Education for Justice FACT SHEET S-5 Fall 2009

HEALTH CARE DIRECTIVES

WHAT IS A HEALTH CARE DIRECTIVE?

A Health Care Directive is a document that lets you name a Health Care Agent. A Health Care Agent is someone who can make decisions about your health care when you are not able to do make decisions yourself. The Health Care Directive also lets you leave instructions about your health care. You may give instructions about your care without naming an agent. Or you may name an agent AND give instructions.

WHAT MUST A HEALTH CARE DIRECTIVE INCLUDE?

· It must be in writing.

· It must be dated and state your name.

· It must be signed in front of a Notary Public OR witnessed by 2 people.

· It must name someone to make decisions for you (Health Care Agent) and/or give health care instructions.

WHO MAY BE A HEALTH CARE AGENT?

Your Health Care Agent must be 18 or older. Pick someone you know well who will follow your wishes and act in your best interest and who will be available to your health care providers. Anyone can be your agent except a health care provider or employee of a provider giving you care, unless you are related to that person by blood, marriage, registered domestic partnership or adoption. You may also say in the Health Care Directive why you want that person to be your agent. It is very important for you to talk to the person you name to be sure that person will be willing to make your health care decisions when it may become necessary and to know what your wishes are for your health care.

CAN MORE THAN ONE PERSON BE MY HEALTH CARE AGENT?

You may name one or more agents or alternates. If you do, you should also say if the agents have to decide things together or if they may make decisions independently.

WHAT POWERS WILL MY HEALTH CARE AGENT HAVE?

Unless you limit your agent’s powers, your agent will automatically be able to:

1. Consent to, refuse or withdraw medical or health care treatment on your behalf.

2. Stop or not start care which is keeping you or may keep you alive.

3. Chose your health care providers.

4. Chose where you will get your health care.

5. Decide if you will live in your home, or a hospice, or a nursing home.

6. Get copies of your medical records.

7. Visit you when you are a patient at a health care facility.

If you want to limit these powers, you must say so in the Directive.

ARE THERE OTHER THINGS I CAN GIVE MY AGENT PERMISSION TO DO?

Yes. You may give the agent permission to do other things if you specifically say so in the Health Care Directive:

1. List in what sorts of situations the Health Care Directive becomes effective.

2. Say whether the agent would be your Guardian or Conservator if a petition is filed. See our fact sheet, Guardianships and Conservatorships.

3. Leave instructions that you would or would not want food or water to be given to you medically if you could not eat or drink on your own, or whether you want artificial breathing help if you were not able to breathe on your own.

4. Say if you want to be kept alive using all medical means, or if and at what point the doctors should not revive you.

5. Give other instructions about your care, such as how your religious beliefs might affect your health care.

6. For women, say how you want a pregnancy to affect your health care.

7. Make organ donations.

8. Say what you want done with your body after your death.

9. You can also give your agent permission to make your health care decisions even if you could still make decisions yourself.

WHEN CAN THE HEALTH CARE AGENT TAKE OVER DECISIONS?

The agent takes over decisions when:

· Your doctor thinks that you cannot make your own decisions, or

· When the Health Care Directive says the agent can take over.

WHAT IS THE JOB OF THE HEALTH CARE AGENT?

The agent should make health care decisions as if they were you. They make sure the Health Care Directive is followed and should get legal help if it is not.

CAN I CANCEL THE HEALTH CARE DIRECTIVE?

Yes. You can cancel all or part of the Directive by:

· Destroying the document.

· Telling another person to destroy it.

· Making a written and dated statement saying what part of the Directive you want to cancel.

· Verbally stating that you want to cancel the Health Care Directive before two witnesses. They do not have to be present at the same time.

· Making a new Health Care Directive.

WHERE SHOULD I KEEP THE HEALTH CARE DIRECTIVE?

Keep it with personal papers in a safe place where others can get it, not in a safe deposit box. Give signed copies to doctors, family, close friends, the agent who helped you write it and an alternate agent. Ask to have it put in your file at your doctor’s office and the hospital, home care agency, hospice or nursing home.

ARE MY OLD “LIVING WILL” OR “DURABLE HEALTH CARE POWER OF ATTORNEY” PAPERS VALID?

Only if they were signed before August 1, 1998. If you update or make new papers, you must use the new Health Care Directive, not a “Living Will” or a “Durable Health Care Power of Attorney.” It is a good idea to update your forms, and this may be the time to do it! You may use the form at the end of this fact sheet. The last 2 pages are a Health Care Directive worksheet. You do not have to do the worksheet part, but it can help you decide about health care needs and can be added to the rest of your form if you want.

Minneapolis Legal Aid – CLE MN Legal Services Coalition 2324 University Avenue W. – Suite 101B St. Paul, MN 55114

Don’t use this fact sheet if it is more than 1 year old. Write us for updates, a fact sheet list, or alternate formats. Fact Sheets aren’t a complete answer to a legal problem. See a lawyer for advice.

MINNESOTA HEALTH CARE DIRECTIVE
Purpose of form		Part I. Part II. Part III.		Allows you to appoint another person (called an agent) to make health care decisions if a doctor decides you are unable to do so. Allows you to give written instructions about what you want. Requires you and others to sign and date to make this legal.
My personal information		My Name:
		Address:
		Home phone: ( )
		Work phone: ( )
		Date of birth:
		Social Security #:
•	I revoke all living wills, Durable Powers of Attorney for Health Care, or other written advance health care directives I have signed in the past.
PART I: Naming An Agent
Agent duties		My health care agent can:
		•	Make health care decisions for me if I am unable to make and communicate decisions for myself.
		•	Make decisions based on any instructions in Part II of this document or in other documents.
		•	Make decisions based on what he or she knows about my wishes.
		•	Act in my best interests if instructions are not available.
Agent roles		When naming my health care agent, I must choose one of the following: Initial the line in front of the statement you WANT.
Act alone			I appoint one person to serve as my primary health care agent to
			make decisions for me if I am unable to make or communicate these decisions for myself. My primary agent may act alone. If my primary agent is not able, willing, or available, each alternate agent I name may act alone, in the order listed.
Act together			I appoint two or more persons to act together as my health care
			agent. My primary agent and alternate agents must act together and be in agreement when making decisions. If they are not all readily available, or if they disagree, a majority of the agents who are readily available may make decisions for me.
My primary health care		I appoint: Agent’s name:
agent		Address:
		Home Phone: ( )
		Work Phone: ( )
My first		Agent’s name:
alternate		Address:
health care
agent		Home Phone: ( )
		Work Phone: ( )
My second		Agent’s name:
alternate		Address:
health care
agent		Home Phone: ( )
		Work Phone: ( )
(If needed) Reasons for naming health care		I have named as my agent a health care provider, or employee of a health care provider, who is currently or might be providing direct care to me when decisions are needed. That person is not related to me by blood, marriage, registered domestic partnership, or adoption. My reasons for
provider		wanting to appoint that person as my agent are:
Powers of my agent		If I am unable to decide or speak for myself, my agent has the power to:
		•	Consent to, refuse, or withdraw any health care, treatment, service, or procedure;
		•	Stop or nor start health care which is keeping or might keep me alive;
		•	Choose my health care providers;
		•	Choose where I live when I need health care and what personal security measures are needed to keep me safe; and
		•	Obtain copies of my medical records and allow others to see them.

Additional powers of my agent		If I WANT my agent to have any of the following powers, I must initial the line in front of the statement.
		I also authorize my agent to:
			Make health care decisions for me even if I am able to decide or
			speak for myself.
			Carry out my wishes regarding a funeral, burial, or what will
			happen to my body when I die.
			Make decisions about mental health treatment including
			electroconvulsive therapy and antipsychotic medication, including neuroleptics.
			In the event I am pregnant, determine whether to attempt to
			continue my pregnancy to delivery based upon my agent’s understanding of my values, preferences, or instructions.
			Continue as my health care agent even if a dissolution,
			annulment, or termination of our marriage or domestic partner- ship is in process or has been completed.
Limiting the		I wish to limit the powers of my health care agent in the following way(s):
powers of my
agent
PART II: Health Care Instructions
•	I give the following instructions about my health care (my values and beliefs, what I do and do not want, views about medical treatments or situations).
•	I am attaching additional instructions concerning my health care values and
	preferences. Initial one line:				Yes		No
•	I authorize donations of organs, tissue, or other body parts after my death.
	Initial one line:			Yes		No

PART III: Making This Document Legal
My signature/ mark and date	I agree with everything in this document and have made this document willingly:
	My signature:
	Date:
	(day / month / year)
Notary Public OR Witnesses
Notary Public	STATE OF MINNESOTA
	County of
NOTE: Must
not be named	This document was signed or acknowledged before me this
as agent or				(day)
alternate	of		by the above-named principal.
agent.	(month) (year)
	Signature of Notary Public
Two Witnesses	This document was signed or acknowledged in my presence. I am not an agent or alternate agent in this document.
NOTE: Only	Witness Signature:
one witness	Address:
can be a
direct care	Date:
provider or		(month / day / year)
employee of a
provider on	Witness Signature:
the day this is	Address:
signed.
	Date:
		(month / day / year)

Health Care Instructions Worksheet

For Minnesota Health Care Directive

My Health Care Goals

Having a sense of what is important to you can help your decision-makers make health care decisions under different and complex circumstances. Read each statement below and on a scale of “0” to “4,” rate how important each of the health care goals are to you. In this case, “4” means “Extremely Important” and “0” means “Not Important At All.” Remember, reasonable medical care should always include maintaining a person’s comfort, hygiene, and human dignity.

Health Care Goals			0 = Not Important 2 = Somewhat Important 4 = Extremely Important
How Important Is Pain Control?		0		1	2	3	4
•	Being as comfortable and free from pain as possible.
•	Having pain controlled, even if my ability to think clearly is reduced.
•	Having pain controlled, even if it shortens my life.
How Important Is the Use of Life Prolonging Treatment When:
•	I have a reasonable chance of recovering both physically and mentally (50/50+).
•	I have some physical limitations but can socially relate to those I care about.
•	I can live a longer life no matter what my physical or mental health.
•	I have little or no chance of doing everyday activities I enjoy.
•	I am not able to socially relate to those I care about.
•	I have a terminal illness and treatment will only prolong when I die.
•	I have severe and permanent brain injury and there is little chance of regaining consciousness.
•	I have severe dementia or confusion and my condition will only get worse.
Importance of Finances and Health Care
•	Having my wishes followed regardless of whether or not my finances are exhausted.
•	Not being a final burden to those around me.
•	Not having my health care costs affect the financial situations of those I care about.

I also want my decision-makers to know the following things are important to me when receiving health care:

My Medical Treatment Preferences

It is helpful for others to know if and why you have strong feelings about certain medical treatments. Some of the more difficult medical decisions are about treatments used to prolong life, such as those listed below. Most medical treatments can be tried for awhile and then stopped if they do not help. Discuss these medical treatments with a health care professional to make sure you understand what they might mean for you given your current, as well as future, health conditions.

Medical Procedure	When It Is Used and Its Effects	My Feelings About This Procedure
Ventilator/Respirator A breathing machine A Do Not Intubate (DNI) order is put on your medical record when you do not want this procedure.	When you cannot breathe on your own You cannot talk or eat by mouth on this machine.
Nutrition support and hydration	When you cannot eat or drink by mouth, feeding solutions can provide enough nutrition to support life indefinitely. Feeding solutions can be put through a tube in your stomach, nose, intestines, or veins.
Cardiopulmonary Resuscitation (CPR) A Do Not Resuscitate (DNR) order is put on your medical record when you do not want this procedure.	Actions to make your heart and lungs start if they stop, including pounding on your chest, electric shocks, medications, and a tube in your throat.
Dialysis	A machine means of cleaning the blood when kidneys are not working.

My feelings or concerns about other medical treatments include:
If I am pregnant, my feelings about medical treatment would include:
My Religious and Spiritual Beliefs Religious or spiritual beliefs and traditions influence how people feel about certain medical treatments, what quality of life means to them, and how they wish to be treated when they are dying or when they have died.
My decision-makers should know the following about how my religious or spiritual beliefs
should affect my health care:
My religion/spirituality is:
My congregation/spiritual community (name, city, state):
I wish to have my (priest/pastor/rabbi/shaman/spiritual leader) consulted.	Yes	No
If yes, the person to be contacted is:
Feelings About Quality and Length of Life
I have the following beliefs about whether life should be preserved as long as possible:
The following kinds of mental or physical conditions would make me think that medical
Treatment should no longer be used to keep me alive:

My Preferences for Care When Dying If a choice is possible and reasonable when I am dying, I would prefer to receive care:
		At home
		At a hospital. Which one?
		At a nursing home. Which one?
		Through hospice services/care. Which one?
		From other health care providers. Which ones?
Other wishes I have about my care if I am dying:
My Wishes About Donating Organs, Tissues, or Other Body Parts Initial the lines that apply to you:
			I DO wish to donate organs, tissue, or other body parts when I die.
				Any needed organs, tissue, or other body parts
				Only the following listed organs, tissue, or body parts:
Limitations or special wishes I have include:
			I DO NOT wish to donate organs, tissue, or other body parts when I die.
Additional Health Care Instructions My decision-makers should also know these things about me to help them make decisions about my health care:
I agree that these are my health care instructions and have completed this willingly.
My signature:
Date completed:
(month / day / year)
•	This worksheet is an attachment to my Health Care Directive:
		Initial one box:			Yes	No