Fillable Printable Durable Power of Attorney for Health Care and Living Will

Durable Power of Attorney for Health Care and Living Will

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This advance directive form is an official document where you can write down your preferences for your

health care. If someday you can’t make health care decisions for yourself anymore, this advance directive

can help guide the people who will make decisions for you.

You can use this form to:

Name specific people to make health care decisions for you

Describe your preferences for how you want to be treated

Describe your preferences for medical care, mental health care, long-term care, or other types of health

care

When you complete this form, it’s important that you also talk to your doctor, family, and other loved ones

who may help to decide about your care. You should explain what you meant when you filled out the form.

A health care professional can help you with this form and can answer any questions that you have. If you

need more space for any part of the form, you may attach extra pages. Be sure to initial and date every page

that you attach.

VA ADVANCE DIRECTIVE

DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL

OMB Approval Number 2900-0556

Estimated Burden Avg: 30 minutes

Expiration Date: 10/31/2017

PART I: PERSONAL INFORMATION

NAME (Last, First, Middle): LAST FOUR DIGITS OF SSN:

STREET ADDRESS:

CITY, STATE, ZIP:

HOME PHONE WITH AREA CODE: WORK PHONE WITH AREA CODE: MOBILE PHONE WITH AREA CODE:

Privacy Act Information and Paperwork Reduction Act Notice

The information requested on this form is solicited under the authority of 38 C.F.R. §17.32. It is being collected to document

your preferences for your health care in the event that you can’t speak for yourself anymore. The information you provide

may be disclosed outside the VA as permitted by law. Possible disclosures include those that are described in the “routine

uses” identified in the VA system of records 24VA19, Patient Medical Record-VA, published in the Federal Register in

accordance with the Privacy Act of 1974. This is also available in the Compilation of Privacy Act Issuances at

health care providers may not understand your preferences as well. If you don’t fill out this form, there won’t be any effect on

the benefits you are entitled to receive. The Paperwork Reduction Act of 1995 requires us to let you know that this

information collection follows the clearance requirements of section 3507 of this Act. We estimate that it will take you about

30 minutes to fill out this form, including the time for reviewing instructions, searching existing data sources, gathering and

maintaining the data needed, and completing and reviewing the information you write down. A Federal agency may not

conduct or sponsor, and a person is not required to respond to a collection of information, unless it displays a current valid

OMB control number. The OMB Control No. for this information collection is 2900-0556.

http://www.gpoaccess.gov/privacyact/index.html. You may choose to fill out this form or not. But without this information, VA

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Name (Last, First, Middle):

VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL

NAME (Last, First, Middle)

LAST FOUR DIGITS OF SSN:

Place your initials in the box next to your choice. Choose only one.

Relationship to Me:

A - HEALTH CARE AGENT

PART II: DURABLE POWER OF ATTORNEY FOR HEALTH CARE

I don't wish to appoint a Health Care Agent right now.

(Skip this section and go to Part III, Living Will.)

I appoint the person named below to make decisions about my health care if I can't decide for myself

anymore.

This section of the advance directive form is called a Durable Power of Attorney for Health Care. It lets you

appoint a specific person to make health care decisions for you in case you can’t make decisions for

yourself anymore. This person will be called your Health Care Agent.

Your Health Care Agent should be someone:

You trust

Who knows you well

l Who is familiar with your values and beliefs

If you get too sick to make decisions for yourself, your Health Care Agent will have the authority to make all

health care decisions for you. This includes decisions to admit and discharge you from any hospital or other

health care institution. Your Health Care Agent can also decide to start or stop any type of health care

treatment. He or she can access your personal health information, including your medical records.

NOTE: Information about whether you have been tested for HIV or treated for AIDS, sickle cell anemia,

substance abuse or alcoholism will only be shared with your Health Care Agent under very limited

circumstances. If you wish to give general permission for VA to share this information with your Health Care

Agent, you will need to give special written consent by completing VA Form 10-5345. You can get VA Form

10-5345 from your VA health care provider or you can get it using a computer from this website

Street Address:

City, State, Zip:

Work Phone with Area Code:Home Phone with Area Code: Mobile Phone with Area Code:

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http://www4.va.gov/vaforms/medical/pdf/vha-10-5345-fill.pdf

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This section of the advance directive form is called a Living Will. This section of it lets you write down how

you want to be treated in case you aren't able to decide for yourself anymore. Its purpose is to help others

decide about your care.

VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL

NAME (Last, First, Middle) LAST FOUR DIGITS OF SSN:

PART III: LIVING WILL

A - SPECIFIC PREFERENCES ABOUT LIFE-SUSTAINING TREATMENTS

If I have permanent, severe brain damage that

makes me unable to recognize my family or friends

(for example, severe dementia).

If I am unconscious, in a coma, or in a vegetative

state and there is little or no chance of recovery.

In this section, you can indicate your preferences for life-sustaining treatments in certain situations. Some

examples of life-sustaining treatments are:

CPR (cardiopulmonary resuscitation)

a breathing machine (mechanical ventilation)

kidney dialysis

a feeding tube (artificial nutrition and hydration)

Think about each situation described on the left and ask yourself, “In that situation, would I want to have

life-sustaining treatments?” Place your initials in the box that best describes your treatment preference. You

may complete some, all, or none of this section. Choose only one box for each statement.

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Yes.

I would want

life-sustaining

treatments.

I'm not sure. It

would depend

on the

circumstances.

No.

I would not want

life-sustaining

treatments.

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Fill out this section if you want to appoint a second person to make health care decisions for you,

in case the first person isn’t available.

City, State, Zip:

Street Address:

Work Phone with Area Code:Home Phone with Area Code: Mobile Phone with Area Code:

Name (Last, First, Middle): Relationship to Me:

If the person named above can't or doesn't want to make decisions for me, I appoint the person

named below to act as my Health Care Agent.

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B - ALTERNATE HEALTH CARE AGENT

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL

NAME (Last, First, Middle) LAST FOUR DIGITS OF SSN:

B - MENTAL HEALTH PREFERENCES

This section is optional. You may skip this section if you do not have a serious mental health problem or if you

do not want to write down your preferences for mental health care. If you have a serious mental health

condition, you might want to write down medications that have worked for you in the past and that you would

want again, or you might want to write down the mental health facilities or hospitals that you like and those

that you don’t like. If you need more space, you may attach extra pages and use this space to refer to

attached pages. Be sure to initial and date every page that you attach.

If I need to use a breathing machine and be in bed

for the rest of my life.

If I have pain or other severe symptoms that cause

suffering and can't be relieved.

If I have a condition that will make me die very soon,

even with life-sustaining treatments.

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Other:

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Yes.

I would want

life-sustaining

treatments.

I'm not sure. It

would depend

on the

circumstances.

No.

I would not want

life-sustaining

treatments.

If I have a permanent condition where other people

must help me with my daily needs (for example,

eating, bathing, toileting).

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D - HOW STRICTLY YOU WANT YOUR PREFERENCES FOLLOWED

I want my preferences, as expressed in this Living Will, to serve as a general guide. I understand

that in some situations, the person making decisions for me may decide something different from the

preferences I express above, if they think it's in my best interests.

I want my preferences, as expressed in this Living Will, to be followed strictly, even if the person

making decisions for me thinks that this isn't in my best interests.

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Place your initials in the box next to the statement that reflects how strictly you want others to follow your

preferences. Choose only one.

This section is optional. In this space, you can write other important preferences for your health care that

aren’t described somewhere else in this document. For example, these might be social, cultural, or

faith-based preferences for care, or preferences about treatments such as feeding tubes, blood transfusions,

or pain medications. If you need more space, you may attach extra pages and use this space to refer to

attached pages. Be sure to initial and date every page that you attach.

C - ADDITIONAL PREFERENCES

VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL

NAME (Last, First, Middle) LAST FOUR DIGITS OF SSN:

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City, State, Zip:

Street Address:

VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL

NAME (Last, First, Middle) LAST FOUR DIGITS OF SSN:

B - WITNESSES' SIGNATURES

Two people must witness your signature. VA employees may be witnesses if they are members of:

The Chaplain Service

The Social Work Service

l Nonclinical employees (e.g., Medical Administration Service, Voluntary Service, or Environmental

Management Service)

Other employees of your VA facility may not sign as witnesses to your advance directive unless they’re in your family.

Witness #1

Name (Printed or Typed):

SIGNATURE:

DATE:

Witness #2

City, State, Zip:

Street Address:

Name (Printed or Typed):

SIGNATURE:

DATE:

I personally witnessed the signing of this advance directive. I am not appointed as Health Care Agent in this

advance directive. I am not financially responsible for the care of the person making this advance directive.

To the best of my knowledge, I am not named in the person’s will.

I personally witnessed the signing of this advance directive. I am not appointed as Health Care Agent in this

advance directive. I am not financially responsible for the care of the person making this advance directive.

To the best of my knowledge, I am not named in the person's will.

A - YOUR SIGNATURE

PART IV: SIGNATURES

SIGNATURE

DATE

By my signature below, I certify that this form accurately describes my preferences.

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known by me to be the person who completed this document and acknowledged it as their free act

and deed. IN WITNESS WHEREOF, I have set my hand and affixed my official seal in the County

VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL

NAME (Last, First, Middle) LAST FOUR DIGITS OF SSN:

PART V: SIGNATURE AND SEAL OF NOTARY PUBLIC (Opt ional)

This VA Advance Directive form is valid in VA facilities without being notarized. However, you may need to

have it notarized to be legally binding outside the VA health care setting. Space for a Notary's signature and

seal is included below.

[SEAL]

On this day of , in the year of , personally appeared before

, State of

, on the date written above.

Notary Public Commission Expires