Oregon Advance Directive for Health Care

OREGON ADVANCE DIRECTIVE FOR HEALTH CARE

ORS 127.529 · 2021 Oregon Laws chapter 328

This form lets you share your values, beliefs, goals and wishes for health care if you cannot

express them yourself. It also lets you name a health care representative, who must agree to

serve, to make health care decisions when you cannot make them yourself.

Discuss this directive and your wishes with your representative. Completing the entire form is

recommended. Sections 1, 2, 5, 6 and 7 appoint a representative. Sections 3 and 4 give care

instructions.

This Advance Directive is not a Portable Orders for Life-Sustaining Treatment form, or POLST.

If you have an older advance directive, this new directive replaces it. ORS 127.658 preserves

the effect of qualifying directives executed under prior law.

You must sign this form and use either two adult witnesses or a notary. A representative

appointment is not effective until the representative accepts it. A witness may not be your

attending physician or attending health care provider, or a representative or alternate appointed

in this form. If you are a patient in a long-term care facility and use witnesses, one witness must

meet the facility-designation rule in ORS 127.515.

1. ABOUT ME

____________________________________________________

Name (first, middle, last)

________________________

Date of birth

________________________

Home telephone

________________________

Work telephone

________________________

Cell telephone

____________________________________________________________

Address

__________________________________________

E-mail

2. MY HEALTH CARE REPRESENTATIVE

I choose the following person as my health care representative to make health care decisions

for me if I cannot speak for myself.

Health care representative

____________________________________________________

Name (first, middle, last)

____________________________

Relationship

________________________

Home telephone

________________________

Work telephone

________________________

Cell telephone

____________________________________________________________

Address

__________________________________________

E-mail

I choose the following people as alternates if my first choice is unavailable or if I cancel the first

appointment.

First alternate health care representative

____________________________________________________

Name (first, middle, last)

____________________________

Relationship

________________________

Home telephone

________________________

Work telephone

________________________

Cell telephone

____________________________________________________________

Address

__________________________________________

E-mail

Second alternate health care representative

____________________________________________________

Name (first, middle, last)

____________________________

Relationship

________________________

Home telephone

________________________

Work telephone

________________________

Cell telephone

____________________________________________________________

Address

__________________________________________

E-mail

3. MY HEALTH CARE INSTRUCTIONS

This section expresses my wishes, values and goals. These instructions guide my

representative and providers even if I do not appoint a representative or the representative

cannot be reached.

A. MY HEALTH CARE DECISIONS

For each situation, initial one option only.

Terminal condition

This applies if I have an illness that cannot be cured or reversed and my providers believe it will

result in my death within six months regardless of treatment.

I want to try all available treatments to sustain my life, such as artificial feeding and

hydration with feeding tubes, IV fluids, kidney dialysis and breathing machines.

I want to try to sustain my life with artificial feeding and hydration with feeding tubes and

IV fluids. I do not want other treatments to sustain my life, such as kidney dialysis and

breathing machines.

I do not want treatments to sustain my life, such as artificial feeding and hydration with

feeding tubes, IV fluids, kidney dialysis or breathing machines. I want to be kept

comfortable and be allowed to die naturally.

I want my health care representative to decide for me, after talking with my health care

providers and taking into account the things that matter to me. I have expressed what

matters to me in section B below.

Advanced progressive illness

This applies if I have an advanced illness that will not improve, will very likely worsen and result

in death, and my providers believe I will never again be able to communicate, swallow safely,

care for myself, or recognize family and other people.

I want to try all available treatments to sustain my life, such as artificial feeding and

hydration with feeding tubes, IV fluids, kidney dialysis and breathing machines.

I want to try to sustain my life with artificial feeding and hydration with feeding tubes and

IV fluids. I do not want other treatments to sustain my life, such as kidney dialysis and

breathing machines.

I do not want treatments to sustain my life, such as artificial feeding and hydration with

feeding tubes, IV fluids, kidney dialysis or breathing machines. I want to be kept

comfortable and be allowed to die naturally.

I want my health care representative to decide for me, after talking with my health care

providers and taking into account the things that matter to me. I have expressed what

matters to me in section B below.

Permanently unconscious

This applies if I am not conscious and my providers believe it is very unlikely that I will ever

become conscious again.

I want to try all available treatments to sustain my life, such as artificial feeding and

hydration with feeding tubes, IV fluids, kidney dialysis and breathing machines.

I want to try to sustain my life with artificial feeding and hydration with feeding tubes and

IV fluids. I do not want other treatments to sustain my life, such as kidney dialysis and

breathing machines.

I do not want treatments to sustain my life, such as artificial feeding and hydration with

feeding tubes, IV fluids, kidney dialysis or breathing machines. I want to be kept

comfortable and be allowed to die naturally.

I want my health care representative to decide for me, after talking with my health care

providers and taking into account the things that matter to me. I have expressed what

matters to me in section B below.

More about care I want or do not want. I may attach additional pages.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

B. WHAT MATTERS MOST TO ME AND FOR ME

This section applies when I am terminally ill, have an advanced progressive illness, or am

permanently unconscious.

What is important to me about my life:

________________________________________________________________________

________________________________________________________________________

What I value most about my life:

________________________________________________________________________

________________________________________________________________________

What is important for me about my life:

________________________________________________________________________

________________________________________________________________________

I do not want life-sustaining procedures if I cannot be supported and be able to do the

following. Initial all that apply.

Express my needs.

Be free from long-term severe pain and suffering.

Know who I am and who I am with.

Live without being hooked up to mechanical life support.

Participate in activities that have meaning to me, such as:

______________________________________

More about what matters most to me:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

C. MY SPIRITUAL BELIEFS

Spiritual or religious beliefs, rituals or sacraments I want my representative and caregivers to

know about:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

4. MORE INFORMATION

A. Life and values

Family history, health care experiences, culture, career, support system, beliefs and values:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

B. Place of care

Places where I prefer, or do not want, to receive care:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

C. Other

Documents attached to and made part of this Advance Directive:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

D. Inform others

My representative may authorize providers, as privacy law permits, to discuss my health and

care with the following person. Only my representative may make decisions about my care.

____________________________________________________

Name (first, middle, last)

____________________________

Relationship

________________________

Home telephone

________________________

Work telephone

________________________

Cell telephone

____________________________________________________________

Address

__________________________________________

E-mail

5. MY SIGNATURE

____________________________________________________

My signature

____________________________________________________

Printed name

________________________

Date

6. WITNESS

Complete either A or B when you sign.

A. NOTARY

State of __________________ County of ______________________

Signed or attested before me on ________________, 20______,

by ________________________________________________.

____________________________________________________

Notary Public - State of Oregon

Commission expires: ______________________

(Affix seal here)

B. WITNESS DECLARATION

The person completing this form is personally known to me or has provided proof of identity, has

signed or acknowledged the person's signature on the document in my presence and appears

not to be under duress and to understand the purpose and effect of this form. I am not the

person's health care representative or alternate health care representative, and I am not the

person's attending health care provider.

First witness

____________________________________________________

Witness name (print)

____________________________________________________

Signature

________________________

Date

Second witness

____________________________________________________

Witness name (print)

____________________________________________________

Signature

________________________

Date

7. ACCEPTANCE BY MY HEALTH CARE REPRESENTATIVE

I accept this appointment and agree to serve as health care representative.

Health care representative

____________________________________________________

Printed name

____________________________________________________

Signature or other verification of acceptance

________________________

Date

First alternate health care representative

____________________________________________________

Printed name

____________________________________________________

Signature or other verification of acceptance

________________________

Date

Second alternate health care representative

____________________________________________________

Printed name

____________________________________________________

Signature or other verification of acceptance

________________________

Date