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Vermont Living Will (Advance Health Care Directive) |
The Vermont living will, known also as the ‘advance health care directive’, is to facilitate a person, who is referred to as the `Principal`, with choices over the medical treatment they receive when they are so ill that they can no longer do this themselves. is a legal binding document once signed by all relevant parties. It needs two witnesses and is created in accordance to the US statutes §§9700 9720. The will contains specific stipulations regarding health care directions to the principal but can be limited or added to for the principals personal requirements.
How to Write
Advanced Directive For Health Care
The principal must enter their details.
- Name.
- Address.
- ZIP code.
- Date.
- Date of birth.
- Telephone number.
- Email address.
Agent
The principal must initial the statement which describes their wishes regarding the power of the agent.
- When the principal is no longer able to.
- Immediately.
- For a condition stated here by the principal.
The details of the agent and alternative agent`s must be entered.
- Name.
- Address.
- (Optional) Relationship to principal.
- Daytime/Evening telephone numbers.
- Telephone number.
- Email address.
The principal must initial if they wish to appoint co-agents and enter the details of theses co-agents.
- Name.
- Address.
- (Optional) Relationship to principal.
- Daytime/Evening telephone numbers.
- Telephone number.
- Email address.
The principal must initial the relevant statement regarding the decision making of co-agents.
- By agreement of ALL co-agents.
- By majority decision of all present.
- By the person present in event of emergency.
The principal must enter details of any other instructions to co-agents.
The principal must enter their name, date of birth and the date at the top of this page (Page 3).
Others Involved In The Principals Health Care
The principal must enter the details of the clinician or doctor.
- Name.
- Address.
- Telephone number.
The details must be entered of any other persons who MAY be consulted about the principal`s medical health care decisions.
The details must be entered of any other persons who SHOULD NOT be consulted by the agent about the principal`s medical health care decisions.
The details must be entered of any other persons who MAY receive information about the principal`s condition.
The details of a person who MAY NOT bring legal action regarding matters covered by the health care directive and may not make health care decisions for the principal.
The principal must initial and/or enter details to designate one of the options as a guardian.
- Health care agent.
- Person named here.
The principal may list other alternate guardians.
The principal may mane persons they do not wish to be their guardian.
The principal must enter their name, date of birth and the date at the top of this page (Page 4).
Statement Of Values And Goals.
The principal may enter details regarding their medical health care goals and their approach to choices of medical health care.
The principal must enter their name, date of birth and the date at the top of this page (Page 4).
End Of Life Treatment Wishes
The principal must initial any of the statements they wish to apply to their end of life treatment.
- All possible treatments to extend my life.
- Not want my life extended by any of the following means.
Breathing machines (ventilator or respirator).
Tube feeding (feeding and hydration by medical means).
Antibiotics.
Other medications to extend my life.
Any means
Other means specified by the principal.
- The agent to decide.
- Care preserving dignity and providing comfort and relief from discomfort.
- Pain relief even though this may hasten death.
- Hospice care when it is appropriate in any setting.
- To die at home if this is possible
- Other wishes and instructions stated here.
Other Treatment Wishes
The principal must initial any of the statements which apply to their other wishes regarding treatment.
- To have a Do Not Resuscitate (DNR) Order.
- In a critical health crisis that may not be life-ending and more time is needed to determine if I can get better, I want treatments started.
- If, after a reasonable period of time recovery is unlikely, all life extending treatment to be stopped, including breathing machines or tube feeding.
- If unable to think or act for oneself and not likely improve, not to have the following life extending treatment.
Breathing machines (ventilators or respirators)
Feeding tubes/by artificial means.
Antibiotics.
Other medications to extend life.
Any other treatment to extend life.
Other stated by the principal.
- If the likely costs, risks and burdens of treatment are more than the principal wishes to endure, I do not want life-extending treatment. The patient must state these costs risks and burdens.
- If the principal is found to be pregnant they must initial the treatments they would wish to receive.
All life sustaining treatment.
Only the following life sustaining treatments.
Breathing machines (ventilators or respirators)
Feeding tubes/by artificial means.
Antibiotics.
Other medications to extend life.
Any other treatment to extend life.
Other stated by the principal.
No life sustaining treatment.
Hospital Treatment Facilities
The principal must enter the details of any specific hospital facility they wish to be treated at.
- Facility name.
- Address.
- Telephone number.
The principal must enter the details of any specific hospital facility they DO NOT wish to be treated at.
- Facility name.
- Address.
- Telephone number.
Preffered Medications Or Treatments
The principal must enter details of and reasons for their other wishes regarding their preferred medication and treatments.
Consent For Student Education, Drug Trials And Treatment Studies
The principal must indicate their specific wishes by initialing and circling the statements which apply to them.
Mental Health Treatment
The principal must number the required treatments which they prefer to receive in order of preference.
- Medication in pill form.
- Liquid medication.
- Medication by injection.
- Physical restraints.
- Seclusion.
- Seclusion and physical restraints combined.
- Other reason for preferences.
Electro-convulsive Therapy
The principal must initial the appropriate statements which apply to their wishes regarding electro-convulsive therapy.
- NOT consent to the administration of any form of ECT.
- Consent / do not consent to unilateral ECT.
- Consent / do not consent to bifrontal ECT.
- Consent / do not consent to bilateral ECT.
Consent / authorize agent to consent to ECT as follows.
Agree to the number of treatments the Psychiatrist deems appropriate.
Agree to the number of treatments a named specific doctor considers appropriate.
Agree to the number of treatments agent considers appropriate.
Agree to no more than a specific number of treatments stated by the principal.
Any other instructions regarding ECT.
The principal must enter their name, date of birth and the date at the top of this page (Page 8).
Waiver
The principal must provide details regarding the wavering of their right to decide upon their medical health treatment, handing this authority to the agent.
- Agents name.
- Enter treatments they DO want to be provided regardless.
- Enter details of treatments they DO NOT want to be provided regardless.
- Initial `Yes` or `No` with respects to handing authority over to their agent to being admitted to a medical facility.
- Initial `Yes` or `No` regarding giving the agent permission to withhold release from a mental health care institution for up to four days.
- Principal`s signature.
- Date.
Acknowledgements
The agent, alternative agent and the clinician must enter their details.
- Agent`s signature.
- Agent`s name.
- Agent`s telephone number.
- Date.
- Clinician“s Signature.
- Clinician`s title.
- Facility.
- Date.
- Clinician`s name.
- Designated person`s signature.
- Position.
- Date.
The principal must enter their name, date of birth and the date at the top of this page (Page 10).
Anatomical Donation
The principal must initial the relevant statements which apply to their wishes regarding an anatomical donation.
- Donate the following organs and tissues.
Any needed organs or tissues.
Major organs.
Tissues such as skin and bones.
Eye tissue such as corneas.
Agent to decide.
The named person(s) to make any decisions.
- I desire to donate my body to research or educational programs. (Note: you will have to make your own arrangements through a Medical School or other program.
- I do not wish to be an organ donor.
The principal must enter their name, date of birth and the date at the top of this page (Page 11).
Disposition Of The principal`s Body
The principal must give details regarding the disposal or burial of their body after death.
- A funereal and casket burial at the location stated by the principal, mentioning the details of the plot selected.
- Cremation with instructions for the distribution of the ashes.
- The agent or family to carry out the directions with the instructions according to the principal.
- The agent or alternative agent to be solely responsible.
- The person named by the principal to be responsible.
Name of person.
Address of person.
Telephone/Cellphone number of person.
Email address.
- The family to be responsible.
The principal must state their wishes regarding autopsy after death.
- Support an autopsy after death.
- Allow the family or agent to decide whether or not to support an autopsy after death.
The principal must enter details of any pre-arrangements for a funeral.
- Name.
- Address.
- Telephone number.
The principal must enter their name, date of birth and the date at the top of this page (Page 12).
Signatures And Witnesses.
The principal must enter their signatures.
- Sign to show they understand the document.
- Sign to say they will distribute copies of the document to their agent (Optional).
- Sign to say they will distribute copies of the document to their doctor (Optional).
The witnesses must enter their signatures.
- Signature.
- Name.
- Date.
The person who explained this document if the principal is a resident of a health care facility.
- Name.
- Address.
- Telephone number.
- Title.
- Date.
The details of the people who will have a copy of this document must be listed.
- Vermont advanced directive registry.
- Agent/Alternative agent.
- Family members names and addresses.
- Medical doctors name and address.
- Hospital`s name.
- Names and addresses of other persons.
