S.B. 117 Enrolled

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: Steven R. Mascaro
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 to determine whether an adult lacks health care
17 decision making capacity, if the physician assistant is permitted to make that
18 determination under a delegation of services agreement;
19 . provides that a physician assistant may prepare or sign a life with dignity order, if
20 the physician assistant is permitted to prepare or sign the life with dignity order
21 under a delegation of services agreement; and
22 . makes technical changes.
23 Monies Appropriated in this Bill:
24 None
25 Other Special Clauses:
26 None
27 Utah Code Sections Affected:
28 AMENDS:
29 75-2a-103, as last amended by Laws of Utah 2008, Chapters 3 and 107

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31 75-2a-106, as repealed and reenacted by Laws of Utah 2008, Chapter 107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

58 (b) an independent practitioner;
59 (c) acting under a consultation and referral plan with a physician; and
60 (d) acting within the scope of practice for that person, as provided by law, rule, and
61 specialized certification and training in that person's area of practice.
62 (5) "Best interest" means that the benefits to the person resulting from a treatment
63 outweigh the burdens to the person resulting from the treatment, taking into account:
64 (a) the effect of the treatment on the physical, emotional, and cognitive functions of
65 the person;
66 (b) the degree of physical pain or discomfort caused to the person by the treatment or
67 the withholding or withdrawal of treatment;
68 (c) the degree to which the person's medical condition, the treatment, or the
69 withholding or withdrawal of treatment, result in a severe and continuing impairment of the
70 dignity of the person by subjecting the person to humiliation and dependency;
71 (d) the effect of the treatment on the life expectancy of the person;
72 (e) the prognosis of the person for recovery with and without the treatment;
73 (f) the risks, side effects, and benefits of the treatment, or the withholding or
74 withdrawal of treatment; and
75 (g) the religious beliefs and basic values of the person receiving treatment, to the
76 extent these may assist the decision maker in determining the best interest.
77 (6) "Capacity to appoint an agent" means that the adult understands the consequences
78 of appointing a particular person as agent.
79 (7) "Declarant" means an adult who has completed and signed or directed the signing
80 of an advance health care directive.
81 (8) "Default surrogate" means the adult who may make decisions for an 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 (9) "Emergency medical services provider" means a person who is licensed,

86 designated, or certified under Title 26, Chapter 8a, Utah Emergency Medical Services System
87 Act.
88 (10) "Generally accepted health care standards":
89 (a) is defined only for the purpose of:
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) "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) "Health care decision":
103 (a) means a decision about an adult's health care made by, or on behalf of, an adult,
104 that 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) "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) "Health care facility" means:
121 (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 (15) "Health care provider" is as defined in Section 78B-3-403 , except that it does not
126 include an emergency medical services provider.
127 (16) (a) "Life sustaining care" means any medical intervention, including procedures,
128 administration of medication, or use of a medical device, that maintains life by sustaining,
129 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 (17) "Life with dignity order" means an order, designated by the Department of Health
133 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 (18) "Minor" means a person who:
137 (a) is under 18 years of age; and
138 (b) is not an emancipated minor.
139 (19) "Physician" means a physician and surgeon or osteopathic surgeon licensed under
140 Title 58, Chapter 67, Utah Medical Practice Act or Chapter 68, Utah Osteopathic Medical
141 Practice Act.

142 (20) "Physician assistant" means a person licensed as a physician assistant under Title
143 58, Chapter 70a, Physician Assistant Act.
144 [(20)] (21) "Reasonably available" means:
145 (a) readily able to be contacted without undue effort; and
146 (b) willing and able to act in a timely manner considering the urgency of the
147 circumstances.
148 [(21)] (22) "Substituted judgment" means the standard to be applied by a surrogate
149 when making a health care decision for an adult who previously had the capacity to make
150 health care decisions, which requires the surrogate to consider:
151 (a) specific preferences expressed by the adult:
152 (i) when the adult had the capacity to make health care decisions; and
153 (ii) at the time the decision is being made;
154 (b) the surrogate's understanding of the adult's health care preferences;
155 (c) the surrogate's understanding of what the adult would have wanted under the
156 circumstances; and
157 (d) to the extent that the preferences described in Subsections [(21)] (22)(a) through
158 (c) are unknown, the best interest of the adult.
159 [(22)] (23) "Surrogate" means a health care decision maker who is:
160 (a) an appointed agent;
161 (b) a default surrogate under the provisions of Section 75-2a-108 ; or
162 (c) a guardian.
163 Section 2. Section 75-2a-104 is amended to read:
164 75-2a-104. Capacity to make health care decisions -- Presumption -- Overcoming
165 presumption.
166 (1) An adult is presumed to have:
167 (a) health care decision making capacity; and
168 (b) capacity to make or revoke an advance health care directive.
169 (2) To overcome the presumption of capacity described in Subsection (1)(a), a

170 physician [or], an APRN, or, subject to Subsection (6), a physician assistant who has
171 personally examined the adult and assessed the adult's health care decision making capacity
172 must:
173 (a) find that the adult lacks health care decision making capacity;
174 (b) record the finding in the adult's medical chart including an indication of whether
175 the adult is likely to regain health care decision making capacity; and
176 (c) make a reasonable effort to communicate the determination to:
177 (i) the adult;
178 (ii) other health care providers or health care facilities that the [physician or APRN]
179 person who makes the finding would routinely inform of such a finding; and
180 (iii) if the adult has a surrogate, any known surrogate.
181 (3) (a) [If a physician or APRN finds that an adult lacks] An adult who is found to
182 lack health care decision making capacity in accordance with Subsection (2)[, the adult] may,
183 at any time, challenge the finding by:
184 (i) submitting to a health care provider a written notice stating that the adult disagrees
185 with the physician's finding; or
186 (ii) orally informing the health care provider that the adult disagrees with the finding.
187 (b) A health care provider who is informed of a challenge under Subsection (3)(a),
188 shall, if the adult has a surrogate, promptly inform the surrogate of the adult's challenge.
189 (c) A surrogate informed of a challenge to a finding under this section, or the adult if
190 no surrogate is acting on the adult's behalf, shall inform the following of the adult's challenge:
191 (i) any other health care providers involved in the adult's care; and
192 (ii) the health care facility, if any, in which the adult is receiving care.
193 (d) Unless otherwise ordered by a court, a finding [by a physician], under Subsection
194 (2), that the adult lacks health care decision making capacity, is not in effect if the adult
195 challenges the finding under Subsection (3)(a).
196 (e) If an adult does not challenge the finding described in Subsection (2), the health
197 care provider and health care facility may rely on a surrogate, pursuant to the provisions of this

198 chapter, to make health care decisions for the adult.
199 (4) A health care provider or health care facility that relies on a surrogate to make
200 decisions on behalf of an adult has an ongoing obligation to consider whether the adult
201 continues to lack health care decision making capacity.
202 (5) If at any time a health care provider finds, based on an examination and
203 assessment, that the adult has regained health care decision making capacity, the health care
204 provider shall record the results of the assessment in the adult's medical record, and the adult
205 can direct the adult's own health care.
206 (6) A physician assistant may not make a finding described in Subsection (2), unless
207 the physician assistant is permitted to make the finding under the physician assistant's
208 delegation of services agreement, as defined in Section 58-70a-102 .
209 Section 3. Section 75-2a-106 is amended to read:
210 75-2a-106. Emergency medical services -- Life with dignity order.
211 (1) A life with dignity order may be created by or on behalf of a person as described in
212 this section.
213 (2) A life with dignity order shall, in consultation with the person authorized to
214 consent to the order pursuant to this section, be prepared by:
215 (a) the physician [or], APRN, or, subject to Subsection (11), physician assistant of the
216 person to whom the life with dignity order relates; or
217 (b) a health care provider who:
218 (i) is acting under the supervision of a person described in Subsection (2)(a); and
219 (ii) is:
220 (A) a nurse, licensed under Title 58, Chapter 31b, Nurse Practice Act;
221 (B) a physician assistant, licensed under Title 58, Chapter 70a, Physician Assistant
222 Act;
223 (C) a mental health professional, licensed under Title 58, Chapter 60, Mental Health
224 Professional Practice Act; or
225 (D) another health care provider, designated by rule as described in Subsection (10).

226 (3) A life with dignity order shall be signed:
227 (a) personally, by the physician [or], APRN, or, subject to Subsection (11), physician
228 assistant of the person to whom the life with dignity order relates; and
229 (b) (i) if the person to whom the life with dignity order relates is an adult with health
230 care decision making capacity, by:
231 (A) the person; or
232 (B) an adult who is directed by the person to sign the life with dignity order on behalf
233 of the person;
234 (ii) if the person to whom the life with dignity order relates is an adult who lacks
235 health care decision making capacity, by:
236 (A) the surrogate with the highest priority under Section 75-2a-111 ;
237 (B) the majority of the class of surrogates with the highest priority under Section
238 75-2a-111 ; or
239 (C) a person directed to sign the order by, and on behalf of, the persons described in
240 Subsection (3)(b)(ii)(A) or (B); or
241 (iii) if the person to whom the life with dignity order relates is a minor, by a parent or
242 guardian of the minor.
243 (4) If a life with dignity order relates to a minor and directs that life sustaining
244 treatment be withheld or withdrawn from the minor, the order shall include a certification by
245 two physicians that, in their clinical judgment, an order to withhold or withdraw life sustaining
246 treatment is in the best interest of the minor.
247 (5) A life with dignity order:
248 (a) shall be in writing, on a form approved by the Department of Health;
249 (b) shall state the date on which the order was made;
250 (c) may specify the level of life sustaining care to be provided to the person to whom
251 the order relates; and
252 (d) may direct that life sustaining care be withheld or withdrawn from the person to
253 whom the order relates.

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

282 with Subsection (9)(a), by:
283 (i) signing a written revocation of the life with dignity order; or
284 (ii) completing and signing a new life with dignity order.
285 (c) A surrogate may not revoke a life with dignity order during the period of time
286 beginning when an emergency service provider is contacted for assistance, and ending when
287 the emergency ends.
288 (10) (a) The Department of Health shall adopt rules, in accordance with Title 63G,
289 Chapter 3, Utah Administrative Rulemaking Act, to:
290 (i) create the forms and systems described in this section; and
291 (ii) develop uniform instructions for the form established in Section 75-2a-117 .
292 (b) The Department of Health may adopt rules, in accordance with Title 63G, Chapter
293 3, Utah Administrative Rulemaking Act, to designate health care professionals, in addition to
294 those described in Subsection (2)(b)(ii), who may prepare a life with dignity order.
295 (c) The Department of Health may assist others with training of health care
296 professionals regarding this chapter.
297 (11) A physician assistant may not prepare or sign a life with dignity order, unless the
298 physician assistant is permitted to prepare or sign the life with dignity order under the
299 physician assistant's delegation of services agreement, as defined in Section 58-70a-102 .
300 Section 4. Section 75-2a-109 is amended to read:
301 75-2a-109. Effect of current health care preferences -- When a surrogate may
302 act.
303 (1) An adult with health care decision making capacity retains the right to make health
304 care decisions as long as the adult has health care decision making capacity as defined in
305 Section 75-2a-103 . For purposes of this chapter, the inability to communicate through speech
306 does not mean that the adult lacks health care decision making capacity.
307 (2) An adult's current health care decisions, however expressed or indicated, always
308 supersede an adult's prior decisions or health care directives.
309 (3) Unless otherwise directed in an advance health care directive, an advance health

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

338 Street Address: _____________________________________________________________
339 City, State, Zip Code:
340 _____________________________________________________________
341 Telephone: _________________________ Cell Phone: ____________________________
342 Birth date: _____________
343 __________________________________________________________________________
344 __
345 Part I: My Agent (Health Care Power of Attorney)
346 A. No Agent
347 If you do not want to name an agent: initial the box below, then go to Part II; do not name an
348 agent in B or C below. No one can force you to name an agent.
349 ______ I do not want to choose an agent.
350 B. My Agent
351 Agent's Name:
352 ______________________________________________________________
353 Street Address:
354 ______________________________________________________________
355 City, State, Zip Code:
356 ______________________________________________________________
357 Home Phone: ( ) _________ Cell Phone: ( ) _________ Work Phone: ( ) __________
358 C. My Alternate Agent
359 This person will serve as your agent if your agent, named above, is unable or unwilling to
360 serve.
361 Alternate Agent's Name:
362 ______________________________________________________
363 Street Address:
364 ______________________________________________________________
365 City, State, Zip Code:

366 ______________________________________________________________
367 Home Phone: ( ) _________ Cell Phone: ( ) _________ Work Phone: ( ) __________
368 D. Agent's Authority
369 If I cannot make decisions or speak for myself (in other words, after my physician or [APRN]
370 another authorized provider finds that I lack health care decision making capacity under
371 Section 75-2a-104 of the Advance Health Care Directive Act), my agent has the power to
372 make any health care decision I could have made such as, but not limited to:
373 * Consent to, refuse, or withdraw any health care. This may include care to prolong my life
374 such as food and fluids by tube, use of antibiotics, CPR (cardiopulmonary resuscitation), and
375 dialysis, and mental health care, such as convulsive therapy and psychoactive medications.
376 This authority is subject to any limits in paragraph F of Part I or in Part II of this directive.
377 * Hire and fire health care providers.
378 * Ask questions and get answers from health care providers.
379 * Consent to admission or transfer to a health care provider or health care facility, including a
380 mental health facility, subject to any limits in paragraphs E and F of Part I.
381 * Get copies of my medical records.
382 * Ask for consultations or second opinions.
383 My agent cannot force health care against my will, even if a physician has found that I lack
384 health care decision making capacity.
385 E. Other Authority
386 My agent has the powers below ONLY IF I initial the "yes" option that precedes the statement.
387 I authorize my agent to:
388 YES _____ NO _____ Get copies of my medical records at any time, even when I can
389 speak for myself.
390 YES _____ NO _____ Admit me to a licensed health care facility, such as a hospital,
391 nursing home, assisted living, or other facility for long-term placement other than convalescent
392 or recuperative care.
393 F. Limits/Expansion of Authority

394 I wish to limit or expand the powers of my health care agent as follows:
395 __________________________________________________________________________
396 __
397 __________________________________________________________________________
398 __
399 G. Nomination of Guardian
400 Even though appointing an agent should help you avoid a guardianship, a guardianship may
401 still be necessary. Initial the "YES" option if you want the court to appoint your agent or, if
402 your agent is unable or unwilling to serve, your alternate agent, to serve as your guardian, if a
403 guardianship is ever necessary.
404 YES _____ NO _____
405 I, being of sound mind and not acting under duress, fraud, or other undue influence, do hereby
406 nominate my agent, or if my agent is unable or unwilling to serve, I hereby nominate my
407 alternate agent, to serve as my guardian in the event that, after the date of this instrument, I
408 become incapacitated.
409 H. Consent to Participate in Medical Research
410 YES _____ NO _____ I authorize my agent to consent to my participation in medical
411 research or clinical trials, even if I may not benefit from the results.
412 I. Organ Donation
413 YES _____ NO _____ If I have not otherwise agreed to organ donation, my agent may
414 consent to the donation of my organs for the purpose of organ transplantation.
415 __________________________________________________________________________
416 Part II: My Health Care Wishes (Living Will)
417 I want my health care providers to follow the instructions I give them when I am being treated,
418 even if my instructions conflict with these or other advance directives. My health care
419 providers should always provide health care to keep me as comfortable and functional as
420 possible.
421 Choose only one of the following options, numbered Option 1 through Option 4, by placing

422 your initials before the numbered statement. Do not initial more than one option. If you do
423 not wish to document end-of-life wishes, initial Option 4. You may choose to draw a line
424 through the options that you are not choosing.
425 Option 1
426 ________ Initial
427 I choose to let my agent decide. I have chosen my agent carefully. I have talked with my
428 agent about my health care wishes. I trust my agent to make the health care decisions for me
429 that I would make under the circumstances.
430 Additional Comments:
431 _____________________________________________________________________
432 Option 2
433 ________ Initial
434 I choose to prolong life. Regardless of my condition or prognosis, I want my health care team
435 to try to prolong my life as long as possible within the limits of generally accepted health care
436 standards.
437 Other:
438 _____________________________________________________________________
439 Option 3
440 ________ Initial
441 I choose not to receive care for the purpose of prolonging life, including food and fluids by
442 tube, antibiotics, CPR, or dialysis being used to prolong my life. I always want comfort care
443 and routine medical care that will keep me as comfortable and functional as possible, even if
444 that care may prolong my life.
445 If you choose this option, you must also choose either (a) or (b), below.
446 ______ Initial
447 (a) I put no limit on the ability of my health care provider or agent to withhold or withdraw
448 life-sustaining care.
449 If you selected (a), above, do not choose any options under (b).

450 ______ Initial
451 (b) My health care provider should withhold or withdraw life-sustaining care if at least one of
452 the following initialed conditions is met:
453 _____ I have a progressive illness that will cause death.
454 _____ I am close to death and am unlikely to recover.
455 _____ I cannot communicate and it is unlikely that my condition will improve.
456 _____ I do not recognize my friends or family and it is unlikely that my condition will
457 improve.
458 _____ I am in a persistent vegetative state.
459 Other:
460 _____________________________________________________________________
461 Option 4
462 ________ Initial
463 I do not wish to express preferences about health care wishes in this directive.
464 Other:
465 _____________________________________________________________________
466 Additional instructions about your health care wishes:
467 __________________________________________________________________________
468 __________________________________________________________________________
469 ____
470 If you do not want emergency medical service providers to provide CPR or other life
471 sustaining measures, you must work with a physician or APRN to complete an order that
472 reflects your wishes on a form approved by the Utah Department of Health.
473 Part III: Revoking or Changing a Directive
474 I may revoke or change this directive by:
475 1. Writing "void" across the form, or burning, tearing, or otherwise destroying or defacing this
476 document or directing another person to do the same on my behalf;
477 2. Signing a written revocation of the directive, or directing another person to sign a

478 revocation on my behalf;
479 3. Stating that I wish to revoke the directive in the presence of a witness who: is 18 years of
480 age or older; will not be appointed as my agent in a substitute directive; will not become a
481 default surrogate if the directive is revoked; and signs and dates a written document
482 confirming my statement; or
483 4. Signing a new directive. (If you sign more than one Advance Health Care Directive, the
484 most recent one applies.)
485 Part IV: Making My Directive Legal
486 I sign this directive voluntarily. I understand the choices I have made and declare that I am
487 emotionally and mentally competent to make this directive. My signature on this form revokes
488 any living will or power of attorney form, naming a health care agent, that I have completed in
489 the past.
490 ____________________________________
491 Date
492 ________________________________________________
493 Signature
494 __________________________________________________________________________
495 __
496 City, County, and State of Residence
497 I have witnessed the signing of this directive, I am 18 years of age or older, and I am not:
498 1. related to the declarant by blood or marriage;
499 2. entitled to any portion of the declarant's estate according to the laws of intestate succession
500 of any state or jurisdiction or under any will or codicil of the declarant;
501 3. a beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or
502 transfer on death deed that is held, owned, made, or established by, or on behalf of, the
503 declarant;
504 4. entitled to benefit financially upon the death of the declarant;
505 5. entitled to a right to, or interest in, real or personal property upon the death of the declarant;

506 6. directly financially responsible for the declarant's medical care;
507 7. a health care provider who is providing care to the declarant or an administrator at a health
508 care facility in which the declarant is receiving care; or
509 8. the appointed agent or alternate agent.
510 _____________________________________
511 __________________________________
512 Signature of Witness Printed Name of Witness
513 _____________________________________ ___________ _________ _________
514 Street Address City State Zip Code
515 If the witness is signing to confirm an oral directive, describe below the circumstances under
516 which the directive was made.
517 __________________________________________________________________________
518 __________________________________________________________________________
519 ____