Fillable Printable Health Care Directive Form - Minnesota

Health Care Directive Form - Minnesota

MINNESOTA STATUTE § 145C

HEALTH CARE DIRECTIVE

_________________________________________________________________________________________________

(Your Name)

I, _______________________________________________________________________, understand this document allows me to do

ONE OR BOTH of the following:

Part I: Name another person (called the health care agent) to make health care decisions for me if I

am unable to decide or speak fo r myse l f. My health care agent must make health care decisions for me

based on the instructions I provide in this document (Part II), if any, the wishes I have made known to

him or her, or must act in my best interest if I have not made my health care wishes known .

AND/OR

Part II:

Give health care instructions to guide others making health care decisions for me. If I have

named a health care agent, these instructions are to be used by the agent. These instructions may also be

used by my health care providers, others assisting with my health care, and my family, in the event I

cannot make decisions for myself.

Part I: Appointment of Health Agent

This is who I want to make health care decisions for me if I am unable to decide or speak for myself (I

know I can change my agent or alternate agent at any time and I know I do not have to appoint an agent

or an alternate agent). NOTE: If you appoint an agent, you should discuss this health care directive with

your agent and give your agent a copy. If you do not wish to appoint an agent, you may leave Part I

blank and go to Part II.

When I am unable to decide or speak for myself, I trust and appoint ____________________________________________

___________ to make health care decisions for me. This person is called my health care agent.

Relationship of my health car e agent to me: __________________________________________________________________________

Telephone number of my health care agent: ___________________________________________________________________________

Address of my health care agent: ________________________________________________________________________________

_______________________________________________________________________________________________________________________________

(Optional) Appointment of Alternate Health Care Agent: If my health care agent is not reasonably available,

I trust and appoint __________________________________________ to be my health care agent instead.

Relationship of alternate health care agent to me: ____________________________________________________________________

Telephone number of my alternate health care agent: _________________________________________________________________

Address of my alternate health care agent: _____________________________________________________________________________

________________________________________________________________________________________________________________________________

THIS IS WHAT I WANT MY HEALTH CARE AGENT

TO BE ABLE TO DO IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF

(I know I can change these choices)

My health care agent is automatically given the powers listed below in (A) through (D). My health care

agent must follow my health care instructions in this document or any other instructions I have given

to my agent. If I have not given health care instructions, then my agent must act in my best interest.

Whenever I am unable to decide or speak for myself, my health care agent has the power to:

(A) Make any health care decision for me. This includes the power to give, refuse, or withdraw

consent to any care, treatment, service, or procedures. This includes deciding whether to stop

or not start health care that is keeping me or might keep me alive, and deciding about intrusive

mental health treatment.

(B) Choose my health care providers .

(C)

Choose where I live and receive care and support when those choices relate to my health care

needs.

(D)

Review my medical records and have the same r ights that I would have to give my

medical records to other people.

If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR if I want to

LIMIT any power in (A) through (D), I MUST say that here: ___________________________________________________

_____________________________________________________________________________________________________________________________

My health care agent is NOT automatically given the powers listed below in (1) and (2). If I WANT my

agent to have any of the powers in ( 1) and (2), I must INITIAL the line in front of the power; then my

agent WILL HAVE that power .

(1)

To decide whether to donate any parts of my body, including organs, tissues, and eyes,

when I die.

(2) To decide what will happen with my body when I die (burial, cremation).

If I wa nt to say anything more about my health care agent's powers or limits on the powers, I can say it

here:

____________________________________________________________________________________

Part II: Health Care Instructions

NOTE: Co mplete this Part II if you wish to give health care instructions. If you appointed an

agent in Part I, completing this Part II is optional but would be very helpful to your agent.

However, if you chose not to appoint an agent in Part I, you MUST complete some or all o f

this Part 11 if you wish to make a valid health care directive.

These are instructions for my hea lt h care when I am unable to decide or speak for myself. These

instructions must be followed (so long as they address my needs). THESE ARE MY BELIEFS

AND VALUES ABOUT MY HEALTH CARE (I know I can change these choices or leave any of

them bl an k)

I want you to know these things about me to help you make decisions about my health care:

1. My goals for my health care:____________________________________________________________

_________________________________________________________________________________

2. My fears about my health care:__________________________________________________________

_________________________________________________________________________________

3. My spiritual o r religious beliefs and traditions:_ _____________________________________________

_________________________________________________________________________________

4. My beliefs about when life would be no l onger worth living:___________________________________

_________________________________________________________________________________

5. My thoughts about how my .medica l condition mig ht affect my family:__________________________

_________________________________________________________________________________

6. (For a woman of childbearing age) My thoughts about how my heal th ca re should be handled in the event

I am pre gna nt : _______________________________________________________________________

___________________________________________________________________________________

THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE

(I know I can change these choices or leave any of them blank)

Many medical treatments may be used to try to improve my medical condition or to prolong

my life. Examples include artificial breathing by a machine connected to a tube in the

lungs, artificia l feeding or fluids through tubes, attempts to start a stopped heart, surgeries,

dialysis, antibio tics, and blood transfusions . Most medical treatments can be tried for a

while and then stopped if they do not help.

I have these views about my health care in these situations:

(NOTE: You can discuss general feelings, specific treatments, or leave any of them blank)

1. If I had a reasonable chance of recovery, and were temporarily unable to decide or speak for

myself, I would want:_____________________________________________________________

________________________________________________________________________________

2. If I were dying and unable to decide or speak for myself, I would want: _____________________

________________________________________________________________________________

3. If I were permanently unconscious and unable to decide or speak for myself, I would want: __

_____________________________________________________________________________

4. If I were completely dependent on others for my care and unab le to decide or speak for myself, I

would want:__________________________________________________________________________________

________________________________________________________________________________

5. In all circumstances, my doctors will try to keep me comfortable and reduce my pain . This is how I

feel about pain relief if it would affect my alertness or if it could shorten my life:_____________

_____________________________________________________________________________

There are other things that I want or do not want for my health care, if possible:

1. Who I would like to be my doctor:_________________________________________________

_____________________________________________________________________________

2. Where I would like to live to receive health care: _____________________________________

_____________________________________________________________________________

3. Where I would like to die and other wishes I have about dying:__________________________

_____________________________________________________________________________

4. My wishes about donating parts of my body when I die:________________________________

_____________________________________________________________________________

5. My wishes about what happens to my body when I die (cremation, burial):_________________

_____________________________________________________________________________

6. Any other things:____________________________________________________________________________________

_______________________________________________________________________________________________________

Part III: Making The Document Legal

This document must be signed by me. It also must be verified either by a notary public (Option 1) OR

witnessed by two witnesses (Option 2). It must be dated when it is verified or witnessed .

I am thinking clearly, I agree with everything that is written in this document, and I have made

this document willingly.

_______________________________________________________ _

My signature

If I cannot sign my name, I can ask someone

to sign this document for me.

Date signed:

Date of birth : _______________________

Address: ___________________________________________________________________________

_______________________________________________________

________________________________________________ ________________________________________________________

Signature of person who I asked to

sign this document for me

Printed name of person who I asked to

sign this document for me

Option 1: Notary Public

In my presence on ____________________ (date), _____________________________________(name)

acknowledged his/her signature on this document or acknowledged that he/she authorized the

person signing this document to sign on his/her behalf. I am not named as a health care agent or

alternate health care agent in this document .

Subscribed and sworn to before me this

_______ day of _____________, _______.

___________________________________

Notary Public

Option 2: Two Witnesses

Two witness must sign. Only one of the two witnesses can be a health care provider or an

employee of a health care provider giving direct care to me on the day I sign this document.

Witness One:

(i)

In my presence on __________ (date), ________________________________(name)

acknowledged his/her signature on this document or acknowledged that he/she

authorized the person signing this document to sign on his/her behalf.

(ii)

I am at least 18 years of age.

(iii)

I am not named as a health care agent or an alternate health care agent in this document.

(iv) If I am a health care provider or an employee of a health care provider giving direct care

to the person listed above in (i), I must initial this box: [ ]

I certify that the information in (i) through (iv) is true and correct.

________________________________________________________

(Signature of Witness One)

Address: ________________________________________________________________________________________________________

_______________________________________________________________________________________________________

Witness Two:

(i) In my presence on __________ (date), ________________________________(name)

acknowledged his/her signature on this document or acknowledged that he/she

authorized the person signing this document to sign on his/her behalf.

(ii) I am at least 18 years of age.

(iii) I am not named as a health care agent or an alternate health care agent in this document.

(iv) If I am a health care provider or an employee of a health care provider giving direct care

to the person listed above in (i), I must initial this box: [ ]

I certify that the information in (i) through (iv) is true and correct.

________________________________________________________

(Signature of Witness Two)

Address: ________________________________________________________________________________________________________

_______________________________________________________________________________________________________

REMINDER: Keep this document with your personal papers in a safe place (not in a safe

deposit box). Give signed copies to your doctors, family, close friends, health

care agent, and alternate health care agent. Make sure your doctor is willing

to follow your wishes. This document should be part of your medical record

at you r physician's office and at the hospital , home care agency, hospice, or

nursing facility where you receive your care.