Advance Healthcare Directive for Virginia

VIRGINIA ADVANCE HEALTHCARE DIRECTIVE



This form is used to make your wishes known about what medical treatment or other care you would or would not want if you become too sick to speak for yourself. You are not required to have an advance directive. If you do have an advance directive, be sure that your doctor, family, and friends know you have one and know where it is located.

SECTION 1. LIVING WILL

I, _____________ (hereinafter, the "Principal," "I," "my," or "me"), being of sound mind and at least 18 years old, would like to make the following wishes known. I direct that my family, my doctors and healthcare workers, and all others follow the directions I am writing down. 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 someone at least 18 years of age of my wishes and asking him or her to write them down.

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

If I Become Terminally Ill

"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.

"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.

Initial one:

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

If you selected this option, do you still want such treatment if the likely risks and burdens of treatment would outweigh the expected benefits?

Yes ____ No ____

____ I do NOT want to have life-sustaining treatment if I am terminally ill or injured.

____ I want to have my healthcare agent decide this for me when the time comes.

"Artificially-provided food and hydration" is food and water through a tube or an IV. I understand that if I am terminally ill or injured I may need to be given food and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me.

Initial one:

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

____ I want to have food and water provided through a tube or an IV if I am terminally ill or injured only as a limited trial to see if I can improve.

____ I do NOT want to have food and water provided through a tube or an IV if I am terminally ill or injured.

____ I want to have my healthcare agent decide this for me when the time comes.

If I Become Permanently Unconscious

"Permanently 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.

"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.

Initial one:

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

If you selected this option, do you still want such treatment if the likely risks and burdens of treatment would outweigh the expected benefits?

Yes ____ No ____

____ I do NOT want to have life-sustaining treatment if I am permanently unconscious.

____ I want to have my healthcare agent decide this for me when the time comes.

"Artificially-provided food and hydration" is food and water through a tube or an IV. I understand that if I become permanently unconscious, I may need to be given food and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me.

Initial one:

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

____ I want to have food and water provided through a tube or an IV if I am permanently unconscious only as a limited trial to see if I can improve.

____ I do NOT want to have food and water provided through a tube or an IV if I am permanently unconscious.

____ I want to have my healthcare agent decide this for me when the time comes.

Relief from Pain

Initial "Yes" or "No":

I want treatment to alleviate pain or discomfort to me even if it hastens my death.

Yes ____ No ____

SECTION 2. ACKNOWLEDGMENTS

I understand the following:

  • I understand the full importance of this Living Will and am mentally competent to make this Living Will. No participant in the making of this Living Will or in its being carried into effect shall be held responsible in any way for complying with my directions.
  • 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 who will follow my directions.
  • 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.
  • If the time comes for me to stop receiving life-sustaining treatment or food and water through a tube or an IV, I direct that my doctor talk about the good and bad points of doing this, along with my wishes, with my healthcare agent, if I have one.

Effect of a Copy

All copies of this document shall be given the same effect as an original.

SECTION 3. PHYSICIAN AFFIDAVIT (OPTIONAL)

You have the option of consulting a physician before initialing any choice in this document. If you do consult a physician, it is recommended that you have them complete this affidavit and give them a copy to keep.

I, Dr. ___________________________________, have reviewed this document with _____________ and have discussed his or her questions regarding the possible medical consequences of the treatment choices provided herein. This discussion occurred on _______________ (date).

I agreed to comply with the provisions of this directive.

Physician's signature: ______________________________ Date: ________________

SECTION 4. EXECUTION

MY SIGNATURE

I sign this directive voluntarily. I understand the choices I have made and declare that I am emotionally and mentally competent to make this directive.

Your Name: _____________

Date of Birth: _____________

Signature: __________________________________ Date: ____________________

(If you are physically unable to sign, this directive may be signed by someone else writing your name in your presence and with your express permission.)

SECTION 5. WITNESSES

To properly have this document witnessed you must sign your advance directive in the presence of two adult witnesses. Any person over the age of 18 can act as a witness, including a spouse, other relative, or healthcare provider.

To properly have this document witnessed you MUST have two witnesses sign in accordance with the paragraph below.

Witnesses

I AM WITNESSING THIS FORM UNDER PENALTY OF PERJURY AND SWEAR AS FOLLOWS: that the individual who signed or acknowledged this advance healthcare directive is personally known to me, or that the individual's identity was proven to me by convincing evidence; that the individual signed or acknowledged this advance directive in my presence; that I believe this person to be of sound mind and under no duress, fraud, or undue influence; that I did not sign the person's signature without consent, and I am not the healthcare agent; that I am not the individual's healthcare provider, an employee of the individual's healthcare provider, the operator of a community healthcare facility, an employee of a community healthcare facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly; that I am not related to the person by blood, adoption, or marriage and not entitled to any part of his or her estate; and that I am at least 18 years of age and am not directly responsible for paying for his or her medical care.

FIRST WITNESS

Name: _________________________________________

Address: ______________________________________

_____________________________________________

_____________________________________________

Sign: __________________________________ Date: ______________________

SECOND WITNESS

Name: _________________________________________

Address: ______________________________________

_____________________________________________

_____________________________________________

Sign: __________________________________ Date: ______________________

Note: If the Principal is physically unable to sign, each witness must also sign the following statement:

The Principal has directly indicated to me that this document expresses his or her wishes and that the Principal intends to adopt this document at this time.

Witness Signature: _______________________________ Date: ______________________

Witness Signature: _______________________________ Date: ______________________

Notary Public (Optional)

State of ____________________________

SS.

County of ____________________________

On this the ________ day of __________________, 20___, before me, the undersigned, a notary public in and for said County and State, personally appeared _____________, personally known to me (or proved to me on the basis of satisfactory evidence) , and of sound mind and free from duress, to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or entity upon behalf of which the person(s) acted, executed the instrument.

WITNESS my hand and official seal.

___________________________________

(Print name)

___________________________________

(Signature)

NOTARY PUBLIC

My Commission Expires: ________________________ [Affix seal]

Note: If the Principal is physically unable to sign, the notary must also sign the following statement:

The Principal has directly indicated to me that this Advance Directive expresses his or her wishes and that the Principal intends to adopt this Advance Directive at this time.

Notary: ______________________________ Date:_____________

Instructions for Your Living Will

(a.k.a. Advance Healthcare Directive)



Completing Your Document

A living will allows its maker, called the "Principal," to specify his or her healthcare preferences in the event he or she is incapacitated or unable to speak. This helps the Principal and his or her family to rest easy knowing that the Principal's wishes will be honored. Each living will also includes a durable power of attorney for health care section, which names a healthcare Agent (also called a Proxy) who can make decisions for the Principal in the event he or she lacks capacity. The Agent is required to follow the directions stated in the living will and to act in the Principal's best interest in situations in which the Principal's wishes are not specified. For this reason, it is important for the Principal to discuss his or her wishes with the Agent so that the Agent can act accordingly should the situation arise. It is a good idea for the Principal to name a trusted friend or family member as the Agent.

It is important to note that the Principal will initial next to all of his or her main preferences concerning health care once the document is printed out. Therefore, most of the questions you will answer on LegalNature's online form builder will be related to optional matters used for customizing your document according to the Principal's preferences.

Special Directions (Optional)

After entering the Principal's basic information, you will have the option to specify what the Principal wants or does not want to occur when he or she becomes terminally ill, injured, or permanently unconscious. For instance, the Principal may specify any specific pain relief measures that are wanted or not wanted. Also, describe any chronic illness or serious disability that the Principal may have that he or she does not want to be misinterpreted as a terminal condition. Again, this section is optional, so if the Principal has no specific directions then you can skip to the next step.

Guardian Nomination (Optional)

On this step you have the option of nominating a Guardian to manage the Principal's personal affairs in the event he or she becomes incapacitated. This person will make decisions such as where the Principal lives or what the Principal eats. If the Principal doesn't nominate a Guardian, a court may appoint one when the time comes.


Designation of Primary Physician (Optional)

Here you can designate the primary physician in charge of the Principal's health care. It is a good idea for the Principal to review the living will with the physician so that the physician understands the Principal's healthcare preferences and the Principal understands his or her choices.

Organ Donation and Autopsy (Optional)

Including this section will allow the Principal to specify whether or not he or she wants to be an organ donor and whether an autopsy will be performed upon death. If the Principal has not specified these preferences yet in a formal document, it is probably a good idea to do so here.

Mental Health (Optional)

On the following step you will have the option to include the Principal's wishes concerning mental health treatments, including whether or not the Principal consents to receiving psychotropic medications. These are medications such as antipsychotics or antidepressants. List any medications the Principal does or does not wish to receive and any other preferences concerning mental health treatments. Enter "N/A" if you wish to skip any of these questions.

Funeral and Burial (Optional)

The funeral and burial section allows the Principal to indicate the manner in which his or her remains will be disposed of and the location of any funeral. You can customize this section any way you need to.

Witnessing Your Document

After completing your document, you will need to print it out and read the witnessing instructions included in it. Each state has slightly different requirements on how a living will must be witnessed and executed. Any witnesses, including any notary, will need to physically see the Principal sign the document. Be sure to read the document carefully and have all the required persons sign. Also, your document will tell you if you need to have your signature notarized. If it says that a notary is optional, then you do not have to use a notary, but using one will help prove the document is valid if it is ever contested in court.

Registering your Living Will

Many states maintain a registry for the living wills of their citizens. Registering the living will can help the healthcare provider and family to be able to locate a copy of it in the event they cannot find the original. If you are interested in registering, check online to see if your state maintains one and follow the directions for filing.

Changing Your Document

If the Principal decides that he or she wants to change or revoke the living will and/or durable power of attorney for health care, the Principal can do so at any time while he or she still has the mental capacity to do so.

NOTE: THIS IS AN IMPORTANT LEGAL DOCUMENT AND MAY AFFECT YOUR HEALTHCARE IN THE EVENT YOU ARE UNABLE TO SPEAK FOR YOURSELF. CONSULT A LICENSED ATTORNEY IN YOUR STATE IF THERE IS ANYTHING YOU DO NOT UNDERSTAND IN THE DOCUMENT.

Please note that the language you see here changes depending on your answers to the document questionnaire.
Individual Healthcare

Advance Healthcare Directive

An advanced healthcare directive allows you to make your wishes known about what type of medical care you want to receive should you become terminally ill or permanently unconscious. You can clarify all your medical wishes and instructions upfront so that no misunderstandings occur when it is too late.

LegalNature’s form also allows you to specify the circumstances in which you want to receive life-sustaining treatments and any limitations on those treatments. The advanced healthcare directive includes an optional medical power of attorney so that you can appoint a healthcare agent to make healthcare decisions on your behalf, according to the instructions listed. Additionally, It can even be used to specify your funeral and burial instructions.

LegalNature will help you get started drafting and downloading your living will in just a few simple steps to get protected today.

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