VIRGINIA ADVANCE MEDICAL DIRECTIVE
I, CURTIS C. CLIENT, of 123 Main Street, Anytown, USA, willfully and voluntarily make known my desire and do hereby declare:
LIVING WILL
Statement of My Intent
In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intent that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences of such refusal.
So long as I am competent, I intend to control my own medical care. I therefore wish to be informed of my condition and prognosis so long as I am able to comprehend them. I would consider myself competent if I were able to understand my illness, able to grasp the nature and effect of proposed treatment and able to know the risk in either accepting or refusing it.
I desire that every effort should be made to inform me and to consult with me in order to obtain my directions concerning my care, even if I am unable to communicate with words, but can only indicate my desires with non-verbal powers of communication.
This declaration is made after careful consideration and is in accordance with my strong convictions and beliefs. I want my wishes and directions as expressed in this declaration to be carried out to the extent permitted by law. Insofar as they are not legally enforceable, I hope that my family, my physician, the courts, and all others who may be involved in such decision-making will regard themselves as morally bound by this declaration.
Notwithstanding any other provisions of this Living Will, and without limiting any other provisions of this Living Will; if I suffer from a persistent vegetative state, I specifically refuse any treatment that is not directed at alleviating specifically, and with high probability of success, the underlying condition causing the persistent vegetative state.
I wish to die naturally, with only the administration of medication or the performance of any medical procedures deemed necessary to provide me with comfort and care or to alleviate pain, even though they may shorten my remaining life. I ask that an appropriate time be allowed for family and friends to gather to say farewell, but without excessively prolonging my natural death.
Directive Not To Use Or To Discontinue Life Prolonging Medical Treatment When Recovery Is Unlikely
If two physicians, one of whom is my attending physician and both of whom are familiar with my condition and neither of whom is a trustee or beneficiary under my living trust or will, have determined with reasonable medical probability and noted in my medical records the existence of any of the following conditions, I direct that I be allowed to die, and not be kept alive by mechanical means, artificial devices, or other medical treatment. It is my desire that if any of these conditions exist such procedures be withheld and if previously instituted that they be discontinued:
- that I have a disease, illness or other condition which is incurable, terminal and expected to result in my death from that injury, disease, or illness within six (6) months and thus that the use of life sustaining procedures would serve only to prolong the dying process, and they have further determined that I am unable to give informed consent to medical treatment; or
- that I am in a coma or in a vegetative state and the coma or vegetative state is irreversible, meaning that there is no reasonable medical probability of my ever regaining consciousness, or if I am in a vegetative state, the higher function of my brain has ceased. In such a case the two physicians shall include an appropriate specialist; or
- that my consciousness is irrevocably impaired such that I am so severely demented that I am unable to make my own decisions, unable to respond to commands or requests, unable to recognize and meaningfully interact with my family or other loved ones, or unable to convey in any way the attributes that I associate with personhood, such as the ability to experience joy, desire, pleasure and consciousness of myself as a continuing entity. This determination may be made by a neurologist and must be made with certainty that is reasonable (not absolute) in light of present medical knowledge; or
- that if as a result of illness or injury I am otherwise severely or irreversibly disabled and there is no reasonable expectation of recovery to decision making capacity and the ability to care independently for my own self, or the ability to recognize and meaningfully interact with my family or other loved ones, or to convey in any way the attributes I associate with personhood, such as the ability to experience joy, desire, pleasure and consciousness of myself as a continuing entity. This determination may be made by a qualified neurologist and must be made with certainty that is reasonable (not absolute) in light of present medical knowledge.
Definition of Medical Treatment or Procedures
By “medical treatments or procedures” I mean interventions by medical doctors, nurses, paramedics, or any other health care provider, in the care of my body and mind. This includes but is not limited to all medical and surgical procedures, mechanical or otherwise, treatments, therapies, drugs (including, but not limited to antibiotics), and hormones that may substitute for, replace, supplant, enhance, suppress, or assist any bodily function. With respect to all medical treatments or procedures, I include both existing technology and any methods or techniques that may be hereafter developed. This definition specifically includes (but is not limited to) maintenance of respiration or heartbeat, renal dialysis, administration of blood products, transplants, and nutrition and hydration by artificial means.
Provision For Pain Control
I wish to have pain relieving drugs of any type administered, or other surgical or medical procedures calculated to alleviate my pain. Such pain relief may be authorized even though its use may lead to physical damage, addiction or even hasten the moment of (but not intentionally cause) my death.
Do Not Resuscitate (DNR) Order
Under the circumstances described on Page 2, I expressly consent to a Do Not Resuscitate (DNR) order, and direct that such order be placed in my medical record.
Artificial Nutrition and Hydration
Under the circumstances described on Page 2, if I am unable to eat by swallowing my food I specifically do not want any artificial means of nutrition and hydration, notwithstanding the possibility that I could suffer temporary discomfort from the withholding of such treatment.
Antibiotics
Except as herein described, I specifically direct that no attempts be made to treat any reversible secondary condition, when the circumstances described on Page 2 exist. In the event of infections, including pneumonia or other serious infections, I do not want parenteral antibiotics or oral antibiotics which in any way could be interpreted as life-saving. If needed to prevent the spread of contagious infection, then appropriate treatment can be given to address these limited circumstances.
Chemotherapy
In the event that I am diagnosed with cancer and chemotherapy is proposed, I specifically direct that if death is imminent within six months, my agent shall not authorize or consent to chemotherapy if such treatment is unlikely to improve my condition or to reduce pain.
Blood Transfusion
If I should ever need blood transfusions and the conditions on Page 2 exist, it is my desire not to receive such transfusions.
Desire For Home Care
If at all possible, and if doing so does not impose an undue cost or other burden on my family, I would like to live out my last days at home with appropriate medical, nursing, social, and emotional support and any necessary medical or other equipment needed to keep me comfortable. Alternatively, my agent under my Durable Medical Power of Attorney may choose hospice care, or care in a facility which my agent deems appropriate. Under the circumstances described on Page 2, I refuse permission to be transferred to a hospital if the sole purpose is to prolong my life.
Desire For Loving And Dignified Care
If I should suffer a serious disease, injury, or illness, I desire that those who love and care for me touch me and tell me so, demonstrating that I am precious to them. I ask that those involved in my medical care conduct themselves so that it is apparent that I am included in their respect and care for all humanity, trying to make me aware of that respect through any of my senses, regardless of my condition. I particularly ask that I not be left alone or isolated with silence when dying.
Preexisting Condition
If at the time my agent has to make decisions on my behalf and I have a preexisting condition for which I am taking medication, I authorize my Agent to continue such medication for comfort only. If the medication in any way prolongs the dying process, then I direct my Agent to discontinue the medication.
Release Of Liability
I hereby release and hold harmless any person who, in good faith, terminates life-sustaining procedures in accordance with the guidelines in this declaration.
HEALTHCARE POWER OF ATTORNEY
I hereby appoint my wife CATHY C. CLIENT, of 123 Main Street, Anytown, USA, as my agent to make health care decisions for me.
I hereby grant to my agent, named above, full power and authority to make health care decisions on my behalf as described below whenever I have been determined to be incapable of making an informed decision about providing, withholding or withdrawing medical treatment. The phrase “incapable of making an informed decision” means unable to understand the nature, extent and probable consequences of a proposed medical decision or unable to make a rational evaluation of the risks and benefits of a proposed medical decision as compared with the risks and benefits of alternatives to that decision, or unable to communicate such understanding in any way. My agent’s authority hereunder is effective as long as I am incapable of making an informed decision except as expressly stated in the Living Will portion of this Directive (as hereinabove set forth).
The determination that I am incapable of making an informed decision shall be made by my attending physician and a second physician or licensed clinical psychologist after a personal examination of me and shall be certified in writing. Such certification shall be required before treatment is withheld or withdrawn, and before, or as soon as reasonably practicable after, treatment is provided, and every 180 days thereafter while the treatment continues.
In exercising the power to make health care decisions on my behalf, my agent shall follow my desires and preferences as stated in this document or as otherwise known to my agent. My agent shall be guided by my medical diagnosis and prognosis and any information provided by my physicians as to the intrusiveness, pain, risks, and side effects associated with treatment or non-treatment. My agent shall not authorize a course of treatment which she knows, or upon reasonable inquiry ought to know, is contrary to my religious beliefs or my basic values, whether expressed orally or in writing. If my agent cannot determine what treatment choice I would have made on my own behalf, then my agent shall make a choice for me based upon what she believes to be in my best interests.
POWERS OF MY AGENT
The powers of my agent shall include the following:
A. To consent to or refuse or withdraw consent to any type of medical care, treatment, surgical procedure, diagnostic procedure , medication and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, artificially administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the power to consent to the administration of dosages of pain-relieving medication in excess of recommended dosages in an amount sufficient to relieve pain, even if such medication carries the risk of addiction or inadvertently hastens my death;
B. To request, review, and receive, to the extent I could do so individually, any information, verbal or written, regarding my physical or mental health, including, but not limited to, my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160-164. I hereby authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose, and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present, or future medical or mental health condition. This authority given my agent shall supersede any other agreement which I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. This authority given my agent shall be effective immediately, has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider;
C. To employ and discharge my health care providers;
D. To authorize my admission to or discharge (including transfer to another facility) from any hospital, hospice, nursing home, adult home or other medical care facility for services other than those for treatment of mental illness requiring admission procedures provided in Article 1 (§37.1-63 et seq.) of Chapter 2 of Title 37.1;
E. To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers; and,
F. To make decisions regarding visitation.
Further, my agent shall not be liable for the costs of treatment pursuant to his authorization, based solely on that authorization.
AUTHORIZATION FOR YOUR AGENT TO MAKE AN ANATOMICAL GIFT
Upon my death, I direct that an anatomical gift of all or any part of my body may be made pursuant to Article 2 (§ 32.1-289 et seq.) of Chapter 8 of Title 32.1 of the Virginia Code of 1950 as amended or restated, and in accordance with my directions, if any. I hereby authorize my agent to make any such anatomical gift following my death.
This advance directive shall not terminate in the event of my disability.
I revoke any prior health care directives, “Living Wills” and any prior powers of attorney for health care.
Persons dealing with my agent may rely fully on a photocopy of this document as though the photocopy was an original.
By signing below, I indicate that I am emotionally and mentally competent to make this advance directive and that I understand the purpose and effect of this document.
_______________________________________
CURTIS C. CLIENT
Dated: __________________
