First Substitute S.B. 117

Senator Allen M. Christensen proposes the following substitute bill:

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 or a psychologist to determine whether an adult
17 lacks health care decision making capacity;
18 . provides that a physician assistant may sign a life with dignity order; and
19 . makes technical changes.
20 Monies Appropriated in this Bill:
21 None
22 Other Special Clauses:
23 None
24 Utah Code Sections Affected:
25 AMENDS:

26 75-2a-103, as last amended by Laws of Utah 2008, Chapters 3 and 107
27 75-2a-104, as last amended by Laws of Utah 2008, Chapter 107
28 75-2a-106, as repealed and reenacted by Laws of Utah 2008, Chapter 107
29 75-2a-109, as last amended by Laws of Utah 2008, Chapter 107
30 75-2a-117, as last amended by Laws of Utah 2008, Chapter 107
31
32 Be it enacted by the Legislature of the state of Utah:
33 Section 1. Section 75-2a-103 is amended to read:
34 75-2a-103. Definitions.
35 As used in this chapter:
36 (1) "Adult" means a person who is:
37 (a) at least 18 years of age; or
38 (b) an emancipated minor.
39 (2) "Advance health care directive":
40 (a) includes:
41 (i) a designation of an agent to make health care decisions for an adult when the adult
42 cannot make or communicate health care decisions; or
43 (ii) an expression of preferences about health care decisions;
44 (b) may take one of the following forms:
45 (i) a written document, voluntarily executed by an adult in accordance with the
46 requirements of this chapter; or
47 (ii) a witnessed oral statement, made in accordance with the requirements of this
48 chapter; and
49 (c) does not include a life with dignity order.
50 (3) "Agent" means a person designated in an advance health care directive to make
51 health care decisions for the declarant.
52 (4) "APRN" means a person who is:
53 (a) certified or licensed as an advance practice registered nurse under Subsection
54 58-31b-301 (2)(d);
55 (b) an independent practitioner;
56 (c) acting under a consultation and referral plan with a physician; and

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

88 Utah law; and
89 (ii) enabling health care providers to interpret the statutory form set forth in Section
90 75-2a-117 ; and
91 (b) means the standard of care that justifies a provider in declining to provide life
92 sustaining care because the proposed life sustaining care:
93 (i) will not prevent or reduce the deterioration in the health or functional status of a
94 person;
95 (ii) will not prevent the impending death of a person; or
96 (iii) will impose more burden on the person than any expected benefit to the person.
97 (11) "Health care" means any care, treatment, service, or procedure to improve,
98 maintain, diagnose, or otherwise affect a person's physical or mental condition.
99 (12) "Health care decision":
100 (a) means a decision about an adult's health care made by, or on behalf of, an adult, that
101 is communicated to a health care provider;
102 (b) includes:
103 (i) selection and discharge of a health care provider and a health care facility;
104 (ii) approval or disapproval of diagnostic tests, procedures, programs of medication,
105 and orders not to resuscitate; and
106 (iii) directions to provide, withhold, or withdraw artificial nutrition and hydration and
107 all other forms of health care; and
108 (c) does not include decisions about an adult's financial affairs or social interactions
109 other than as indirectly affected by the health care decision.
110 (13) "Health care decision making capacity" means an adult's ability to make an
111 informed decision about receiving or refusing health care, including:
112 (a) the ability to understand the nature, extent, or probable consequences of health
113 status and health care alternatives;
114 (b) the ability to make a rational evaluation of the burdens, risks, benefits, and
115 alternatives of accepting or rejecting health care; and
116 (c) the ability to communicate a decision.
117 (14) "Health care facility" means:
118 (a) a health care facility as defined in Title 26, Chapter 21, Health Care Facility

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

150 (a) specific preferences expressed by the adult:
151 (i) when the adult had the capacity to make health care decisions; and
152 (ii) at the time the decision is being made;
153 (b) the surrogate's understanding of the adult's health care preferences;
154 (c) the surrogate's understanding of what the adult would have wanted under the
155 circumstances; and
156 (d) to the extent that the preferences described in Subsections [(21)] (23)(a) through (c)
157 are unknown, the best interest of the adult.
158 [(22)] (24) "Surrogate" means a health care decision maker who is:
159 (a) an appointed agent;
160 (b) a default surrogate under the provisions of Section 75-2a-108 ; or
161 (c) a guardian.
162 Section 2. Section 75-2a-104 is amended to read:
163 75-2a-104. Capacity to make health care decisions -- Presumption -- Overcoming
164 presumption.
165 (1) An adult is presumed to have:
166 (a) health care decision making capacity; and
167 (b) capacity to make or revoke an advance health care directive.
168 (2) To overcome the presumption of capacity described in Subsection (1)(a), a
169 physician, physician assistant, psychologist, or an APRN who has personally examined the
170 adult and assessed the adult's health care decision making capacity must:
171 (a) find that the adult lacks health care decision making capacity;
172 (b) record the finding in the adult's medical chart including an indication of whether
173 the adult is likely to regain health care decision making capacity; and
174 (c) make a reasonable effort to communicate the determination to:
175 (i) the adult;
176 (ii) other health care providers or health care facilities that the [physician or APRN]
177 person who makes the finding would routinely inform of such a finding; and
178 (iii) if the adult has a surrogate, any known surrogate.
179 (3) (a) [If a physician or APRN finds that an adult lacks] An adult who is found to lack
180 health care decision making capacity in accordance with Subsection (2)[, the adult] may, at any

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

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

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

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

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

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

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

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

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

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

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