North Dakota Health Care Directive

HEALTH CARE DIRECTIVE

North Dakota · N.D.C.C. § 23-06.5-17

I, __________________________________________________

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

PART I: Name another individual, called the health care agent, to make health care decisions for me if I am unable to make and communicate them. My agent must follow Part II and my known wishes, or act in my best interest if my wishes are unknown.

AND/OR

PART II: Give health care instructions to guide my agent, health care providers, others assisting with my care, and my family if I cannot make and communicate decisions.

AND/OR

PART III: Make an organ and tissue donation upon my death by signing a document of anatomical gift.

PART I: APPOINTMENT OF HEALTH CARE AGENT

Complete this part only if you want an agent. You may change your agent or alternate at any time. A treating health care provider, a nonrelative employee of that provider, a long-term care facility operator, or a nonrelative employee of that facility may not serve as agent.

Health care agent: __________________________________________

Relationship: _______________________________________________

Telephone: ________________________________________________

Address: ___________________________________________________

OPTIONAL ALTERNATE AGENT

Alternate agent: ___________________________________________

Relationship: _______________________________________________

Telephone: ________________________________________________

Address: ___________________________________________________

AGENT POWERS

My health care agent is automatically given powers (A) through (D), subject to my instructions and best interests:

(A) Make any health care decision, including giving, refusing, or withdrawing consent to care, life-sustaining care, and mental health treatment.

(B) Choose my health care providers.

(C) Choose where I live and receive care and support when related to health care needs.

(D) Review and disclose my medical records with the same rights I would have.

Limits on powers (A) through (D):

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The following powers are NOT automatic. INITIAL a box only if you want your agent to have that power:

(1) Decide whether to donate any parts of my body, including organs, tissues, and eyes, when I die.

(2) Decide what will happen with my body when I die, including burial or cremation.

Additional powers or limits:

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PART II: HEALTH CARE INSTRUCTIONS

Complete this part if you wish to give instructions. If you appoint no agent, complete at least Part II(B) to make a valid health care directive.

(A) MY BELIEFS AND VALUES

My goals for health care:

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My fears about health care:

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My spiritual or religious beliefs and traditions:

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

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How my condition might affect my family:

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(B) WHAT I WANT AND DO NOT WANT

Treatments may include breathing machines, tube feeding or fluids, attempts to restart the heart, surgery, dialysis, antibiotics, and transfusions. Treatments can often be tried and stopped if they do not help.

If I had a reasonable chance of recovery and were temporarily unable to decide, I would want:

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If I were dying and unable to decide, I would want:

PART II(B): HEALTH CARE INSTRUCTIONS — CONTINUED

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If I were permanently unconscious and unable to decide, I would want:

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If I were completely dependent on others and unable to decide, I would want:

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Pain relief if it affects alertness or might shorten life:

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Preferred health care provider:

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Where I would like to live while receiving care:

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

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What happens to my body after death:

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Any other wishes:

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PART III: MAKING AN ANATOMICAL GIFT

(A) I WANT TO BE AN ORGAN DONOR

☐ I would like to be an organ donor at death. I have told my family and ask them to honor my wishes.

☐ Any needed organs and tissue.

☐ Only the following organs and tissue: ______________________________

(B) I DO NOT WANT TO BE AN ORGAN DONOR

☐ I do not want to be an organ donor at death. I have told my family and ask them to honor my wishes.

PART IV: MAKING THE DOCUMENT LEGAL

EARLIER DESIGNATIONS REVOKED. I revoke any earlier health care directive.

Date: ________________________

City: _______________________________

State: ____________________________

Principal's Signature: ______________________________________

THIS HEALTH CARE DIRECTIVE WILL NOT BE VALID UNLESS IT IS NOTARIZED OR SIGNED BY TWO QUALIFIED WITNESSES PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. Date and sign every attached additional page at the same time.

DISQUALIFIED NOTARIES AND WITNESSES UNDER § 23-06.5-05(2)

The notary or witness may not be your agent or alternate, your spouse, a person related to you by blood, marriage, or adoption, a person entitled to inherit from your estate, a person with a claim against your estate, a person directly financially responsible for your medical care, or your attending physician. At least one witness also may not be a provider giving you direct care or that provider's employee.

OPTION 1: NOTARY PUBLIC

State of: ___________________________________

County of: __________________________________

Date: ______________________

Declarant's name: _______________________________________

The declarant acknowledged the signature on this document or acknowledged directing another individual to sign on the declarant's behalf.

Notary Public Signature: _____________________________________

My commission expires: _______________________________

OPTION 2: TWO WITNESSES

WITNESS ONE

Date: ______________________

Declarant's name: _______________________________________

The declarant acknowledged the signature or acknowledged directing another individual to sign. I am at least eighteen years old.

If I am a provider or employee giving direct care, I must initial this box:

I am a provider or employee giving direct care.

I certify these statements are true and correct.

Witness Signature: _________________________________________

Address: ___________________________________________________

WITNESS TWO

Date: ______________________

Declarant's name: _______________________________________

The declarant acknowledged the signature or acknowledged directing another individual to sign. I am at least eighteen years old.

If I am a provider or employee giving direct care, I must initial this box:

I am a provider or employee giving direct care.

I certify these statements are true and correct.

Witness Signature: _________________________________________

Address: ___________________________________________________

PRINCIPAL'S STATEMENT

I have read the attached written explanation of the nature and effect of appointing a health care agent.

Date: __________________________

Principal's Signature: ______________________________________

ATTACHED EXPLANATION: APPOINTING A HEALTH CARE AGENT

This plain-language explanation is educational and is not legal advice. By appointing an agent, you authorize that person to make health care decisions when you cannot make and communicate them. The agent must follow this directive and your known wishes. If your wishes are unknown, the agent must act in your best interest.

The agent automatically receives the powers listed in Part I(A) through (D), unless you limit them. Body donation and disposition powers are not automatic. You must initial the separate box for each power you want to grant. You may name an alternate if the first agent is unavailable.

Talk with your agent about your values, treatment goals, and instructions. Give the agent and health care providers copies. You may change or revoke the appointment as North Dakota law permits. Completing this optional statutory form is not the only way to create a directive under North Dakota law. Consider legal advice for questions about your circumstances.