New Mexico Advanced Health Care Directive - Living Will and Health Care Proxy

Document Sample
New Mexico Advanced Health Care Directive - Living Will and Health Care Proxy Powered By Docstoc
					Docstoc Legal Agreements




                             This Advanced Health Care Directive (Living Will and Health Care Proxy) is intended to be
                             used by an individual located in New Mexico to express his or her directions regarding
                             whether or not life-sustaining procedures are to be utilized in the event of the individual's
                             incapacity. The directive provides for the appointment of a Health Care Proxy in case the
                             individual is unable to speak for him or herself due to terminal illness, injury, or permanent
                             unconsciousness. This document contains both standard provisions commonly found in
                             advanced health care directives and opportunities for customization to address the specific
                             directions of the individual.
             ®




                           DISCLAIMERS: ALL INFORMATION AND FORMS ARE PROVIDED “AS IS” WITHOUT ANY WARRANTY OF ANY KIND, EXPRESS, IMPLIED, OR
                           OTHERWISE, INCLUDING AS TO THEIR LEGAL EFFECT AND COMPLETENESS. They are for general guidance and should be modified by you o r your
                           attorney to meet your specific needs and the laws of your state. Use at your own risk. Docstoc, its employees or contractors who wrote or modified any
                           form, are NOT providing legal or any other kind of advice and are not creating or entering into an Attorney -Client relationship. The information and forms
                           are not a substitute for the advice of your own attorney. Use of this document and our service are deemed to be your acknowledgement and agreement to
                           the following: The disclaimers and links on this page and the back page(s); our Terms of Service (http://www.docstoc.com/popterm.aspx?page_id=15), and
                           read more here (http://www.docstoc.com/popterm.aspx?page_id=114) for additional disclaimers and more. You also agree that if you are not the person
                           using the document and services that you will provide such person(s) who will be with these front and back disclaimer pages. This document is not
                           approved, endorsed by, or affiliated with any State, or governmental or licensing entity.
                           Entire document copyright © Docstoc®, Inc., 2010 - 2013. All Rights Reserved
                         ADVANCED HEALTH CARE DIRECTIVE

                              (Living Will and Health Care Proxy)

1. LIVING WILL

   I, ________________ [Instruction: Insert the name of person making the direction],
   being of sound mind, would like to make and express the following wishes known. I direct
   that my family, my doctors and health care workers, and all others follow such directions I
   am writing down in this document. I know that at any time I can change my mind about these
   directions by tearing up this form and writing a new one. I can also do away with these
   directions by tearing them up and by telling some adult person of my wishes and asking him/
   her to write them down as per my instructions.

   I understand that these directions will only be used in case I am not being able to speak for
   myself.

   a. If I become terminally ill or injured

       Terminally ill or injured is when my doctor and another doctor decide that I have a
       condition that cannot be cured and that I will likely die in the near future from this
       condition.

        i. Life sustaining treatment.

           Life sustaining treatment includes drugs, machines, or medical procedures that would
           keep me alive, but would not cure me. I know that even if I choose not to have life
           sustaining treatment, I will still get medicines and treatments that ease my pain and
           keep me comfortable.

           [Instruction: Insert your initial by either “Yes” or “No” in the appropriate box]

           I want to have life sustaining treatment if I am terminally ill or injured.

           ____ Yes

           ____ No

       ii. Artificially provided Food and Hydration (food and water through a tube). I
           understand that if I am terminally ill or injured I may need to be given food and water
           through a tube to keep me alive if I can no longer chew or swallow on my own or
           with someone helping me.

           [Instruction: Insert your initial by either “Yes” or “No” in the appropriate box]

           I want to have food and water provided through a tube if I am terminally ill or
           injured.




© Copyright 2011 Docstoc Inc. registered document proprietary, copy not                  2
           ____ Yes

           ____ No

   b. If I Become Permanently Unconscious.

       Permanent unconsciousness is when my doctor and another doctor agree that within a
       reasonable degree of medical certainty, I can no longer think, feel anything, knowingly
       move, or be aware of being alive. They believe this condition will last indefinitely
       without hope for improvement and have watched me long enough to make that decision. I
       understand that at least one of these doctors must be qualified to make such a diagnosis.

        i. Life sustaining treatment. Life sustaining treatment includes drugs, machines, or
           other medical procedures that would keep me alive, but would not cure me. I know
           that even if I choose not to have life sustaining treatment, I will still get medicines
           and treatments that ease my pain and keep me comfortable.

           [Instruction: Insert your initial by either “Yes” or “No” in the appropriate box]

           I want to have life-sustaining treatment if I am permanently unconscious.

           ____ Yes

           ____ No

       ii. Artificially provided Food and Hydration (Food and water through a tube). I
           understand that if I become permanently unconscious, I may need to be given food
           and water through a tube to keep me alive if I can no longer chew or swallow on my
           own or with someone helping me.

           [Instruction: Insert your initial by either “Yes” or “No” in the appropriate box]

           I want to have food and water provided through a tube if I am permanently
           unconscious.

           ____ Yes

           ____ No

   Other Directions: [Instruction: Choose any one clause as applicable]

   In addition to the directions I have listed on this form, I also want the following:

   ___________________________________________________________________________
   ___________________________________________________________________________
   ___________________________________________________________________________
   ___________________________________________________________________________




© Copyright 2011 Docstoc Inc. registered document proprietary, copy not                   3
   [Instruction: Choose this clause if you want to insert any other things you want done or
   not done]

                                                   OR

   If you do not have other directions, place your initials here:

   ____ No, I do not have any other directions. [Instruction: Choose this clause by placing
   your initial if you do not have other directions]

2. IF I NEED SOMEONE TO SPEAK FOR ME.

   This form can be used in the State of New Mexico to name a person you would like to make
   medical or other decisions for you if you become too sick to speak for yourself. This person
   is called a Health Care Proxy. You do not have to name a Health Care Proxy. The directions
   in this form will be followed even if you do not name a Health Care Proxy.

   [Instruction: Insert your initials by giving only one answer as per applicable]

   _____ I do not want to name a health care proxy.

   [Instruction: If you check this answer, refer to Section 3]

   _____ I want the person listed below to be my Health Care Proxy. I have talked with this
   person about my wishes.

   First choice for Health Care Proxy: _______________________________

   [Instruction: Insert the name of first choice for health care proxy]

   Relationship to me: ___________________________________

   [Instruction: Insert the relationship of the health care proxy with the person making
   this instrument]

   Address: ___________________________________________________________________

   [Instruction: Insert the address of first choice of health care proxy]

   Phone number: ___________________________

   [Instruction: Insert the contact number of first choice for health care proxy]

   If this person is not able, not willing, or not available to be my Health Care Proxy, this is my
   next choice:

   Second choice for Health Care Proxy: _______________________________

   [Instruction: Insert the name of second choice for health care proxy]


© Copyright 2011 Docstoc Inc. registered document proprietary, copy not                4
   Relationship to me: ___________________________________

   [Instruction: Insert the relationship of the second health care proxy with the person
   making this instrument]

   Address: ___________________________________________________________________
   [Instruction: Insert the address of second choice of health care proxy]

   Phone number: ___________________________

   [Instruction: Insert the contact number of second choice for health care proxy]

   Instructions for Health Care Proxy:

   [Instruction: Insert your initial by either “Yes” or “No” in the appropriate box]

   I want my Health Care Proxy to make decisions about whether to give me food and water
   through a tube.

   ____ Yes

   ____ No

   [Instruction: Insert your initials by giving only one answer as per applicable]

   ____ I want my Health Care Proxy to follow only the directions as listed on this form.

   ____ I want my Health Care Proxy to follow my directions as listed on this form and to make
   any decisions about things I have not covered in the form.

   ____ I want my Health Care Proxy to make the final decision, even though it could mean
   doing something different from what I have listed on this form.

3. THE THINGS LISTED ON THIS FORM ARE WHAT I WANT.

   I understand the following:

   a. If my doctor or hospital does not want to follow the directions I have listed, they must see
      that I get to a doctor or hospital that will follow my directions.

   b. If I am pregnant, or if I become pregnant, the choices I have made on this form will not
      be followed until after the birth of the baby.

   c. If the time comes for me to stop receiving life sustaining treatment or food and water
      through a tube, I direct that my doctor talk about the good and bad points of doing this,
      along with my wishes, with my Health Care Proxy, if I have one, and with the following
      people:




© Copyright 2011 Docstoc Inc. registered document proprietary, copy not               5
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ________________________________________________________________________
       ____________

4. MY SIGNATURE

   Your name: _____________________ [Instruction: Insert your name]

   The month, day, and year of your birth: ____ [Month] ____ [Date] ____ [Year]

   Your signature: _____________________ [Instruction: Insert your signature]

   Date signed: ____ [Month] ____ [Date] ____ [Year]

5. WITNESSES:

   I am witnessing this form because I believe this person to be of sound mind. I did not sign the
   person’s signature, and I am not the Health Care Proxy. I am not related to the person by
   blood, adoption, or marriage and not entitled to any part of his or her estate. I am not directly
   responsible for paying for his or her medical care.

   ____________________________________

   [Instruction: Insert signature of Witness#1]

   _______________________________________________

   [Instruction: Insert printed/typed name of Witness#1]

   ____ [Month] ____ [Date], 20____

   ____________________________________

   [Instruction: Insert signature of Witness#2]

   _______________________________________________

   [Instruction: Insert printed/typed name of Witness#2]

   ____ [Month] ____ [Date], 20____

6. SIGNATURE OF HEALTH CARE PROXY

   I, ____________________________ [Instruction: Insert the name of health care proxy],
   am willing to serve as the Health Care Proxy.

   ______________________________________________


© Copyright 2011 Docstoc Inc. registered document proprietary, copy not                 6
   [Instruction: Insert the signature of health care proxy]

   ____ [Month] ____ [Date], 20____

   Signature of Second Choice for Health Care Proxy:

   I, ____________________________ [Instruction: Insert the name of second choice for
   health care proxy], am willing to serve as the Health Care Proxy if the first choice cannot
   serve.

   _____________________________________________________________

   [Instruction: Insert the signature of second choice for health care proxy]

   ____ [Month] ____ [Date], 20____




© Copyright 2011 Docstoc Inc. registered document proprietary, copy not            7

				
DOCUMENT INFO
Shared By:
Tags:
Stats:
views:113
posted:11/19/2011
language:English
pages:8
Description: This Advanced Health Care Directive (Living Will and Health Care Proxy) is intended to be used by an individual located in New Mexico to express his or her directions regarding whether or not life-sustaining procedures are to be utilized in the event of the individual's incapacity. The directive provides for the appointment of a Health Care Proxy in case the individual is unable to speak for him or herself due to terminal illness, injury, or permanent unconsciousness. This document contains both standard provisions commonly found in advanced health care directives and opportunities for customization to address the specific directions of the individual.
This document is also part of a package Essential New Mexico Legal Documents 144 Documents Included