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North Dakota Health Care Directive

I ______________________________________________ understand this document allows me to do ONE OR ALL of the following:

PART I: Name another person (called the health care agent) to make health care decisions for me if I am unable to make and communicate health care decisions for myself. My health care agent must make health care decisions for me based on the instructions I provide in this document (Part II), if any, the wishes I have made known to him or her, or my agent must act in my best interest if I have not made my health care wishes known.

AND/OR

PART II: Give health care instructions to guide others making health care decisions for me. If I have named a health care agent, these instructions are to be used by the agent. These instructions may also be used by my health care providers, others assisting with my health care and my family, in the event I cannot make and communicate decisions for myself.

AND/OR

PART III: Allows me to make an organ and tissue donation upon my death by signing a document of anatomical gift.

PART I: APPOINTMENT OF HEALTH CARE AGENT

THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS FOR ME IF I AM UNABLE TO MAKE AND COMMUNICATE HEALTH CARE DECISIONS FOR MYSELF

(I know I can change my agent or alternate agent at any time and I know I do not have to appoint an agent or an alternate agent.)

NOTE: If you appoint an agent, you should discuss this health care directive with your agent and give your agent a copy. If you do not wish to appoint an agent, you may leave Part I blank and go to Part II and/or Part III. None of the following may be designated as your agent: your treating health care provider, a nonrelative employee of your treating health care provider, an operator of a long-term care facility, or a nonrelative employee of a long-term care facility.

When I am unable to make and communicate health care decisions for myself, I trust and appoint ______________________________________________ to make health care decisions for me. This person is called my health care agent.

Relationship of my health care agent to me: ______________________________________

Telephone number of my health care agent: ______________________________________

Address of my health care agent: ______________________________________________
_________________________________________________________________________

(OPTIONAL) APPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If my health care agent is not reasonably available, I trust and appoint ________________________________
_________________________________ to be my health care agent instead.

Relationship of my alternate health care agent to me: ________________________________

Telephone number of my alternate health care agent: ________________________________

Address of my alternate health care agent: ________________________________________
___________________________________________________________________________

THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO DO IF I AM UNABLE TO MAKE AND COMMUNICATE HEALTH CARE DECISIONS FOR MYSELF

(I know I can change these choices.)

My health care agent is automatically given the powers listed below in (A) through (D). My health care agent must follow my health care instructions in this document or any other instructions I have given to my agent. If I have not given health care instructions, then my agent must act in my best interest.

Whenever I am unable to make and communicate health care decisions for myself, my health care agent has the power to:

(A) Make any health care decision for me. This includes the power to give, refuse, or withdraw consent to any care, treatment, service, or procedures. This includes deciding whether to stop or not start health care that is keeping me or might keep me alive and deciding about mental health treatment.

(B) Choose my health care providers.

(D) Review my medical records and have the same rights that I would have to give my medical records to other people.

If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR if I want to LIMIT any power in (A) through (D), I MUST say that here:

__________________________________________________________________________

My health care agent is NOT automatically given the powers listed below in (1) and (2). If I WANT my agent to have any of the powers in (1) and (2), I must INITIAL the line in front of the power; then my agent WILL HAVE that power.

[ ______ ] (1) To decide whether to donate any parts of my body, including organs, tissues, and eyes, when I die.

[ ______ ] (2) To decide what will happen with my body when I die (burial, cremation).

If I want to say anything more about my health care agent's powers or limits on the powers, I can say it here:

__________________________________________________________________________

PART II: HEALTH CARE INSTRUCTIONS

NOTE: Complete this Part II if you wish to give health care instructions. If you appointed an agent in Part I, completing this Part II is optional but would be very helpful to your agent. However, if you chose not to appoint an agent in Part I, you MUST complete, at a minimum, Part II (B) if you wish to make a valid health care directive.

These are instructions for my health care when I am unable to make and communicate health care decisions for myself. These instructions must be followed (so long as they address my needs).

(A) THESE ARE MY BELIEFS AND VALUES ABOUT MY HEALTH CARE

(I know I can change these choices or leave any of them blank.)

I want you to know these things about me to help you make decisions about my health care:

My goals for my health care:

__________________________________________________________________________

My fears about my health care:

__________________________________________________________________________

My spiritual or religious beliefs and traditions:

__________________________________________________________________________

My beliefs about when life would be no longer worth living:

__________________________________________________________________________

My thoughts about how my medical condition might affect my family:

__________________________________________________________________________

(B) THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE

(I know I can change these choices or leave any of them blank.)

Many medical treatments may be used to try to improve my medical condition or to prolong my life. Examples include artificial breathing by a machine connected to a tube in the lungs, artificial feeding or fluids through tubes, attempts to start a stopped heart, surgeries, dialysis, antibiotics, and blood transfusions. Most medical treatments can be tried for a while and then stopped if they do not help.

I have these views about my health care in these situations:

(Note: You can discuss general feelings, specific treatments, or leave any of them blank.)

If I had a reasonable chance of recovery and were temporarily unable to make and communicate health care decisions for myself, I would want:

__________________________________________________________________________

If I were dying and unable to make and communicate health care decisions for myself, I would want:

__________________________________________________________________________

If I were permanently unconscious and unable to make and communicate health care decisions for myself, I would want:

__________________________________________________________________________

If I were completely dependent on others for my care and unable to make and communicate health care decisions for myself, I would want:

__________________________________________________________________________

In all circumstances, my doctors will try to keep me comfortable and reduce my pain. This is how I feel about pain relief if it would affect my alertness or if it could shorten my life:

__________________________________________________________________________

There are other things that I want or do not want for my health care, if possible:

Who I would like to be my doctor:

__________________________________________________________________________

Where I would like to live to receive health care:

__________________________________________________________________________

Where I would like to die and other wishes I have about dying:

__________________________________________________________________________

My wishes about what happens to my body when I die (cremation, burial):

__________________________________________________________________________

Any other things:

__________________________________________________________________________

PART III: MAKING AN ANATOMICAL GIFT

I would like to be an organ donor at the time of my death. I have told my family my decision and ask my family to honor my wishes. I wish to donate the following (initial one statement):

[ ______ ] Any needed organs and tissue.

[ ______ ] Only the following organs and tissue: __________________________________

________________________________________________________________

PART IV: MAKING THE DOCUMENT LEGAL

DATE AND SIGNATURE OF PRINCIPAL

(YOU MUST DATE AND SIGN THIS HEALTH CARE DIRECTIVE)

I sign my name to this Health Care Directive Form on _____________ (date) at ______________________ (city) ______________________ (state).

I revoke any prior health care directive.

_______________________________________

(you sign here)

(THIS POWER OF ATTORNEY HEALTH CARE DIRECTIVE WILL NOT BE VALID UNLESS IT IS NOTARIZED OR SIGNED BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS HEALTH CARE DIRECTIVE.)

NOTARY PUBLIC OR STATEMENT OF WITNESSES

This document must be (1) notarized or (2) witnessed by two qualified adult witnesses. The person notarizing this document may be an employee of a health care or long-term care provider providing your care. At least one witness to the execution of the document must not be a health care or long-term care provider providing you with direct care or an employee of the health care or long-term care provider providing you with direct care. None of the following may be used as a notary or witness:

1. A person you designate as your agent or alternate agent;

2. Your spouse;

3. A person related to you by blood, marriage, or adoption;

4. A person entitled to inherit any part of your estate upon your death; or

5. A person who has, at the time of executing this document, any claim against your estate.

Option 1: Notary Public

In my presence on _____________ (date), _______________________________ (name of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person signing this document to sign on the declarant's behalf.

_______________________________________

(Signature of Notary Public)

My commission expires __________________________ , 20__.

Option 2: Two Witnesses

Witness One:

(1) In my presence on ____________ (date), _________________________________ (name of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person signing this document to sign on the declarant's behalf.

(2) I am at least eighteen years of age.

(3) If I am a health care provider or an employee of a health care provider giving direct care to the declarant, I must initial this box: [ ______ ].

I certify that the information in (1) through (3) is true and correct.

_______________________________________

(Signature of Witness One)

_______________________________________

(Address)

_______________________________________

(City, State, ZIP)

Witness Two:

(2) I am at least eighteen years of age.

(3) If I am a health care provider or an employee of a health care provider giving direct care to the declarant, I must initial this box: [ ______ ].

I certify that the information in (1) through (3) is true and correct.

_______________________________________

(Signature of Witness Two)

_______________________________________

(Address)

_______________________________________

(City, State, ZIP)

ACCEPTANCE OF APPOINTMENT OF HEALTH CARE AGENT

I accept this appointment and agree to serve as agent for health care decisions. I understand I have a duty to act consistently with the desires of the principal as expressed in this appointment. I understand that this document gives me authority over health care decisions for the principal only if the principal becomes incapable incapacitated. I understand that I must act in good faith in exercising my authority under this power of attorney. I understand that the principal may revoke this power of attorney at any time in any manner.

If I choose to withdraw during the time the principal is competent, I must notify the principal of my decision. If I choose to withdraw when the principal is incapable of making the principal's not able to make health care decisions, I must notify the principal's physician.

___________________________________ _____________

(Signature of Agent) (Date)

___________________________________ _____________

(Signature of Alternate Agent) (Date)

PRINCIPAL'S STATEMENT

I have read a written explanation of the nature and effect of an appointment of a health care agent that is attached to my health care directive.

Dated this day of ________________, 20____.

___________________________________
(Signature of Principal)

STATEMENT AFFIRMING EXPLANATION OF DOCUMENT TO

RESIDENT OF LONG-TERM CARE FACILITY

(Only necessary if person is a resident of long-term care facility and Part I is completed appointing an agent. This statement does not need to be completed if the resident has read a written explanation of the nature and effect of an appointment of a health care agent and completed the Principal's Statement above.)

I have explained the nature and effect of this health care directive to _________________________________ (name of principal) who signed this document and who is a resident of _____________________________________________ (name and city of facility). I am (check one of the following):

[ ______ ] A recognized member of the clergy.

[ ______ ] An attorney licensed to practice in North Dakota.

[ ______ ] A person designated by the district court for the county in which the above-named facility is located.

[ ______ ] A person designated by the North Dakota Department of Human Services.

Dated on _______________, 20____.

___________________________________
(Signature)

STATEMENT AFFIRMING EXPLANATION OF DOCUMENT TO

HOSPITAL PATIENT OR PERSON BEING ADMITTED TO HOSPITAL

(Only necessary if person is a patient in a hospital or is being admitted to a hospital and Part I is completed appointing an agent. This statement does not need to be completed if the patient or person being admitted has read a written explanation of the nature and effect of an appointment of a health care agent and completed the Principal's Statement above.)

I have explained the nature and effect of this health care directive to _______________________________ (name of principal) who signed this document and who is a patient or is being admitted as a patient of __________________________________ (name and city of hospital). I am (check one of the following):

[ ______ ] An attorney licensed to practice in North Dakota.

[ ______ ] A person designated by the hospital to explain the health care directive.

Dated on _______________, 20____.

___________________________________
(Signature)

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North Dakota Health Care Directive

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