Advanced Health Care
Directive (Living Will
And Health Care Proxy)
ocstoc Legal Agreements
This Advanced Health Care Directive (Living Will and Health Care Proxy)
is intended to be used by individuals to express their directions regarding
whether or not life-sustaining procedures are to be utilized. The document
provides for the appointment of a Health Care Proxy in case the individual is
unable to speak for him/herself either because he/she is terminally ill,
injured, or permanently unconscious.
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Entire document © Docstoc, Inc., 2010, 2011
© Copyright 2011 Docstoc Inc. registered document proprietary, copy not 1
Attorney Drafted
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.
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[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.
____ 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
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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:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
[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 Utah 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]
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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]
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.
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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:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________
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]
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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.
______________________________________________
[Instruction: Insert the signature of health care proxy]
____ [Month] ____ [Date], 20____
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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____
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