S.B. 117

This document includes Senate Committee Amendments incorporated into the bill on Fri, Jan 30, 2009 at 11:04 AM by rday. --> This document includes Senate Committee Amendments (CORRECTED) incorporated into the bill on Mon, Feb 2, 2009 at 12:19 PM by rday. -->

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Senate Committee Amendments 1-30-2009 rd/trv 1

ADVANCE HEALTH CARE DIRECTIVE ACT
2 AMENDMENTS
3 2009 GENERAL SESSION
4 STATE OF UTAH
5 Chief Sponsor: Allen M. Christensen
6 House Sponsor: ____________
7
8 LONG TITLE
9 General Description:
10 This bill amends the Advance Health Care Directive Act to expand the list of health
11 care professionals authorized to determine whether an adult lacks health care decision
12 making capacity and to sign a life with dignity order.
13 Highlighted Provisions:
14 This bill:
15 . defines terms;
16 . authorizes a physician assistant S. [ , ] or .S a psychologist S. [ , or a clinical social
16a worker ] .S to
17 determine whether an adult lacks health care decision making capacity or the
18 capacity to make or revoke an advance health care directive;
19 . provides that a physician assistant may sign a life with dignity order; and
20 . makes technical changes.
21 Monies Appropriated in this Bill:
22 None
23 Other Special Clauses:
24 None
25 Utah Code Sections Affected:
26 AMENDS:
27 75-2a-103, as last amended by Laws of Utah 2008, Chapters 3 and 107

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- 2 - 28 75-2a-104, as last amended by Laws of Utah 2008, Chapter 107
29 75-2a-106, as repealed and reenacted by Laws of Utah 2008, Chapter 107
30 75-2a-109, as last amended by Laws of Utah 2008, Chapter 107
31 75-2a-117, as last amended by Laws of Utah 2008, Chapter 107
32
33 Be it enacted by the Legislature of the state of Utah:
34 Section 1. Section 75-2a-103 is amended to read:
35 75-2a-103. Definitions.
36 As used in this chapter:
37 (1) "Adult" means a person who is:
38 (a) at least 18 years of age; or
39 (b) an emancipated minor.
40 (2) "Advance health care directive":
41 (a) includes:
42 (i) a designation of an agent to make health care decisions for an adult when the adult
43 cannot make or communicate health care decisions; or
44 (ii) an expression of preferences about health care decisions;
45 (b) may take one of the following forms:
46 (i) a written document, voluntarily executed by an adult in accordance with the
47 requirements of this chapter; or
48 (ii) a witnessed oral statement, made in accordance with the requirements of this
49 chapter; and
50 (c) does not include a life with dignity order.
51 (3) "Agent" means a person designated in an advance health care directive to make
52 health care decisions for the declarant.
53 (4) "APRN" means a person who is:
54 (a) certified or licensed as an advance practice registered nurse under Subsection
55 58-31b-301 (2)(d);
56 (b) an independent practitioner;
57 (c) acting under a consultation and referral plan with a physician; and
58 (d) acting within the scope of practice for that person, as provided by law, rule, and

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Senate Committee Amendments 1-30-2009 rd/trv 59

specialized certification and training in that person's area of practice.
60 (5) "Best interest" means that the benefits to the person resulting from a treatment
61 outweigh the burdens to the person resulting from the treatment, taking into account:
62 (a) the effect of the treatment on the physical, emotional, and cognitive functions of the
63 person;
64 (b) the degree of physical pain or discomfort caused to the person by the treatment or
65 the withholding or withdrawal of treatment;
66 (c) the degree to which the person's medical condition, the treatment, or the
67 withholding or withdrawal of treatment, result in a severe and continuing impairment of the
68 dignity of the person by subjecting the person to humiliation and dependency;
69 (d) the effect of the treatment on the life expectancy of the person;
70 (e) the prognosis of the person for recovery with and without the treatment;
71 (f) the risks, side effects, and benefits of the treatment, or the withholding or
72 withdrawal of treatment; and
73 (g) the religious beliefs and basic values of the person receiving treatment, to the extent
74 these may assist the decision maker in determining the best interest.
75 (6) "Capacity to appoint an agent" means that the adult understands the consequences
76 of appointing a particular person as agent.
77 S. [ (7) "Clinical social worker" means a person licensed as a clinical social worker under
78 Title 58, Chapter 60, Mental Health Professional Practice Act.
79 [ ] (7) [ ] (8) ] .S "Declarant" means an adult who has completed and signed or directed the
80 signing of an advance health care directive.
81 S. [ [ ] (8) [ ] (9) ] .S "Default surrogate" means the adult who may make decisions for an
81a individual
82 when either:
83 (a) an agent or guardian has not been appointed; or
84 (b) an agent is not able, available, or willing to make decisions for an adult.
85 S. [ [ ] (9) [ ] (10) ] .S "Emergency medical services provider" means a person who is
85a licensed,
86 designated, or certified under Title 26, Chapter 8a, Utah Emergency Medical Services System
87 Act.
88 S. [ [ ] (10) [ ] (11) ] .S "Generally accepted health care standards":
89 (a) is defined only for the purpose of:

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- 4 - 90 (i) this chapter and does not define the standard of care for any other purpose under
91 Utah law; and
92 (ii) enabling health care providers to interpret the statutory form set forth in Section
93 75-2a-117 ; and
94 (b) means the standard of care that justifies a provider in declining to provide life
95 sustaining care because the proposed life sustaining care:
96 (i) will not prevent or reduce the deterioration in the health or functional status of a
97 person;
98 (ii) will not prevent the impending death of a person; or
99 (iii) will impose more burden on the person than any expected benefit to the person.
100 [(11)] (12) "Health care" means any care, treatment, service, or procedure to improve,
101 maintain, diagnose, or otherwise affect a person's physical or mental condition.
102 [(12)] (13) "Health care decision":
103 (a) means a decision about an adult's health care made by, or on behalf of, an adult, that
104 is communicated to a health care provider;
105 (b) includes:
106 (i) selection and discharge of a health care provider and a health care facility;
107 (ii) approval or disapproval of diagnostic tests, procedures, programs of medication,
108 and orders not to resuscitate; and
109 (iii) directions to provide, withhold, or withdraw artificial nutrition and hydration and
110 all other forms of health care; and
111 (c) does not include decisions about an adult's financial affairs or social interactions
112 other than as indirectly affected by the health care decision.
113 [(13)] (14) "Health care decision making capacity" means an adult's ability to make an
114 informed decision about receiving or refusing health care, including:
115 (a) the ability to understand the nature, extent, or probable consequences of health
116 status and health care alternatives;
117 (b) the ability to make a rational evaluation of the burdens, risks, benefits, and
118 alternatives of accepting or rejecting health care; and
119 (c) the ability to communicate a decision.
120 [(14)] (15) "Health care facility" means:

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(a) a health care facility as defined in Title 26, Chapter 21, Health Care Facility
122 Licensing and Inspection Act; and
123 (b) private offices of physicians, dentists, and other health care providers licensed to
124 provide health care under Title 58, Occupations and Professions.
125 S. [ [ ] (15) [ ] (16) ] .S "Health care provider" is as defined in Section 78B-3-403 , except that it
126 does not include an emergency medical services provider.
127 S. [ [ ] (16) [ ] (17) ] .S (a) "Life sustaining care" means any medical intervention, including
128 procedures, administration of medication, or use of a medical device, that maintains life by
129 sustaining, restoring, or supplanting a vital function.
130 (b) "Life sustaining care" does not include care provided for the purpose of keeping a
131 person comfortable.
132 S. [ [ ] (17) [ ] (18) ] .S "Life with dignity order" means an order, designated by the
132a Department of
133 Health under Section 75-2a-106 (5)(a), that gives direction to health care providers, health care
134 facilities, and emergency medical services providers regarding the specific health care
135 decisions of the person to whom the order relates.
136 S. [ [ ] (18) [ ] (19) ] .S "Minor" means a person who:
137 (a) is under 18 years of age; and
138 (b) is not an emancipated minor.
139 S. [ [ ] (19) [ ] (20) ] .S "Physician" means a physician and surgeon or osteopathic surgeon
139a licensed
140 under Title 58, Chapter 67, Utah Medical Practice Act or Chapter 68, Utah Osteopathic
141 Medical Practice Act.
142 S. [ (21) ] 20 .S "Physician assistant" means a person licensed as a physician assistant
142a under Title
143 58, Chapter 70a, Physician Assistant Act.
144 S. [ (22) ] 21 .S "Psychologist" means a person licensed as a psychologist under Title 58,
144a Chapter
145 61, Psychologist Licensing Act.
146 [(20)] S. [ (23) ] 22 .S "Reasonably available" means:
147 (a) readily able to be contacted without undue effort; and
148 (b) willing and able to act in a timely manner considering the urgency of the
149 circumstances.
150 [(21)] S. [ (24) ] 23 .S "Substituted judgment" means the standard to be applied by a surrogate
151 when making a health care decision for an adult who previously had the capacity to make

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health care decisions, which requires the surrogate to consider:
153 (a) specific preferences expressed by the adult:
154 (i) when the adult had the capacity to make health care decisions; and
155 (ii) at the time the decision is being made;
156 (b) the surrogate's understanding of the adult's health care preferences;
157 (c) the surrogate's understanding of what the adult would have wanted under the
158 circumstances; and
159 (d) to the extent that the preferences described in Subsections [(21)] (24)(a) through (c)
160 are unknown, the best interest of the adult.
161 [(22)] S. [ (25) ] (24) .S "Surrogate" means a health care decision maker who is:
162 (a) an appointed agent;
163 (b) a default surrogate under the provisions of Section 75-2a-108 ; or
164 (c) a guardian.
165 Section 2. Section 75-2a-104 is amended to read:
166 75-2a-104. Capacity to make health care decisions -- Presumption -- Overcoming
167 presumption.
168 (1) An adult is presumed to have:
169 (a) health care decision making capacity; and
170 (b) capacity to make or revoke an advance health care directive.
171 (2) To overcome the presumption of capacity, a physician, physician assistant,
172 psychologist, S. [ clinical social worker ] .S , or an APRN who has personally examined the adult and
173 assessed the adult's health care decision making capacity must:
174 (a) find that the adult lacks health care decision making capacity;
175 (b) record the finding in the adult's medical chart including an indication of whether
176 the adult is likely to regain health care decision making capacity; and
177 (c) make a reasonable effort to communicate the determination to:
178 (i) the adult;
179 (ii) other health care providers or health care facilities that the [physician or APRN]
180 person who makes the finding would routinely inform of such a finding; and
181 (iii) if the adult has a surrogate, any known surrogate.
182 (3) (a) [If a physician or APRN finds that an adult lacks] An adult who is found to lack

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184 time, challenge the finding by:
185 (i) submitting to a health care provider a written notice stating that the adult disagrees
186 with the physician's finding; or
187 (ii) orally informing the health care provider that the adult disagrees with the finding.
188 (b) A health care provider who is informed of a challenge under Subsection (3)(a),
189 shall, if the adult has a surrogate, promptly inform the surrogate of the adult's challenge.
190 (c) A surrogate informed of a challenge to a finding under this section, or the adult if
191 no surrogate is acting on the adult's behalf, shall inform the following of the adult's challenge:
192 (i) any other health care providers involved in the adult's care; and
193 (ii) the health care facility, if any, in which the adult is receiving care.
194 (d) Unless otherwise ordered by a court, a finding [by a physician], under Subsection
195 (2), that the adult lacks health care decision making capacity, is not in effect if the adult
196 challenges the finding under Subsection (3)(a).
197 (e) If an adult does not challenge the finding described in Subsection (2), the health
198 care provider and health care facility may rely on a surrogate, pursuant to the provisions of this
199 chapter, to make health care decisions for the adult.
200 (4) A health care provider or health care facility that relies on a surrogate to make
201 decisions on behalf of an adult has an ongoing obligation to consider whether the adult
202 continues to lack health care decision making capacity.
203 (5) If at any time a health care provider finds, based on an examination and assessment,
204 that the adult has regained health care decision making capacity, the health care provider shall
205 record the results of the assessment in the adult's medical record, and the adult can direct the
206 adult's own health care.
207 Section 3. Section 75-2a-106 is amended to read:
208 75-2a-106. Emergency medical services -- Life with dignity order.
209 (1) A life with dignity order may be created by or on behalf of a person as described in
210 this section.
211 (2) A life with dignity order shall, in consultation with the person authorized to consent
212 to the order pursuant to this section, be prepared by:
213 (a) the physician or APRN of the person to whom the life with dignity order relates; or

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215 (i) is acting under the supervision of a person described in Subsection (2)(a); and
216 (ii) is:
217 (A) a nurse, licensed under Title 58, Chapter 31b, Nurse Practice Act;
218 (B) a physician assistant, licensed under Title 58, Chapter 70a, Physician Assistant
219 Act;
220 (C) a mental health professional, licensed under Title 58, Chapter 60, Mental Health
221 Professional Practice Act; or
222 (D) another health care provider, designated by rule as described in Subsection (10).
223 (3) A life with dignity order shall be signed:
224 (a) personally, by the physician, physician assistant, or APRN of the person to whom
225 the life with dignity order relates; and
226 (b) (i) if the person to whom the life with dignity order relates is an adult with health
227 care decision making capacity, by:
228 (A) the person; or
229 (B) an adult who is directed by the person to sign the life with dignity order on behalf
230 of the person;
231 (ii) if the person to whom the life with dignity order relates is an adult who lacks health
232 care decision making capacity, by:
233 (A) the surrogate with the highest priority under Section 75-2a-111 ;
234 (B) the majority of the class of surrogates with the highest priority under Section
235 75-2a-111 ; or
236 (C) a person directed to sign the order by, and on behalf of, the persons described in
237 Subsection (3)(b)(ii)(A) or (B); or
238 (iii) if the person to whom the life with dignity order relates is a minor, by a parent or
239 guardian of the minor.
240 (4) If a life with dignity order relates to a minor and directs that life sustaining
241 treatment be withheld or withdrawn from the minor, the order shall include a certification by
242 two physicians that, in their clinical judgment, an order to withhold or withdraw life sustaining
243 treatment is in the best interest of the minor.
244 (5) A life with dignity order:

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- 9 - 245 (a) shall be in writing, on a form approved by the Department of Health;
246 (b) shall state the date on which the order was made;
247 (c) may specify the level of life sustaining care to be provided to the person to whom
248 the order relates; and
249 (d) may direct that life sustaining care be withheld or withdrawn from the person to
250 whom the order relates.
251 (6) A health care provider or emergency medical service provider, licensed or certified
252 under Title 26, Chapter 8a, Utah Emergency Medical Services System Act, is immune from
253 civil or criminal liability, and is not subject to discipline for unprofessional conduct, for:
254 (a) complying with a life with dignity order in good faith; or
255 (b) providing life sustaining treatment to a person when a life with dignity order directs
256 that the life sustaining treatment be withheld or withdrawn.
257 (7) To the extent that the provisions of a life with dignity order described in this
258 section conflict with the provisions of an advance health care directive made under Section
259 75-2a-107 , the provisions of the life with dignity order take precedence.
260 (8) An adult, or a parent or guardian of a minor, may revoke a life with dignity order
261 by:
262 (a) orally informing emergency service personnel;
263 (b) writing "void" across the form;
264 (c) burning, tearing, or otherwise destroying or defacing:
265 (i) the form; or
266 (ii) a bracelet or other evidence of the life with dignity order;
267 (d) asking another adult to take the action described in this Subsection (8) on the
268 person's behalf;
269 (e) signing or directing another adult to sign a written revocation on the person's
270 behalf;
271 (f) stating, in the presence of an adult witness, that the person wishes to revoke the
272 order; or
273 (g) completing a new life with dignity order.
274 (9) (a) Except as provided in Subsection (9)(c), a surrogate for an adult who lacks
275 health care decision making capacity may only revoke a life with dignity order if the revocation

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- 10 - 276 is consistent with the substituted judgment standard.
277 (b) Except as provided in Subsection (9)(c), a surrogate who has authority under this
278 section to sign a life with dignity order may revoke a life with dignity order, in accordance with
279 Subsection (9)(a), by:
280 (i) signing a written revocation of the life with dignity order; or
281 (ii) completing and signing a new life with dignity order.
282 (c) A surrogate may not revoke a life with dignity order during the period of time
283 beginning when an emergency service provider is contacted for assistance, and ending when
284 the emergency ends.
285 (10) (a) The Department of Health shall adopt rules, in accordance with Title 63G,
286 Chapter 3, Utah Administrative Rulemaking Act, to:
287 (i) create the forms and systems described in this section; and
288 (ii) develop uniform instructions for the form established in Section 75-2a-117 .
289 (b) The Department of Health may adopt rules, in accordance with Title 63G, Chapter
290 3, Utah Administrative Rulemaking Act, to designate health care professionals, in addition to
291 those described in Subsection (2)(b)(ii), who may prepare a life with dignity order.
292 (c) The Department of Health may assist others with training of health care
293 professionals regarding this chapter.
294 Section 4. Section 75-2a-109 is amended to read:
295 75-2a-109. Effect of current health care preferences -- When a surrogate may act.
296 (1) An adult with health care decision making capacity retains the right to make health
297 care decisions as long as the adult has health care decision making capacity as defined in
298 Section 75-2a-103 . For purposes of this chapter, the inability to communicate through speech
299 does not mean that the adult lacks health care decision making capacity.
300 (2) An adult's current health care decisions, however expressed or indicated, always
301 supersede an adult's prior decisions or health care directives.
302 (3) Unless otherwise directed in an advance health care directive, an advance health
303 care directive or the authority of a surrogate to make health care decisions on behalf of an
304 adult:
305 (a) is effective only after a physician, physician assistant, psychologist, clinical social
306 worker, or APRN makes a determination of incapacity as provided in Section 75-2a-104 ;

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- 11 - 307 (b) remains in effect during any period of time in which the declarant lacks capacity to
308 make health care decisions; and
309 (c) ceases to be effective when:
310 (i) a declarant disqualifies a surrogate or revokes the advance health care directive;
311 (ii) a health care provider finds that the declarant has health care decision making
312 capacity;
313 (iii) a court issues an order invalidating a health care directive; or
314 (iv) the declarant has challenged the finding of incapacity under the provisions of
315 Subsection 75-2a-104 (3).
316 Section 5. Section 75-2a-117 is amended to read:
317 75-2a-117. Optional form.
318 (1) The form created in Subsection (2), or a substantially similar form, is presumed
319 valid under this chapter.
320 (2) The following form is presumed valid under Subsection (1):
321 Utah Advance Health Care Directive
322 (Pursuant to Utah Code Section 75-2a-117 )
323 Part I: Allows you to name another person to make health care decisions for you when you
324 cannot make decisions or speak for yourself.
325 Part II: Allows you to record your wishes about health care in writing.
326 Part III: Tells you how to revoke or change this directive.
327 Part IV: Makes your directive legal.
328 __________________________________________________________________________
329 My Personal Information
330 Name: ____________________________________________________________________
331 Street Address: _____________________________________________________________
332 City, State, Zip Code:
333 _____________________________________________________________
334 Telephone: _________________________ Cell Phone: ____________________________
335 Birth date: _____________
336 ____________________________________________________________________________
337 Part I: My Agent (Health Care Power of Attorney)

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- 12 - 338 A. No Agent
339 If you do not want to name an agent: initial the box below, then go to Part II; do not name an
340 agent in B or C below. No one can force you to name an agent.
341 ______ I do not want to choose an agent.
342 B. My Agent
343 Agent's Name:
344 ______________________________________________________________
345 Street Address:
346 ______________________________________________________________
347 City, State, Zip Code:
348 ______________________________________________________________
349 Home Phone: ( ) _________ Cell Phone: ( ) _________ Work Phone: ( ) __________
350 C. My Alternate Agent
351 This person will serve as your agent if your agent, named above, is unable or unwilling to
352 serve.
353 Alternate Agent's Name:
354 ______________________________________________________
355 Street Address:
356 ______________________________________________________________
357 City, State, Zip Code:
358 ______________________________________________________________
359 Home Phone: ( ) _________ Cell Phone: ( ) _________ Work Phone: ( ) __________
360 D. Agent's Authority
361 If I cannot make decisions or speak for myself (in other words, after my physician or [APRN]
362 another authorized provider finds that I lack health care decision making capacity under
363 Section 75-2a-104 of the Advance Health Care Directive Act), my agent has the power to make
364 any health care decision I could have made such as, but not limited to:
365 * Consent to, refuse, or withdraw any health care. This may include care to prolong my life
366 such as food and fluids by tube, use of antibiotics, CPR (cardiopulmonary resuscitation), and
367 dialysis, and mental health care, such as convulsive therapy and psychoactive medications.
368 This authority is subject to any limits in paragraph F of Part I or in Part II of this directive.

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- 13 - 369 * Hire and fire health care providers.
370 * Ask questions and get answers from health care providers.
371 * Consent to admission or transfer to a health care provider or health care facility, including a
372 mental health facility, subject to any limits in paragraphs E and F of Part I.
373 * Get copies of my medical records.
374 * Ask for consultations or second opinions.
375 My agent cannot force health care against my will, even if a physician has found that I lack
376 health care decision making capacity.
377 E. Other Authority
378 My agent has the powers below ONLY IF I initial the "yes" option that precedes the statement.
379 I authorize my agent to:
380 YES _____ NO _____ Get copies of my medical records at any time, even when I can
381 speak for myself.
382 YES _____ NO _____ Admit me to a licensed health care facility, such as a hospital,
383 nursing home, assisted living, or other facility for long-term placement other than convalescent
384 or recuperative care.
385 F. Limits/Expansion of Authority
386 I wish to limit or expand the powers of my health care agent as follows:
387 ____________________________________________________________________________
388 ____________________________________________________________________________
389 G. Nomination of Guardian
390 Even though appointing an agent should help you avoid a guardianship, a guardianship may
391 still be necessary. Initial the "YES" option if you want the court to appoint your agent or, if
392 your agent is unable or unwilling to serve, your alternate agent, to serve as your guardian, if a
393 guardianship is ever necessary.
394 YES _____ NO _____
395 I, being of sound mind and not acting under duress, fraud, or other undue influence, do hereby
396 nominate my agent, or if my agent is unable or unwilling to serve, I hereby nominate my
397 alternate agent, to serve as my guardian in the event that, after the date of this instrument, I
398 become incapacitated.
399 H. Consent to Participate in Medical Research

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- 14 - 400 YES _____ NO _____ I authorize my agent to consent to my participation in medical
401 research or clinical trials, even if I may not benefit from the results.
402 I. Organ Donation
403 YES _____ NO _____ If I have not otherwise agreed to organ donation, my agent may
404 consent to the donation of my organs for the purpose of organ transplantation.
405 __________________________________________________________________________
406 Part II: My Health Care Wishes (Living Will)
407 I want my health care providers to follow the instructions I give them when I am being treated,
408 even if my instructions conflict with these or other advance directives. My health care
409 providers should always provide health care to keep me as comfortable and functional as
410 possible.
411 Choose only one of the following options, numbered Option 1 through Option 4, by placing
412 your initials before the numbered statement. Do not initial more than one option. If you do not
413 wish to document end-of-life wishes, initial Option 4. You may choose to draw a line through
414 the options that you are not choosing.
415 Option 1
416 ________ Initial
417 I choose to let my agent decide. I have chosen my agent carefully. I have talked with my agent
418 about my health care wishes. I trust my agent to make the health care decisions for me that I
419 would make under the circumstances.
420 Additional Comments:
421 _____________________________________________________________________
422 Option 2
423 ________ Initial
424 I choose to prolong life. Regardless of my condition or prognosis, I want my health care team
425 to try to prolong my life as long as possible within the limits of generally accepted health care
426 standards.
427 Other:
428 _____________________________________________________________________
429 Option 3
430 ________ Initial

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- 15 - 431 I choose not to receive care for the purpose of prolonging life, including food and fluids by
432 tube, antibiotics, CPR, or dialysis being used to prolong my life. I always want comfort care
433 and routine medical care that will keep me as comfortable and functional as possible, even if
434 that care may prolong my life.
435 If you choose this option, you must also choose either (a) or (b), below.
436 ______ Initial
437 (a) I put no limit on the ability of my health care provider or agent to withhold or withdraw
438 life-sustaining care.
439 If you selected (a), above, do not choose any options under (b).
440 ______ Initial
441 (b) My health care provider should withhold or withdraw life-sustaining care if at least one of
442 the following initialed conditions is met:
443 _____ I have a progressive illness that will cause death.
444 _____ I am close to death and am unlikely to recover.
445 _____ I cannot communicate and it is unlikely that my condition will improve.
446 _____ I do not recognize my friends or family and it is unlikely that my condition will
447 improve.
448 _____ I am in a persistent vegetative state.
449 Other:
450 _____________________________________________________________________
451 Option 4
452 ________ Initial
453 I do not wish to express preferences about health care wishes in this directive.
454 Other:
455 _____________________________________________________________________
456 Additional instructions about your health care wishes:
457 ____________________________________________________________________________
458 ____________________________________________________________________________
459 If you do not want emergency medical service providers to provide CPR or other life sustaining
460 measures, you must work with a physician or APRN to complete an order that reflects your
461 wishes on a form approved by the Utah Department of Health.

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- 16 - 462 Part III: Revoking or Changing a Directive
463 I may revoke or change this directive by:
464 1. Writing "void" across the form, or burning, tearing, or otherwise destroying or defacing this
465 document or directing another person to do the same on my behalf;
466 2. Signing a written revocation of the directive, or directing another person to sign a
467 revocation on my behalf;
468 3. Stating that I wish to revoke the directive in the presence of a witness who: is 18 years of
469 age or older; will not be appointed as my agent in a substitute directive; will not become a
470 default surrogate if the directive is revoked; and signs and dates a written document confirming
471 my statement; or
472 4. Signing a new directive. (If you sign more than one Advance Health Care Directive, the
473 most recent one applies.)
474 Part IV: Making My Directive Legal
475 I sign this directive voluntarily. I understand the choices I have made and declare that I am
476 emotionally and mentally competent to make this directive. My signature on this form revokes
477 any living will or power of attorney form, naming a health care agent, that I have completed in
478 the past.
479 ____________________________________
480 Date
481 ________________________________________________
482 Signature
483 ____________________________________________________________________________
484 City, County, and State of Residence
485 I have witnessed the signing of this directive, I am 18 years of age or older, and I am not:
486 1. related to the declarant by blood or marriage;
487 2. entitled to any portion of the declarant's estate according to the laws of intestate succession
488 of any state or jurisdiction or under any will or codicil of the declarant;
489 3. a beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or
490 transfer on death deed that is held, owned, made, or established by, or on behalf of, the
491 declarant;
492 4. entitled to benefit financially upon the death of the declarant;

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- 17 - 493 5. entitled to a right to, or interest in, real or personal property upon the death of the declarant;
494 6. directly financially responsible for the declarant's medical care;
495 7. a health care provider who is providing care to the declarant or an administrator at a health
496 care facility in which the declarant is receiving care; or
497 8. the appointed agent or alternate agent.
498 _____________________________________ __________________________________
499 Signature of Witness Printed Name of Witness
500 _____________________________________ ___________ _________ _________
501 Street Address City State Zip Code
502 If the witness is signing to confirm an oral directive, describe below the circumstances under
503 which the directive was made.
504 ____________________________________________________________________________
505 ____________________________________________________________________________

Legislative Review Note
as of 1-23-09 4:16 PM

Office of Legislative Research and General Counsel