VIRGINIA ADVANCE MEDICAL DIRECTIVE This form with slight

VIRGINIA ADVANCE MEDICAL DIRECTIVE
This form with slight variations, is the form approved by the Virginia General Assembly
in the Health Care Decisions Act. The form contains both a “Living Will” portion, a
portion in which you may appoint an agent to make health care decisions for you, and a
portion in which you may appoint an agent to make an anatomical gift. You may
complete any one or all of these portions of the form. Virginia law does not require the
use of this particular form in order to make a valid advance directive. If you have legal
questions about this form, or would like to develop a different form to meet your
particular needs, you should talk with an attorney. You must sign your advance medical
directive in the presence of two witnesses who are not blood relatives or your spouse. It
is your responsibility under Virginia law to provide a copy of your advance directive to
your attending physician. You also should provide copies of the directive to close
relatives and/or friends.
ADVANCE MEDICAL DIRECTIVE made this ___ day of
_________
,
I, _____________________________________________, willfully and voluntarily
make known my desire and o hereby declare:
(Cross through this portion if you do not want to make a living will in this form.)
“Living Will” Portion of Advance Medical Directive
If at any time my attending physician should determine that I have a terminal condition
where the application of life-prolonging procedures would serve only to artificially
prolong the dying process, I direct that such procedures be withheld or withdrawn, and
that I be permitted to die naturally with only the administration of medication or the
performance of any medical procedure deemed necessary to provide me with comfort
care or to alleviate pain. (OPTION: I specifically direct that the following procedures or
treatments be provided to me:
________________________________________________________________________
___________
In the absence of my ability to give directions regarding the use of such life-prolonging
procedures, it is my intention that this declaration shall be honored by my family and
physician as the final expression of my legal right to refuse medical or surgical treatment
and accept the consequences of such refusal.
(Cross through this portion if you do not want to appoint an agent to make health care
decisions for you.)
Appointment of Agent to Make Health Care Decisions
I hereby appoint the following as my primary agent to make health care decisions on my
behalf as authorized in this document:
________________________________________________________________________
Primary Agent
Telephone Number
________________________________________________________________________
Address
America Living Will Registry, LLC. • 2814 Beach Boulevard • St. Petersburg, FL 33707 • 1-866-305-ALWR • [email protected]
If the above named primary agent is not reasonably available or is unable or unwilling to
act as my agent, then I appoint the following as successor agent to serve in that capacity:
________________________________________________________________________
Successor Agent
Telephone Number
________________________________________________________________________
Address
I hereby grant to my agent, named above, full power and authority to make health care
decisions on my behalf as described below whenever I have been determined to be
incapable of making an informed decision about providing, withholding or withdrawing
medical treatment. The phrase “incapable of making an informed decision” means unable
to understand the nature, extent and probable consequences of a proposed medical
decision or unable to make a rational evaluation of the risks and benefits of a proposed
medical decision as compared with the risks and benefits of alternatives to that decision,
or unable to communicate such understanding in any way. My agent’s authority
hereunder is effective as long as I am incapable of making an informed decision.
The determination that I am incapable of making an informed decision shall be made by
my attending physician and a second physician or licensed clinical psychologist after a
personal examination of me and shall be certified in writing. Such certification shall be
required before treatment is withheld or withdrawn, and before, or as soon as reasonably
practicable after, treatment is provided, and every 180 days thereafter while the treatment
continues.
In exercising the power to make health care decisions on my behalf, my agent shall
follow my desires and preferences as stated in this document or as otherwise known to
my agent. My agent shall be guided by my medical diagnosis and prognosis and any
information provided by my physicians as to the intrusiveness, pain, risks and side effects
associated with treatment or nontreatment. My agent shall not authorize a course of
treatment which he knows, or upon reasonable inquiry ought to know, is contrary to my
religious beliefs or my basic values, whether expressed orally or in writing. If my agent
cannot determine what treatment choice I would have made on my own behalf, then my
agent shall make a choice for me based upon what he believes to be in my best interests.
Further, my agent shall not be liable for the costs of treatment pursuant to his/her
authorization, based solely on that authorization.
OPTION: Powers of my agent. (Cross through any language you do not want and add
any language you do want.)
The powers of my agent shall include the following:
A. To consent to or refuse or withdraw consent to any type of medical care, treatment,
surgical procedure, diagnostic procedure, medication and the use of mechanical or other
procedures that affect any bodily function, including but not limited to artificial
respiration, artificially administered nutrition and hydration, and cardiopulmonary
resuscitation. This authorization specifically includes the power to consent to the
administration of dosages of pain-relieving medication in excess of recommended
America Living Will Registry, LLC. • 2814 Beach Boulevard • St. Petersburg, FL 33707 • 1-866-305-ALWR • [email protected]
dosages in an amount sufficient to relieve pain, even if such medication carries the risk of
addiction or inadvertently hastens my death;
B. To request, receive, and review any information, verbal or written, regarding my
physical or mental health, including but not limited to medical and hospital records, and
to consent to the disclosure of this information;
C. To employ and discharge my health care providers;
D. To authorize my admission to or discharge (including transfer to another facility) from
any hospital, hospice, nursing home, adult home or other medical care facility for
services other than those for treatment of mental illness requiring admission procedures
provided in Article 1 (§37.1-63 et seq.) of Chapter 2 of Title 37.1;
E. To make decisions about who may visit me, subject to physician orders and policies of
any institution to which I am admitted.
F. To take any lawful actions that may be necessary to carry out these decisions,
including the granting of releases of liability to medical providers.
(Cross through this portion if you do not want to appoint an agent to make an anatomical
gift or organ, tissue or eye donation for you.)
Appointment of Agent to Make Anatomical Gift
Upon my death, I direct that an anatomical gift of all of my body or certain organ, tissue
or eye donation may be made pursuant to applicable Virginia law governing anatomical
gifts (§32.1-289 et seq.) and in accordance with my directions, if any. I hereby appoint,
as my agent, of
Address
Phone number
to make any such anatomical gift or organ, tissue or eye donation following my death.
I further direct that:
(Declarant’s directions, if any, concerning anatomical gift or organ, tissue or eye
donation)
This advance directive shall not terminate in the event of my disability. By signing
below, I indicate that I am emotionally and mentally competent to make this advance
directive and that I understand the purpose and effect of this document.
Date
Signature of Declarant
The declarant signed the foregoing advance directive in my presence. I am not the spouse
or a blood relative of the declarant.
________________________________________
Witness
________________________________________
Witness
America Living Will Registry, LLC. • 2814 Beach Boulevard • St. Petersburg, FL 33707 • 1-866-305-ALWR • [email protected]