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Utah Living Will Form (Advance Health Care Directive) – POA |
The Utah living will, or ‘advance health care directive’, aids the principal by allowing them to choose their health care at a time when they are to ill to do so through illness. This can also apply to decisions regarding the end stages of the principal`s life or if the principal wishes to express their wishes with respects to pain relief. A Utah living will and medical power of attorney combined also provides the principal with the option to select another person to have this same authority but with the option for the principal to choose anything which the do not wish the agent to have authority over, they may also choose at any time to nullify the document. It forms a legal binding agreement in the state of Utah in accordance to US statutes §§75-2A- 101 to -125 and needs one witness or a notary.
How to Write
Advanced Health Care Directive
The principal must enter their name at the bottom of each page.
The principal must enter their personal details.
- Name.
- Address.
- ZIP code.
- Home/Cell telephone numbers.
- Date of birth.
Agent
The agent and alternative agent must enter their details.
- Name.
- Address.
- ZIP code.
- Home/Cell telephone numbers.
- Date of birth.
Agent`s Other Authority
The principal must initial either `Yes` or `No` to state their particular wishes regarding the agent`s authority over the mentioned health care options.
- Be able to to obtain copies of the principal`s medical records at any time.
- Be able to admit the principal to a long term medical institution.
Limits/Expansions Of Authority
The principal may enter details of any wishes they might have to limit or extend the power of attorney of the agent.
Nomination Of Guardian
The principal must initial either `Yes` or `No` to state whether or not they require their appointed agent to become their guardian.
Participation In Medical Research
The principal must initial either `Yes` or `No` to state whether or not they wish wish to participate in medical research and clinical trials.
Organ Donation
The principal must initial either `Yes` or `No` to state whether or not they wish wish to make an anatomical donation
Health Care Wishes. Part II
The principal must initial ONE of the following options with regards to the medical health care treatment they wish to receive.
- Option 1 – To let the agent decide.
- Option 2 – To decide to prolong life.
- Option 3 – Not to prolong life without restriction or with the following restrictions;
Have a progressive illness leading to death.
Close to death and unlikely to recover.
Cannot communicate and unlikely to improve.
Do not recognize my friends or family and unlikely to improve.
In a persistent vegetative state.
- Option 4 – Do not wish to express preferences.
The principal may enter details of any other wishes they may have regarding their medical health care.
Making Directive Legal
The principal and witness must enter their details.
- Date.
- Signature of principal.
- City, county and state of residence.
- Signature of witness.
- Name of witness.
- Address of witness.
- If applicable, details of oral directive given by the principal.
