S.B. 178

1

HEALTH CARE DIRECTIVES
2 2001 GENERAL SESSION
3 STATE OF UTAH
4 Sponsor: Peter C. Knudson
5 This act repeals the Personal Choice and Living Will Act within the Uniform Probate Code
6 and enacts a Health Care Directive Act. The act defines terms, provides for health care
7 directives, establishes requirements and suggested forms for directives, and specifies when
8 directives are effective. The act establishes the authority and duties of a health care agent.
9 The act provides for revocation of a health care directive and presumptions related to a
10 health care directive. The act specifies when a health care agent or provider is immune from
11 liability and specifies prohibited practices. The act establishes penalties for violations of the
12 act. The act establishes duties of a provider to provide life sustaining care. The act provides
13 a suggested form for directives.
14 This act affects sections of Utah Code Annotated 1953 as follows:
15 REPEALS AND REENACTS:
16 75-2-1101, as enacted by Chapter 173, Laws of Utah 1985
17 75-2-1102, as last amended by Chapter 129, Laws of Utah 1993
18 75-2-1103, as last amended by Chapter 129, Laws of Utah 1993
19 75-2-1104, as last amended by Chapter 129, Laws of Utah 1993
20 75-2-1105, as last amended by Chapter 129, Laws of Utah 1993
21 75-2-1106, as last amended by Chapter 129, Laws of Utah 1993
22 75-2-1107, as last amended by Chapter 129, Laws of Utah 1993
23 75-2-1108, as enacted by Chapter 173, Laws of Utah 1985
24 75-2-1109, as enacted by Chapter 173, Laws of Utah 1985
25 75-2-1110, as enacted by Chapter 173, Laws of Utah 1985
26 75-2-1111, as enacted by Chapter 173, Laws of Utah 1985
27 75-2-1112, as enacted by Chapter 173, Laws of Utah 1985

28 75-2-1113, as enacted by Chapter 173, Laws of Utah 1985
29 75-2-1114, as enacted by Chapter 173, Laws of Utah 1985
30 75-2-1115, as last amended by Chapter 241, Laws of Utah 1991
31 75-2-1116, as enacted by Chapter 173, Laws of Utah 1985
32 75-2-1117, as enacted by Chapter 173, Laws of Utah 1985
33 REPEALS:
34 75-2-1118, as enacted by Chapter 173, Laws of Utah 1985
35 75-2-1119, as enacted by Chapter 129, Laws of Utah 1993
36 Be it enacted by the Legislature of the state of Utah:
37 Section 1. Section 75-2-1101 is repealed and reenacted to read:
38 Part 11. Health Care Directives Act
39 75-2-1101. Title.
40 This part is known as the "Health Care Directives Act."
41 Section 2. Section 75-2-1102 is repealed and reenacted to read:
42 75-2-1102. Definitions.
43 As used in this part:
44 (1) (a) "Act in good faith" means to act consistently with a legally sufficient health care
45 directive of the principal, or information otherwise made known by the principal, unless the actor
46 has actual knowledge of the modification or revocation of the information expressed.
47 (b) If the information described in Subsection (1)(a) does not provide adequate guidance
48 to the actor, "act in good faith" means acting in the best interests of the principal, considering the
49 principal's overall general health condition and prognosis, and the principal's personal values, to
50 the extent known.
51 (c) Notwithstanding any instruction of the principal, a health care agent, health care
52 provider, or any other person is not acting in good faith if the person commits the crime of
53 assisting suicide.
54 (2) "Decision-making capacity" means the ability to understand the significant benefits,
55 risks, and alternatives to proposed health care and to make and communicate a health care
56 decision.
57 (3) "Health care" means any care, treatment, service, or procedure to maintain, diagnose,
58 or otherwise affect a person's physical or mental condition, and includes to the extent decisions on

59 these matters relate to the health care needs of the person:
60 (a) the provision of nutrition or hydration parenterally or through intubation;
61 (b) establishment of a person's abode within or without the state; and
62 (c) personal security safeguards for a person.
63 (4) "Health care agent" or "agent" means an individual age 18 or older who is appointed
64 by a principal in a health care power of attorney to make health care decisions on behalf of the
65 principal.
66 (5) "Health care decision" means the consent, refusal of consent, or withdrawal of consent
67 to health care.
68 (6) "Health care directive" means a written instrument that complies with this section and
69 includes any one of the following:
70 (a) one or more health care instructions;
71 (b) a health care power of attorney;
72 (c) a directive for medical services;
73 (d) a directive not to resuscitate; or
74 (e) a special power of attorney for health care executed under this chapter before July 1,
75 2001.
76 (7) "Health care facility" means a health care facility as defined in Subsection 26-21-2 (13).
77 (8) "Health care instruction" means a written statement of the principal's values,
78 preferences, guidelines, or directions regarding health care.
79 (9) "Health care power of attorney" means an instrument appointing one or more health
80 care agents to make health care decisions for the principal.
81 (10) "Health care provider" means:
82 (a) a person providing health care services for which the person is:
83 (i) licensed under Title 58, Occupations and Professions; or
84 (ii) licensed or certified under Title 26, Chapter 8a, Utah Emergency Medical Services
85 System Act, as an emergency medical service provider; and
86 (b) a health care facility, organization, or corporation licensed, certified, or otherwise
87 authorized or permitted by the laws of this state to administer health care directly or through an
88 arrangement with other health care providers.
89 (11) "Principal" means an individual age 18 or older who has executed a health care

90 directive.
91 (12) "Reasonably available" means able to be contacted and willing and able to act in a
92 timely manner considering the urgency of the principal's health care needs.
93 Section 3. Section 75-2-1103 is repealed and reenacted to read:
94 75-2-1103. Health care directive.
95 (1) A principal with the capacity to do so may execute a health care directive. A health
96 care directive may include:
97 (a) one or more health care instructions to direct health care providers, others assisting
98 with health care, family members, and a health care agent; or
99 (b) a health care power of attorney to appoint a health care agent to make health care
100 decisions for the principal when the principal, in the judgment of the principal's attending
101 physician, lacks decision-making capacity, unless otherwise specified in the health care directive.
102 (2) In accordance with Title 63, Chapter 46a, Utah Administrative Rulemaking Act, the
103 Department of Health may make rules to require health care providers and facilities to adopt
104 procedures and forms to assure that:
105 (a) the health care instructions made by a principal, or the health care agent, or contained
106 in a health care directive are included in appropriate treatment orders; and
107 (b) the health care instructions or directives transfer with the principal when a discharge
108 of the principal takes place.
109 Section 4. Section 75-2-1104 is repealed and reenacted to read:
110 75-2-1104. Requirements.
111 (1) To be legally sufficient in this state, a health care directive must:
112 (a) be in writing;
113 (b) be dated;
114 (c) state the principal's name;
115 (d) be executed by a principal with capacity to do so with the signature of the principal or
116 with the signature of another person authorized by the principal to sign on behalf of the principal;
117 (e) contain verification of the principal's signature or the signature of the person authorized
118 by the principal to sign on behalf of the principal, either by a notary public, or by a witnesses as
119 provided under this chapter; and
120 (f) include a health care instruction, a health care power of attorney, or both.

121 (2) (a) An individual appointed by the principal under Subsection 75-2-1106 (2)(b), to
122 make the determination of the principal's decision-making capacity is not eligible to act as the
123 health care agent.
124 (b) The following individuals are not eligible to act as the health care agent, unless the
125 individual appointed is related to the principal by blood, marriage, or adoption, or unless the
126 principal has complied with the provisions of Subsection 75-2-1106 (2)(a)(viii):
127 (i) a health care provider attending the principal on the date of execution of the health care
128 directive; or
129 (ii) an employee of:
130 (A) a health care provider attending the principal on the date of execution of the health
131 care directive; or
132 (B) the health care agent who must make decisions for the principal.
133 (3) A health care agent or alternate health care agent appointed in a health care power of
134 attorney may not act as a witness or notary public for the execution of the health care directive that
135 includes the health care power of attorney.
136 (4) (a) At least one witness to the execution of the health care directive must not be a
137 health care provider providing direct care to the principal, or an employee of a health care provider
138 providing direct care to the principal on the date of execution.
139 (b) A person notarizing a health care directive may be an employee of a health care
140 provider providing direct care to the principal.
141 Section 5. Section 75-2-1105 is repealed and reenacted to read:
142 75-2-1105. Executed in another state.
143 (1) A health care directive or similar document executed in another state or jurisdiction
144 is legally sufficient under this chapter if it:
145 (a) complies with the law of the state or jurisdiction in which it was executed; or
146 (b) complies with Section 75-2-1104 .
147 (2) Nothing in this section shall be interpreted to authorize a directive or similar document
148 to facilitate assisted suicide.
149 Section 6. Section 75-2-1106 is repealed and reenacted to read:
150 75-2-1106. Suggested form.
151 (1) (a) A health care directive must comply with the provisions of Section 75-2-1104 .

152 (b) A health care directive may, but need not be in the form contained in Section
153 75-2-1117 .
154 (2) (a) A health care directive may include provisions consistent with this chapter,
155 including:
156 (i) the designation of one or more alternate health care agents to act if the named health
157 care agent is not reasonably available to serve;
158 (ii) directions to joint health care agents regarding the process or standards by which the
159 health care agents are to reach a health care decision for the principal, and a statement whether
160 joint health care agents may act independently of one another;
161 (iii) limitations, if any, on the right of the health care agent or any alternate health care
162 agents to receive, review, obtain copies of, and consent to the disclosure of the principal's medical
163 records;
164 (iv) limitations, if any, on the nomination of the health care agent as guardian or
165 conservator of the principal;
166 (v) a document of gift for the purpose of making an anatomical gift, or an amendment to,
167 revocation of, or refusal to make an anatomical gift;
168 (vi) a declaration regarding mental health treatment under Title 62A, Chapter 12, Part 5;
169 (vii) limitations, if any, to the effect of dissolution or annulment of marriage;
170 (viii) specific reasons why a principal wants a health care provider or an employee of a
171 health care provider attending the principal to be eligible to act as the principal's health care agent;
172 and
173 (ix) health care instructions regarding artificially administered nutrition or hydration.
174 (b) A health care directive may include a statement of the circumstances under which the
175 directive becomes effective other than upon the judgment of the principal's attending physician in
176 the following situations:
177 (i) a principal who in good faith generally selects and depends upon spiritual means or
178 prayer for the treatment or care of disease or remedial care and does not have an attending
179 physician, may include a statement appointing an individual who may determine the principal's
180 decision-making capacity; and
181 (ii) a principal who in good faith does not generally select a physician or a health care
182 facility for the principal's health care needs may include a statement appointing an individual who

183 may determine the principal's decision-making capacity, provided that if the need to determine the
184 principal's capacity arises when the principal is receiving care under the direction of an attending
185 physician in a health care facility, the determination must be made by an attending physician after
186 consultation with the appointed individual.
187 (c) If a person appointed under Subsection (2)(b)(i) or (ii) is not reasonably available and
188 the principal is receiving care under the direction of an attending physician in a health care facility,
189 an attending physician shall determine the principal's decision-making capacity.
190 (d) A health care directive may authorize a health care agent to make health care decisions
191 for a principal even though the principal retains decision-making capacity.
192 Section 7. Section 75-2-1107 is repealed and reenacted to read:
193 75-2-1107. When effective.
194 (1) A health care directive is effective for a health care decision when:
195 (a) it meets the requirements of this section; and
196 (b) the principal, in the opinion of the attending physician of the principal, lacks
197 decision-making capacity to make the health care decision; or
198 (c) if other conditions for effectiveness otherwise specified by the principal have been met.
199 (2) A health care directive is not effective for a health care decision when:
200 (a) the principal, in the opinion of the attending physician of the principal, recovers
201 decision-making capacity; or
202 (b) conditions for effectiveness otherwise specified by the principal have been met.
203 Section 8. Section 75-2-1108 is repealed and reenacted to read:
204 75-2-1108. Authority and duties of health care agent.
205 (1) (a) The health care agent has authority to make any particular health care decision only
206 if:
207 (i) the principal lacks decision-making capacity, in the opinion of the attending physician,
208 to make or communicate that health care decision; or
209 (ii) conditions for effectiveness otherwise specified by the principal have been met.
210 (b) The physician or other health care provider shall continue to obtain the principal's
211 informed consent to all health care decisions for which the principal has decision-making capacity,
212 unless conditions for effectiveness otherwise specified by the principal have been met.
213 (c) An alternate health care agent has authority to act if the primary health care agent is not

214 reasonably available to act.
215 (2) Unless the principal has otherwise specified in the health care directive, the
216 appointment of the health care agent in a health care directive is considered a nomination of a
217 guardian or conservator for the principal.
218 (3) In exercising authority under a health care directive, a health care agent has a duty to
219 act in good faith. A health care agent or any alternate health care agent has a personal obligation
220 to the principal to make health care decisions authorized by the health care power of attorney, but
221 this obligation does not constitute a legal duty to act.
222 (4) (a) In the event of inconsistency between the appointment of a proxy or of a health care
223 agent under this chapter, the most recent appointment takes precedence.
224 (b) In the event of other inconsistencies among documents executed under this chapter
225 or other legally sufficient documents, the provisions of the most recently executed document take
226 precedence only to the extent of the inconsistency.
227 Section 9. Section 75-2-1109 is repealed and reenacted to read:
228 75-2-1109. Authority to review medical records.
229 A health care agent acting pursuant to a health care directive has the same right as the
230 principal to receive, review, and obtain copies of medical records of the principal, and to consent
231 to the disclosure of medical records of the principal, unless the principal has otherwise specified
232 in the health care directive.
233 Section 10. Section 75-2-1110 is repealed and reenacted to read:
234 75-2-1110. Revocation of health care directive.
235 (1) A principal with the capacity to do so may revoke a health care directive in whole or
236 in part at any time by doing any of the following:
237 (a) canceling, defacing, obliterating, burning, tearing, or otherwise destroying the health
238 care directive instrument or directing another in the presence of the principal to destroy the health
239 care directive instrument, with the intent to revoke the health care directive in whole or in part;
240 (b) executing a statement, in writing and dated, expressing the principal's intent to revoke
241 the health care directive in whole or in part;
242 (c) verbally expressing the principal's intent to revoke the health care directive in whole
243 or in part in the presence of two witnesses who do not have to be present at the same time; or
244 (d) executing a subsequent health care directive, to the extent the subsequent instrument

245 is inconsistent with any prior instrument.
246 (2) Unless the principal has otherwise specified in the health care directive, the
247 appointment by the principal of the principal's spouse as health care agent under a health care
248 power of attorney is revoked by the commencement of proceedings for dissolution, annulment, or
249 termination of the principal's marriage.
250 Section 11. Section 75-2-1111 is repealed and reenacted to read:
251 75-2-1111. Presumptions.
252 (1) The principal is presumed to have the capacity to execute a health care directive and
253 to revoke a health care directive, absent clear and convincing evidence to the contrary.
254 (2) A health care provider or health care agent may presume that a health care directive
255 is legally sufficient absent actual knowledge to the contrary. A health care directive is presumed
256 to be properly executed, absent clear and convincing evidence to the contrary.
257 (3) A health care agent, and a health care provider acting pursuant to the direction of a
258 health care agent, are presumed to be acting in good faith, absent clear and convincing evidence
259 to the contrary.
260 (4) A health care directive is presumed to remain in effect until the principal modifies or
261 revokes it, absent clear and convincing evidence to the contrary.
262 (5) This chapter does not create a presumption concerning the intention of an individual
263 who has not executed a health care directive and, except as otherwise provided by Section
264 75-2-1116 , does not impair or supersede any right or responsibility of an individual to consent,
265 refuse to consent, or withdraw consent to health care on behalf of another in the absence of a health
266 care directive.
267 (6) A copy of a health care directive is presumed to be a true and accurate copy of the
268 executed original, absent clear and convincing evidence to the contrary, and must be given the
269 same effect as an original.
270 (7) When a patient lacks decision-making capacity and is pregnant, and in reasonable
271 medical judgment there is a real possibility that if health care to sustain her life and the life of the
272 fetus is provided the fetus could survive to the point of live birth, the health care provider shall
273 presume that the patient would have wanted the health care to be provided, even if the withholding
274 or withdrawal of the health care would be authorized were she not pregnant.
275 Section 12. Section 75-2-1112 is repealed and reenacted to read:

276 75-2-1112. Immunities.
277 (1) A health care agent is not subject to criminal prosecution or civil liability if the health
278 care agent acts in good faith.
279 (2) (a) With respect to health care provided to a patient with a health care directive, a
280 health care provider is not subject to criminal prosecution, civil liability, or professional
281 disciplinary action if the health care provider acts in good faith and in accordance with applicable
282 standards of care.
283 (b) A health care provider is not subject to criminal prosecution, civil liability, or
284 professional disciplinary action if the health care provider relies on a health care decision made
285 by the health care agent and the following requirements are satisfied:
286 (i) the health care provider believes in good faith that the decision was made by a health
287 care agent appointed to make the decision and has no actual knowledge that the health care
288 directive has been revoked; and
289 (ii) the health care provider believes in good faith that the health care agent is acting in
290 good faith.
291 (c) A health care provider who administers health care necessary to keep the principal
292 alive, despite a health care decision of the health care agent to withhold or withdraw that treatment,
293 is not subject to criminal prosecution, civil liability, or professional disciplinary action if that
294 health care provider promptly took all reasonable steps to:
295 (i) notify the health care agent of the health care provider's unwillingness to comply;
296 (ii) document the notification in the principal's medical record; and
297 (iii) permit the health care agent to arrange to transfer care of the principal to another
298 health care provider willing to comply with the decision of the health care agent.
299 Section 13. Section 75-2-1113 is repealed and reenacted to read:
300 75-2-1113. Prohibited practices.
301 (1) A health care provider, insurer, or health care facility may not condition admission to
302 a facility, or the providing of treatment or insurance, on the requirement that an individual execute
303 a health care directive.
304 (2) A policy of life insurance is not legally impaired or invalidated in any manner by the
305 withholding or withdrawing of health care pursuant to the direction of a health care agent
306 appointed pursuant to this chapter, or pursuant to the implementation of health care instructions

307 under this chapter.
308 Section 14. Section 75-2-1114 is repealed and reenacted to read:
309 75-2-1114. Penalties.
310 (1) A person is guilty of a class A misdemeanor if that person:
311 (a) willfully conceals, cancels, defaces, or obliterates a health care directive of a principal
312 without the consent of the principal;
313 (b) willfully conceals or withholds personal knowledge of a revocation of a health care
314 directive;
315 (c) falsifies or forges a health care directive or a revocation of the instrument;
316 (d) coerces or fraudulently induces another to execute a health care directive; or
317 (e) requires or prohibits the execution of a health care directive as a condition for being
318 insured for or receiving all or some health care services.
319 (2) Whoever commits an act prohibited under Subsection (1) is guilty of a felony in the
320 third degree if the act results in bodily harm to the principal or to the person who would have been
321 a principal but for the unlawful act.
322 Section 15. Section 75-2-1115 is repealed and reenacted to read:
323 75-2-1115. Certain practices not condoned.
324 Nothing in this chapter may be construed to condone, authorize, or approve mercy killing,
325 suicide, or euthanasia.
326 Section 16. Section 75-2-1116 is repealed and reenacted to read:
327 75-2-1116. Duties of health care providers to provide life-sustaining health care.
328 (1) If a health care agent acting under this chapter directs the provision of health care,
329 nutrition, or hydration that, in reasonable medical judgment, has a significant possibility of
330 sustaining the life of the principal or declarant, a health care provider shall take all reasonable steps
331 to ensure the provision of the directed health care, nutrition, or hydration if the provider has the
332 legal and actual capability of providing the health care either itself, or by transferring the principal
333 or declarant to a health care provider who has that capability. Any transfer of a principal or
334 declarant under this paragraph must be done promptly and, if necessary to preserve the life of the
335 principal or declarant, by emergency means. This paragraph does not apply if a health care
336 directive indicates an intention to the contrary.
337 (2) A health care provider who is unwilling to provide directed health care under

338 Subsection (1) that the provider has the legal and actual capability of providing may transfer the
339 principal or declarant to another health care provider willing to provide the directed health care,
340 but the provider shall take all reasonable steps to ensure provision of the directed health care until
341 the principal or declarant is transferred.
342 (3) Nothing in this section alters any legal obligation or lack of legal obligation of a health
343 care provider to provide health care to a principal or declarant who refuses, has refused, or is
344 unable to pay for the health care.
345 Section 17. Section 75-2-1117 is repealed and reenacted to read:
346 75-2-1117. Suggested form.
347 The following is a suggested form of a health care directive and is not a required form.
348 HEALTH CARE DIRECTIVE
349 I, ..........................., understand this document allows me to do ONE OR BOTH of the
350 following:
351 PART I: Name another person (called the health care agent) to make health care decisions
352 for me if I am unable to decide or speak for myself. My health care agent must make health care
353 decisions for me based on the instructions I provide in this document (Part II), if any, the wishes
354 I have made known to him or her, or must act in my best interest if I have not made my health care
355 wishes known.
356 AND/OR
357 PART II: Give health care instructions to guide others making health care decisions for me.
358 If I have named a health care agent, these instructions are to be used by the agent. These
359 instructions may also be used by my health care providers, others assisting with my health care,
360 and my family, in the event I cannot make decisions for myself.
361 PART I: APPOINTMENT OF HEALTH CARE AGENT
362 THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS
363 FOR ME IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF
364 (I know I can change my agent or alternate agent at any time and I know I do not have to
365 appoint an agent or an alternate agent)
366 NOTE: If you appoint an agent, you should discuss this health care directive with your agent and
367 give your agent a copy. If you do not wish to appoint an agent, you may leave Part I blank and go
368 to Part II.

369 When I am unable to decide or speak for myself, I trust and appoint:
370 _________________________________________________________________
371 to make health care decisions for me. This person is called my health care agent.
372 Relationship of my health care agent to me: _____________________________
373 Telephone number of my health care agent: _____________________________
374 Address of my health care agent:
375 _____________________________________________________________________________
376 (OPTIONAL) APPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If my health care
377 agent is not reasonably available, I trust and appoint .................... to be my health care agent
378 instead.
379 Relationship of my alternate health care agent to me: __________________________________
380 Telephone number of my alternate health care agent: __________________________________
381 Address of my alternate health care agent: ___________________________________________
382 THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO DO IF I AM
383 UNABLE TO DECIDE OR SPEAK FOR MYSELF
384 (I know I can change these choices)
385 My health care agent is automatically given the powers listed below in (A) through (D).
386 My health care agent must follow my health care instructions in this document or any other
387 instructions I have given to my agent. If I have not given health care instructions, then my agent
388 must act in my best interest.
389 Whenever I am unable to decide or speak for myself, my health care agent has the power
390 to:
391 (A) Make any health care decision for me. This includes the power to give, refuse, or
392 withdraw consent to any care, treatment, service, or procedures. This includes deciding whether
393 to stop or not start health care that is keeping me or might keep me alive, and deciding about
394 intrusive mental health treatment.
395 (B) Choose my health care providers.
396 (C) Choose where I live and receive care and support when those choices relate to my
397 health care needs.
398 (D) Review my medical records and have the same rights that I would have to give my
399 medical records to other people.

400 If I DO NOT want my health care agent to have a power listed above in (A) through (D)
401 OR if I want to LIMIT any power in (A) through (D), I MUST say that here:
402 _____________________________________________
403 _____________________________________________
404 _____________________________________________
405 My health care agent is NOT automatically given the powers listed below in (1) and (2).
406 If I WANT my agent to have any of the powers in (1) and (2), I must INITIAL the line in front of
407 the power; then my agent WILL HAVE that power.
408 (1) To decide whether to donate any parts of my body, including organs, tissues, and eyes,
409 when I die.
410 (2) To decide what will happen with my body when I die (burial, cremation) If I want to
411 say anything more about my health care agent's powers or limits on the powers, I can say it here:
412 .................................................................
413 .................................................................
414 .................................................................
415 PART II: HEALTH CARE INSTRUCTIONS
416 NOTE: Complete this Part II if you wish to give health care instructions. If you appointed an agent
417 in Part I, completing this Part II is optional but would be very helpful to your agent. However, if
418 you chose not to appoint an agent in Part I, you MUST complete some or all of this Part II if you
419 wish to make a valid health care directive.
420 These are instructions for my health care when I am unable to decide or speak for myself. These
421 instructions must be followed (so long as they address my needs).
422 THESE ARE MY BELIEFS AND VALUES ABOUT MY HEALTH CARE
423 (I know I can change these choices or leave any of them blank)
424 I want you to know these things about me to help you make decisions about my health care:
425 My goals for my health care: ...............................................................................................
426 .................................................................
427 My fears about my health care: .............................................................................................
428 .................................................................
429 My beliefs about when life would be no longer worth living: ........................................................
430 .......................................................................................................................................................

431 My thoughts about how my medical condition might affect my family:
432 .........................................................................................................................
433 ..................................................................
434 THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE
435 (I know I can change these choices or leave any of them blank)
436 Many medical treatments may be used to try to improve my medical condition or to prolong my
437 life. Examples include artificial breathing by a machine connected to a tube in the lungs, artificial
438 feeding or fluids through tubes, attempts to start a stopped heart, surgeries, dialysis, antibiotics,
439 and blood transfusions. Most medical treatments can be tried for awhile and then stopped if they
440 do not help.
441 I have these views about my health care in these situations:
442 (Note: You can discuss general feelings, specific treatments, or leave any of them blank)
443 If I am not in a hospital and emergency medical services are called to care for me:
444 ___ Do Not Attempt to Resuscitate (No CPR, intubation, bag mask ventilation,
445 cardiac medication, oxygen delivery, IV therapy, or transport)
446 ___ Comfort Care Only (positioning, wound care, medications, oxygen delivery)
447 ___ All Necessary Care and Transport to Acute Care Facility
448 If I had a reasonable chance of recovery, and were temporarily unable to decide or speak for
449 myself, I would want:
450 If I do not have a pulse and am not breathing:
451 ___ Do Not Attempt to Resuscitate
452 ___ Attempt to Resuscitate
453 If I do have a pulse and/or am breathing on my own:
454 ___ Comfort Measures Only (Examples- medications, oxygen positions, wound care, measures
455 to relieve pain/suffering, reasonable efforts to offer food/fluids orally)
456 ___ Additional Care (All above plus suction, treatment of airway obstruction)
457 ___ Advanced Care (All above plus consider oral/nasal airway, bag-mask/demand valve, monitor
458 cardiac rhythm medications, IV fluids, surgical intervention, blood/blood products, dialysis)
459 If antibiotics might extend my life:
460 ___ No Antibiotics (except if desired for comfort)
461 ___ Treat with antibiotics

462 If artificially administered fluids and/or nutrition might extend my life:
463 ___ No feeding tube or IV fluids
464 ___ No long-term feeding tube or IV fluids (long-term means ______________)
465 ___ Feeding tube and IV Fluids
466 Other Instructions:
467 If I were dying and unable to decide or speak for myself, I would want:
468 If I do not have a pulse and am not breathing:
469 ___ Do Not Attempt to Resuscitate
470 ___ Attempt to Resuscitate
471 If I do have a pulse and/or am breathing on my own:
472 ___ Comfort Measures Only (Examples- medications, oxygen positions, wound care, measures
473 to relieve pain/suffering, reasonable efforts to offer food/fluids orally)
474 ___ Additional Care (All above plus suction, treatment of airway obstruction)
475 ___ Advanced Care (All above plus consider oral/nasal airway, bag-mask/demand valve, monitor
476 cardiac rhythm medications, IV fluids, surgical intervention, blood/blood products, dialysis)
477 If antibiotics might extend my life:
478 ___ No Antibiotics (except if desired for comfort)
479 ___ Treat with antibiotics
480 If artificially administered fluids and/or nutrition might extend my life:
481 ___ No feeding tube or IV fluids
482 ___ No long-term feeding tube or IV fluids (long-term means ______________)
483 ___ Feeding tube and IV Fluids
484 Other Instructions:
485 If I were permanently unconscious and unable to decide or speak for myself, I would want:
486 If I do not have a pulse and am not breathing:
487 ___ Do Not Attempt to Resuscitate
488 ___ Attempt to Resuscitate
489 If I do have a pulse and/or am breathing on my own:
490 ___ Comfort Measures Only (Examples- medications, oxygen positions, wound care, measures
491 to relieve pain/suffering, reasonable efforts to offer food/fluids orally)
492 ___ Additional Care (All above plus suction, treatment of airway obstruction)

493 ___ Advanced Care (All above plus consider oral/nasal airway, bag-mask/demand valve, monitor
494 cardiac rhythm medications, IV fluids, surgical intervention, blood/blood products, dialysis)
495 If antibiotics might extend my life:
496 ___ No Antibiotics (except if desired for comfort)
497 ___ Treat with antibiotics
498 If artificially administered fluids and/or nutrition might extend my life:
499 ___ No feeding tube or IV fluids
500 ___ No long-term feeding tube or IV fluids (long-term means ______________)
501 ___ Feeding tube and IV Fluids
502 Other Instructions:
503 If I were completely dependent on others for my care and unable to decide or speak for myself, I
504 would want:
505 If I do not have a pulse and am not breathing:
506 ___ Do Not Attempt to Resuscitate
507 ___ Attempt to Resuscitate
508 If I do have a pulse and/or am breathing on my own:
509 ___ Comfort Measures Only (Examples- medications, oxygen positions, wound care, measures
510 to relieve pain/suffering, reasonable efforts to offer food/fluids orally)
511 ___ Additional Care (All above plus suction, treatment of airway obstruction)
512 ___ Advanced Care (All above plus consider oral/nasal airway, bag-mask/demand valve, monitor
513 cardiac rhythm medications, IV fluids, surgical intervention, blood/blood products, dialysis)
514 If antibiotics might extend my life:
515 ___ No Antibiotics (except if desired for comfort)
516 ___ Treat with antibiotics
517 If artificially administered fluids and/or nutrition might extend my life:
518 ___ No feeding tube or IV fluids
519 ___ No long-term feeding tube or IV fluids (long-term means ______________)
520 ___ Feeding tube and IV Fluids
521 Other Instructions:
522 In all circumstances, my doctors will try to keep me comfortable and reduce my pain. This is how
523 I feel about pain relief if it would affect my alertness or if it could shorten my life:

524 ...........................................................................................................................
525 .................................................................
526 There are other things that I want or do not want for my health care, if possible:
527 Who I would like to be my doctor: ..........................................................................................
528 .................................................................
529 Where I would like to live to receive health care: .................................................................
530 .........................................................................................................................................................
531 Where I would like to die and other wishes I have about dying: .........................................................
532 .........................................................................................................................................................
533 My wishes about donating parts of my body when I die: ...............................................................
534 .........................................................................................................................................................
535 My wishes about what happens to my body when I die (cremation, burial): .................................
536 ............................................................................................................
537 .................................................................
538 Any other things: ..........................................................................................................
539 .................................................................
540 PART III: MAKING THE DOCUMENT LEGAL
541 This document must be signed by me. It also must either be verified by a notary public (Option
542 1) OR witnessed by two witnesses (Option 2). It must be dated when it is verified or witnessed.
543 I am thinking clearly, I agree with everything that is written in this document, and I have made this
544 document willingly. ..........................................
545 My Signature
546 Date signed:..............................
547 Date of birth:............................
548 Address:...................................
549 .................................................
550 If I cannot sign my name, I can ask someone to sign this document for me.
551 ___________________________________________________________
552 Signature of the person who I asked to sign this document for me.
553 ___________________________________________________________
554 Printed name of the person who I asked to sign this document for me.

555 Option 1: Notary Public
556 In my presence on .................... (date), ....................... (name) acknowledged his/her signature on
557 this document or acknowledged that he/she authorized the person signing this document to sign
558 on his/her behalf. I am not named as a health care agent or alternate health care agent in this
559 document.
560 .............................................................
561 (Signature of Notary) (Notary Stamp)
562 Option 2: Two Witnesses
563 Two witnesses must sign. Only one of the two witnesses can be a health care provider or an
564 employee of a health care provider giving direct care to me on the day I sign this document.
565 Witness One:
566 (i) In my presence on ............... (date), ............... (name) acknowledged his/her signature on this
567 document or acknowledged that he/she authorized the person signing this document to sign on
568 his/her behalf.
569 (ii) I am at least 18 years of age.
570 (iii) I am not named as a health care agent or an alternate health care agent in this document.
571 (iv) If I am a health care provider or an employee of a health care provider giving direct care to
572 the person listed above in (A), I must initial this box:
573 I certify that the information in (i) through (iv) is true and correct.
574 ........................................................
575 (Signature of Witness One)
576 Address: .........................................
577 .......................................................
578 Witness Two:
579 (i) In my presence on .............. (date), ................. (name) acknowledged his/her signature on this
580 document or acknowledged that he/she authorized the person signing this document to sign on
581 his/her behalf.
582 (ii) I am at least 18 years of age.
583 (iii) I am not named as a health care agent or an alternate health care agent in this document.
584 (iv) If I am a health care provider or an employee of a health care provider giving direct care to
585 the person listed above in (A), I must initial this box:

586 I certify that the information in (i) through (iv) is true and correct.
587 .........................................................
588 (Signature of Witness Two)
589 Address: ..........................................
590 .........................................................
591 REMINDER: Keep this document with your personal papers in a safe place (not in a safe deposit
592 box). Give signed copies to your doctors, family, close friends, health care agent, and alternate
593 health care agent. Make sure your doctor is willing to follow your wishes. This document should
594 be part of your medical record at your physician's office and at the hospital, home care agency,
595 hospice, or nursing facility where you receive your care.
596 Section 18. Repealer.
597 This act repeals:
598 Section 75-2-1118, Directive not mercy killing.
599 Section 75-2-1119, Reciprocity.




Legislative Review Note
as of 2-12-01 12:34 PM

A limited legal review of this legislation raises no obvious constitutional or statutory concerns.

Office of Legislative Research and General Counsel