Vermont Advance Directive for Health Care

VERMONT ADVANCE DIRECTIVE FOR HEALTH CARE

18 V.S.A. chapter 231 · PublicLegal expanded advance directive

You have the right to consent to or refuse treatment and to appoint an agent. Fill out any Parts you choose. If you fill out any Part, you must complete Part 9 so the directive is dated, signed, and witnessed under 18 V.S.A. § 9703.

This form does not authorize treatment to be provided or withheld over your objection. That authority requires a separate provision complying with 18 V.S.A. § 9707(h).

Name: ______________________________________

Date of Birth: ______________________

Date Signed: ______________________

Address: _______________________________________________________

City, State, ZIP: _____________________________________________

Phone: __________________________

Email: ______________________________________

PART 1: MY HEALTH CARE AGENT

I appoint the person named below as my health care agent and delegate authority to make health care decisions for me, subject to the instructions and limits in this directive. If a named agent is not reasonably available, I appoint the next alternate named below to serve with the same authority.

Agent limits under 18 V.S.A. § 9702(c): my health care provider may not serve as my agent. Unless related to me as allowed by law, an owner, operator, employee, agent, or contractor of a residential care, health care, or correctional facility where I reside may not serve as my agent.

INITIAL one timing choice:

(___) My agent may act when I am no longer able to make health care decisions.

(___) My agent may act immediately.

(___) My agent may act when this condition or event occurs:

Primary agent I appoint

Name: __________________________________________

Address: ____________________________________________________

Relationship: ____________________________

Phone: ____________________________

Email: ____________________________________

Alternate agent I appoint

Name: __________________________________________

Address: ____________________________________________________

Relationship: ____________________________

Phone: ____________________________

Email: ____________________________________

Next alternate agent I appoint

Name: __________________________________________

Address: ____________________________________________________

Relationship: ____________________________

Phone: ____________________________

Email: ____________________________________

Optional co-agents

Name co-agents only if you want them to act together. State how they may decide, including what happens in an emergency.

Co-agent names and contact information: ___________________________________

______________________________________________________________

______________________________________________________________

Decision instructions: _____________________________________________

______________________________________________________________

______________________________________________________________

PART 2: OTHERS INVOLVED IN MY CARE

Doctor or clinician name: ______________________________________

Address and phone: _____________________________________________

People my agent may consult: __________________________________________

______________________________________________________________

People my agent should not consult: _____________________________________

______________________________________________________________

People who may receive information about my condition: _________________________

______________________________________________________________

People barred from bringing a court action or serving as decision maker:

______________________________________________________________

______________________________________________________________

INITIAL one guardian preference:

(___) I prefer my health care agent as guardian.

(___) I prefer the person named below as guardian. Preferred guardian name and contact information:

PART 3: STATEMENT OF VALUES AND GOALS

State what is most important to you and how others should approach medical choices.

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

PART 4: END-OF-LIFE TREATMENT WISHES

If I am close to death, or unconscious and unlikely to regain consciousness, I INITIAL the wishes that apply:

(___) 1. I want all possible treatments to extend my life.

(___) 2. I do not want my life extended by breathing machines, tube feeding, antibiotics, life-extending medicines, or other life-extending means. Limit or explain this choice below.

(___) 3. I want my agent to decide what treatments I receive, including tube feeding.

(___) 4. I want care that preserves my dignity and provides comfort and relief from symptoms.

(___) 5. I want pain medication even if it may unintentionally hasten my death.

(___) 6. I want hospice care when appropriate in any setting.

(___) 7. I prefer to die at home if possible.

Other wishes or limits: __________________________________________

______________________________________________________________

______________________________________________________________

PART 5: OTHER TREATMENT WISHES

INITIAL each wish that applies:

(___) I wish to have a Do Not Resuscitate order written for me. This wish is not itself a DNR or COLST order. A clinician must issue the order on the Department of Health form under § 9708.

(___) In a critical crisis that may not be life-ending, start treatment. Stop life-extending treatment if a reasonable trial shows I will not improve.

(___) If I am conscious but unable to think or act for myself and unlikely to improve, limit life-extending treatment as stated below. Identify treatment limits below.

(___) If treatment costs, risks, or burdens are more than I wish to endure, I do not want life-extending treatment. Describe the burdens that concern you below.

Treatment limits and burden concerns: ___________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Pregnancy

If I am pregnant when this directive becomes effective, INITIAL one preference:

(___) I want all life-sustaining treatment.

(___) I want only the life-sustaining treatment listed below. List treatment below.

(___) I do not want life-sustaining treatment.

Hospitalization and medication preferences

Preferred hospitals or facilities and why: _______________________________

______________________________________________________________

______________________________________________________________

Facilities to avoid and why: _______________________________________

______________________________________________________________

______________________________________________________________

Preferred medications or treatments: ___________________________________

______________________________________________________________

______________________________________________________________

Medications or treatments to avoid and why: ____________________________

______________________________________________________________

______________________________________________________________

Education and trials

CHECK one choice on each line:

☐ I do wish to participate in student medical education.

☐ I do not wish to participate in student medical education.

☐ I do wish to participate in treatment studies or drug trials.

☐ I do not wish to participate in treatment studies or drug trials.

Mental health emergency guidance

List medicines, hospitals, people to contact, calming measures, crisis-plan directions, and treatments you want or do not want.

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

PART 7: ORGAN AND TISSUE DONATION

INITIAL one choice:

(___) I want to donate any organs and tissues needed.

(___) I want to donate only the organs and tissues listed below.

(___) I do not want to donate organs or tissues.

Donation limits or instructions: _______________________________________

______________________________________________________________

PART 8: DISPOSITION OF MY REMAINS

INITIAL one disposition preference:

(___) I prefer burial at the place described below.

(___) I prefer cremation with ashes handled as described below.

(___) I want my health care agent to decide arrangements after my death.

(___) I want my family to decide arrangements after my death.

Burial, cremation, or other disposition instructions: ____________________________

______________________________________________________________

______________________________________________________________

INITIAL one autopsy preference:

(___) I authorize an autopsy if requested for medical or legal purposes.

(___) I do not authorize an autopsy unless required by law.

I appoint the following person as my agent for disposition of my body after death (optional). Under § 9702(d), unless related to me as allowed by law, a funeral director, crematory operator, cemetery official, or procurement organization employee generally may not serve.

Disposition agent name: ________________________________________

Address and phone: _____________________________________________

(___) I have made pre-need arrangements described below.

Pre-need provider or other instructions: ___________________________________

______________________________________________________________

______________________________________________________________

PART 9: DECLARATION AND SIGNATURES

I declare that this document reflects my desires regarding my future health care, organ and tissue donation, and disposition of my body after death, and that I am signing this Advance Directive of my own free will. I understand that I may revoke or suspend it as allowed by Vermont law.

Principal's Signature: __________________________________________

Date: ________________________

If I am physically unable to sign, another individual may sign in my presence and at my express direction:

Directed signer printed name: ____________________________________

Directed signer signature: ____________________________________

Optional copy acknowledgements:

☐ I gave a copy to my agent.

Agent name and date: _______________________________________

☐ I gave a copy to my clinician.

Clinician name and date: ___________________________________

Each witness must be at least 18 years old. The agent and the principal's spouse, parent, adult sibling, adult child, and adult grandchild may not witness. A health care provider may witness. Each witness affirms that the principal appeared to understand the nature of this document and to be free from duress or undue influence at the time it was signed.

This edition uses the physical-presence execution path under § 9703(b)(1). If a witness is remote, § 9703(b)(2) also requires that the witness know the principal, communicate by telephone or live interactive audio-video, and that the directive include the remote witness's name, contact information, and relationship to the principal.

Witness 1

Printed Name: ______________________________________

Phone or email: ____________________________________

Relationship to principal: ________________________________

Date of signing or conversation: ______________________________

Signature: _____________________________________________

Witness 2

Printed Name: ______________________________________

Phone or email: ____________________________________

Relationship to principal: ________________________________

Date of signing or conversation: ______________________________

Signature: _____________________________________________

Facility explainer acknowledgement, when required

If, at execution, the principal is being admitted to or is a resident of a nursing home or residential care facility, or is being admitted to or is a patient in a hospital, § 9703 requires a qualified individual to explain the nature and effect of the advance directive and sign below. The explainer may also serve as one of the two witnesses.

CHECK the capacity that applies:

☐ Ombudsman

☐ Recognized member of the clergy

☐ Attorney licensed in Vermont

☐ Probate Division designee

☐ Hospital designee under § 9709(d)

☐ Mental health patient representative

☐ Trained uncompensated nursing-home or residential-care volunteer (facility setting only)

☐ Clinician not employed by the nursing home or residential care facility (facility setting only)

Explainer printed name: ______________________________________

Date: ________________________

Signature: _____________________________________________

I affirm that I explained the nature and effect of this advance directive to the principal and that the principal appears willingly and voluntarily executing it.