizes a signature by your authorized agent in an appropriate case. Witnesses and notarization below are OPTIONAL under Idaho law.

I sign this Idaho Advance Care Planning Document — Living Will and Durable Power of Attorney for Health Care — voluntarily, and I understand its contents.

____________________________________________

(your signature)

Date signed: ______________ City and state where signed (optional): ___________________

Optional witnesses

Not required by Idaho law. Up to two adults may watch you sign and complete this block as evidence of your signing.

Witness 1 printed name: ____________________________________________

Witness 1 telephone or address: _____________________________________

Witness 1 signature: ____________________________________________

Witness 2 printed name: ____________________________________________

Witness 2 telephone or address: _____________________________________

Witness 2 signature: ____________________________________________

Optional notarization

Not required by Idaho law. A notary may complete this acknowledgment as added evidence of your signing.

State of Idaho, County of __________________________ — this document was acknowledged before me on ___________________ (date) by __________________________ (name of signer).

Signature of notary public: ________________________________

My commission expires: _______________________ (Seal)

COMPLETING THIS DOCUMENT — GUIDE (not part of the executed document)

Fill it in. Complete Part 1 exactly. Then choose: Part 2 appoints your health care agent; Part 3 records your treatment wishes. Do one or both. Mark one box per section; use the free-text lines for anything specific. Sign and date Part 4.

Witnesses and notary are optional. Idaho does not require witnesses or a notary. Completing the optional blocks may provide additional evidence of your identity, voluntariness, and signing, but does not guarantee acceptance or validity in another state.

Share it. Give copies to your agent and alternates, your doctor, and a trusted family member. Keep the original where your agent can reach it quickly.

Register it if you want. The Idaho Healthcare Directive Registry (Department of Health and Welfare, Boise; (208) 334-5501) stores advance directives so providers can find them in an emergency. Registration is optional. Failure to register does not affect validity, registration does not establish that a document is valid, and providers are not required to search the registry (Idaho Code §§ 39-4513(4), 39-4514(10), 39-4515).

Coordinate with a POST form. If you have (or later get) a Physician Orders for Scope of Treatment form signed with your practitioner, keep its terms consistent with this document. A POST is a medical order; this document is not a substitute for it. If this document conflicts with an existing POST or DNR order, promptly ask the responsible licensed independent practitioner to review and update the medical orders.

Change or cancel it anytime. You may revoke this document at any time by intentionally destroying or canceling it, by a signed writing, by clearly saying you revoke it, or by any other act clearly showing your intent — and you may temporarily suspend it in writing or orally (Idaho Code §§ 39-4511A, 39-4511B). You are responsible for telling your health care providers and agent about any revocation; a provider without actual knowledge of a revocation may rely on the document. Replace old copies, and update the registry if you registered.

Review it. Revisit your document after major life or health changes, and re-sign a fresh one whenever your wishes or your agents change.