Wyoming Advance Health Care Directive

WYOMING ADVANCE HEALTH CARE DIRECTIVE

(Wyoming Health Care Decisions Act · W.S. 35-22-401 through W.S. 35-22-416)

This is a PublicLegal-authored advance health care directive under the Wyoming Health Care Decisions Act. Wyoming repealed its former living-will declaration statute in 2005 (W.S. 35-22-101 through W.S. 35-22-109) and does not publish a current statutory form. Part 1 records your individual instructions. Part 2 appoints a health care agent. If you name an agent, complete the notary or two-witness execution under W.S. 35-22-403(b).

YOUR IDENTITY

My full legal name: ________________________________________________

Date of birth: ____________________________

Address: _______________________________________________________

City, County, and State: __________________________________________

PART 1. INDIVIDUAL INSTRUCTIONS FOR HEALTH CARE

Under W.S. 35-22-403(a), an adult or emancipated minor may give an individual instruction. The instruction may be oral or written and may be limited to take effect only if a specified condition arises. No witness or notary is required for Part 1 alone. Your signature below attributes these instructions to you.

I give the following individual instructions concerning my health care. Unless I limit them, these instructions apply when I lack capacity to make a health care decision, as determined under W.S. 35-22-403(e).

A. End-of-life treatment (check one):

☐ I do not want my life to be prolonged by life-sustaining treatment (including artificial nutrition and hydration) if I have an incurable and irreversible condition that will result in my death within a relatively short time, or if I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or if the likely risks and burdens of treatment would outweigh the expected benefits.

☐ I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

B. Artificial nutrition and hydration (check one):

☐ I want artificial nutrition and hydration provided if needed, even if I have checked the choice not to prolong life above, unless artificial nutrition and hydration cannot reasonably be expected to prolong my life or would be excessively burdensome.

☐ I do not want artificial nutrition and hydration if I have checked the choice not to prolong life above.

☐ I want my agent or, if I have no agent, my surrogate to decide about artificial nutrition and hydration.

C. Relief from pain:

Except as I state in the additional instructions below, I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death.

D. Additional individual instructions:

Use this space for other treatment wishes, religious or personal limitations, organ donation preferences, or conditions under which these instructions take effect. Leave blank if none. ______________________________________________________________ ______________________________________________________________

Signature (Part 1 instructions): ________________________________________

Date: ____________________________

PART 2. POWER OF ATTORNEY FOR HEALTH CARE

Under W.S. 35-22-403(b), an adult or emancipated minor may execute a durable power of attorney for health care. The power must be in writing and signed by you (or by another person in your presence and at your expressed direction). It must be acknowledged before a notarial officer OR signed by at least two qualified witnesses who make the statutory declaration below. Unless related to you by blood, marriage, or adoption, an agent may not be an owner, operator, or employee of a residential or community care facility at which you are receiving care.

1. Designation of agent

I designate as my agent: ____________________________________________

Address: _______________________________________________________

Telephone: ______________________________

2. Alternate agent (optional)

If my agent is not reasonably available, not willing to make a health care decision for me, or is disqualified, I designate the following person as my alternate agent:

Alternate agent: ________________________________________________

Address: _______________________________________________________

Telephone: ______________________________

3. Authority of agent

My agent is authorized to make any health care decision for me that I could make while having capacity, including selection and discharge of health care providers and institutions; approval or disapproval of diagnostic tests, surgical procedures, programs of medication, and orders not to resuscitate; and directions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care (W.S. 35-22-402(a)(ix), W.S. 35-22-403(b)). My agent shall make decisions in accordance with this directive and my other wishes to the extent known to my agent, and otherwise in my best interest, considering my personal values to the extent known (W.S. 35-22-403(f)).

4. When agent's authority becomes effective (check one):

☐ My agent's authority becomes effective only upon a determination that I lack capacity (W.S. 35-22-403(d) default).

☐ My agent's authority becomes effective immediately and continues if I later lack capacity.

5. Limitations on agent's authority (optional): ______________________________________________________________

6. Nomination of guardian (optional) A written advance health care directive may include nomination of a guardian of the person (W.S. 35-22-403(h)).

I nominate as guardian of my person: ________________________________________

EXECUTION OF THIS DIRECTIVE

Sign below. If you completed Part 2 (agent designation), you must also complete either Option A (notarial acknowledgment) or Option B (two qualified witnesses) under W.S. 35-22-403(b). If you completed only Part 1, your signature above and below is enough to attribute your individual instructions; Option A or B is optional authentication.

Principal's signature: _____________________________________________

Print name: ________________________________________________

Date: ____________________________

City and State: ________________________________________

OPTION A — NOTARIAL ACKNOWLEDGMENT

Use this option if you choose acknowledgment before a notarial officer instead of two witnesses (W.S. 35-22-403(b)).

State of Wyoming )

County of ____________________________ )

This instrument was acknowledged before me on __________________ by ____________________________.

Notary Public signature: __________________________________________

Print name: ________________________________________________

My commission expires: ____________________________

OPTION B — TWO WITNESSES

Use this option if you choose two witnesses instead of a notary. None of the following may be a witness: a treating health care provider or employee of the provider; the attorney-in-fact nominated in this writing; or an operator or employee of a community care facility or residential care facility (W.S. 35-22-403(c)). Each witness must make the following declaration in substance (W.S. 35-22-403(b)):

"I declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is known to me to be the principal, and the principal signed or acknowledged this document in my presence."

Witness 1

Signature: ________________________________________________

Print name: ________________________________________________ Date: ____________________________

Witness 2

Signature: ________________________________________________

Print name: ________________________________________________ Date: ____________________________

Give signed copies to your agent, alternate, primary physician, and health care institution. You may revoke all or part of this directive (other than the agent designation) in any manner that communicates an intention to revoke (W.S. 35- 22-404(b)). Revoke an agent designation only by a signed writing (W.S. 35-22-404(a)). A later conflicting directive revokes an earlier one to the extent of the conflict (W.S. 35-22-404(e)).