2013 Georgia Code
Title 31 - Health
Chapter 32 - Advance Directives for Health Care
§ 31-32-4. Form

"GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE

By: Date of Birth:

(Print Name)

(Month/Day/Year)

This advance directive for health care has four parts:

PART ONE HEALTH CARE AGENT. This part allows you to

choose someone to make health care decisions for you when you cannot (or do

not want to) make health care decisions for yourself. The person you choose

is called a health care agent. You may also have your health care agent make

decisions for you after your death with respect to an autopsy, organ donation,

body donation, and final disposition of your body. You should talk to your

health care agent about this important role.

PART TWO TREATMENT PREFERENCES. This part allows you

to state your treatment preferences if you have a terminal condition or if you

are in a state of permanent unconsciousness. PART TWO will become effective

only if you are unable to communicate your treatment preferences. Reasonable

and appropriate efforts will be made to communicate with you about your

treatment preferences before PART TWO becomes effective. You should talk to

your family and others close to you about your treatment preferences.

PART THREE GUARDIANSHIP. This part allows you to

nominate a person to be your guardian should one ever be needed.

PART FOUR EFFECTIVENESS AND SIGNATURES. This part

requires your signature and the signatures of two witnesses. You must

complete PART FOUR if you have filled out any other part of this form.

You may fill out any or all of the first three parts listed above. You must

fill out PART FOUR of this form in order for this form to be effective.

You should give a copy of this completed form to people who might need it,

such as your health care agent, your family, and your physician. Keep a copy

of this completed form at home in a place where it can easily be found if it

is needed. Review this completed form periodically to make sure it still

reflects your preferences. If your preferences change, complete a new advance

directive for health care.

Using this form of advance directive for health care is completely

optional. Other forms of advance directives for health care may be used in

Georgia.

You may revoke this completed form at any time. This completed form will

replace any advance directive for health care, durable power of attorney for

health care, health care proxy, or living will that you have completed before

completing this form.

PART ONE: HEALTH CARE AGENT

[PART ONE will be effective even if PART TWO is not completed. A physician

or health care provider who is directly involved in your health care may not

serve as your health care agent. If you are married, a future divorce or

annulment of your marriage will revoke the selection of your current spouse as

your health care agent. If you are not married, a future marriage will revoke

the selection of your health care agent unless the person you selected as your

health care agent is your new spouse.]

(1) Health Care Agent

I select the following person as my health care agent to make health care

decisions for me:

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

(2) Back-up Health Care Agent

[This section is optional. PART ONE will be effective even if this section

is left blank.]

If my health care agent cannot be contacted in a reasonable time period and

cannot be located with reasonable efforts or for any reason my health care

agent is unavailable or unable or unwilling to act as my health care agent,

then I select the following, each to act successively in the order named,

as my back-up health care agent(s):

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

(3) General Powers of Health Care Agent

My health care agent will make health care decisions for me when I am

unable to communicate my health care decisions or I choose to have my

health care agent communicate my health care decisions.

My health care agent will have the same authority to make any health care

decision that I could make. My health care agent's authority includes, for

example, the power to:

-- Admit me to or discharge me from any hospital, skilled nursing

facility, hospice, or other health care facility or service;

-- Request, consent to, withhold, or withdraw any type of health care;

and

-- Contract for any health care facility or service for me, and to

obligate me to pay for these services (and my health care agent will not

be financially liable for any services or care contracted for me or on

my behalf).

My health care agent will be my personal representative for all purposes of

federal or state law related to privacy of medical records (including the

Health Insurance Portability and Accountability Act of 1996) and will have

the same access to my medical records that I have and can disclose the

contents of my medical records to others for my ongoing health care.

My health care agent may accompany me in an ambulance or air ambulance if

in the opinion of the ambulance personnel protocol permits a passenger and

my health care agent may visit or consult with me in person while I am in a

hospital, skilled nursing facility, hospice, or other health care facility

or service if its protocol permits visitation.

My health care agent may present a copy of this advance directive for

health care in lieu of the original and the copy will have the same meaning

and effect as the original.

I understand that under Georgia law:

-- My health care agent may refuse to act as my health care agent;

-- A court can take away the powers of my health care agent if it finds

that my health care agent is not acting properly; and

-- My health care agent does not have the power to make health care

decisions for me regarding psychosurgery, sterilization, or treatment or

involuntary hospitalization for mental or emotional illness,

developmental disability, or addictive disease.

(4) Guidance for Health Care Agent

When making health care decisions for me, my health care agent should think

about what action would be consistent with past conversations we have had,

my treatment preferences as expressed in PART TWO (if I have filled out

PART TWO), my religious and other beliefs and values, and how I have

handled medical and other important issues in the past. If what I would

decide is still unclear, then my health care agent should make decisions

for me that my health care agent believes are in my best interest,

considering the benefits, burdens, and risks of my current circumstances

and treatment options.

(5) Powers of Health Care Agent After Death

(A) Autopsy

My health care agent will have the power to authorize an autopsy of my body

unless I have limited my health care agent's power by initialing below.

(Initials) My health care agent will not have the power to authorize

an autopsy of my body (unless an autopsy is required by law).

(B) Organ Donation and Donation of Body

My health care agent will have the power to make a disposition of any part

or all of my body for medical purposes pursuant to the Georgia Revised

Uniform Anatomical Gift Act, unless I have limited my health care agent's

power by initialing below.

[Initial each statement that you want to apply.]

(Initials) My health care agent will not have the power to make a

disposition of my body for use in a medical study program.

(Initials) My health care agent will not have the power to donate any

of my organs.

(C) Final Disposition of Body

My health care agent will have the power to make decisions about the final

disposition of my body unless I have initialed below.

(Initials) I want the following person to make decisions about the

final disposition of my body:

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

I wish for my body to be:

(Initials) Buried

OR

(Initials) Cremated

PART TWO: TREATMENT PREFERENCES

[PART TWO will be effective only if you are unable to communicate your

treatment preferences after reasonable and appropriate efforts have been made

to communicate with you about your treatment preferences. PART TWO will be

effective even if PART ONE is not completed. If you have not selected a health

care agent in PART ONE, or if your health care agent is not available, then

PART TWO will provide your physician and other health care providers with your

treatment preferences. If you have selected a health care agent in PART ONE,

then your health care agent will have the authority to make all health care

decisions for you regarding matters covered by PART TWO. Your health care

agent will be guided by your treatment preferences and other factors described

in Section (4) of PART ONE.]

(6) Conditions

PART TWO will be effective if I am in any of the following conditions:

[Initial each condition in which you want PART TWO to be effective.]

(Initials) A terminal condition, which means I have an incurable or

irreversible condition that will result in my death in a relatively short

period of time.

(Initials) A state of permanent unconsciousness, which means I am in

an incurable or irreversible condition in which I am not aware of myself or

my environment and I show no behavioral response to my environment.

My condition will be determined in writing after personal examination by my

attending physician and a second physician in accordance with currently

accepted medical standards.

(7) Treatment Preferences

[State your treatment preference by initialing (A), (B), or (C). If you

choose (C), state your additional treatment preferences by initialing one or

more of the statements following (C). You may provide additional instructions

about your treatment preferences in the next section. You will be provided

with comfort care, including pain relief, but you may also want to state your

specific preferences regarding pain relief in the next section.]

If I am in any condition that I initialed in Section (6) above and I can no

longer communicate my treatment preferences after reasonable and

appropriate efforts have been made to communicate with me about my

treatment preferences, then:

(A) (Initials) Try to extend my life for as long as possible,

using all medications, machines, or other medical procedures that in

reasonable medical judgment could keep me alive. If I am unable to take

nutrition or fluids by mouth, then I want to receive nutrition or fluids

by tube or other medical means.

OR

(B) (Initials) Allow my natural death to occur. I do not want any

medications, machines, or other medical procedures that in reasonable

medical judgment could keep me alive but cannot cure me. I do not want

to receive nutrition or fluids by tube or other medical means except as

needed to provide pain medication.

OR

(C) (Initials) I do not want any medications, machines, or other

medical procedures that in reasonable medical judgment could keep me

alive but cannot cure me, except as follows:

[Initial each statement that you want to apply to option (C).]

(Initials) If I am unable to take nutrition by mouth, I want to

receive nutrition by tube or other medical means.

(Initials) If I am unable to take fluids by mouth, I want to

receive fluids by tube or other medical means.

(Initials) If I need assistance to breathe, I want to have a

ventilator used.

(Initials) If my heart or pulse has stopped, I want to have

cardiopulmonary resuscitation (CPR) used.

(8) Additional Statements

[This section is optional. PART TWO will be effective even if this section

is left blank. This section allows you to state additional treatment

preferences, to provide additional guidance to your health care agent (if you

have selected a health care agent in PART ONE), or to provide information

about your personal and religious values about your medical treatment. For

example, you may want to state your treatment preferences regarding

medications to fight infection, surgery, amputation, blood transfusion, or

kidney dialysis. Understanding that you cannot foresee everything that could

happen to you after you can no longer communicate your treatment preferences,

you may want to provide guidance to your health care agent (if you have

selected a health care agent in PART ONE) about following your treatment

preferences. You may want to state your specific preferences regarding pain

relief.]

(9) In Case of Pregnancy

[PART TWO will be effective even if this section is left blank.]

I understand that under Georgia law, PART TWO generally will have no force

and effect if I am pregnant unless the fetus is not viable and I indicate

by initialing below that I want PART TWO to be carried out.

(Initials) I want PART TWO to be carried out if my fetus is not

viable.

PART THREE: GUARDIANSHIP

(10) Guardianship

[PART THREE is optional. This advance directive for health care will be

effective even if PART THREE is left blank. If you wish to nominate a person

to be your guardian in the event a court decides that a guardian should be

appointed, complete PART THREE. A court will appoint a guardian for you if the

court finds that you are not able to make significant responsible decisions

for yourself regarding your personal support, safety, or welfare. A court will

appoint the person nominated by you if the court finds that the appointment

will serve your best interest and welfare. If you have selected a health care

agent in PART ONE, you may (but are not required to) nominate the same person

to be your guardian. If your health care agent and guardian are not the same

person, your health care agent will have priority over your guardian in making

your health care decisions, unless a court determines otherwise.]

[State your preference by initialing (A) or (B). Choose (A) only if you

have also completed PART ONE.]

(A) (Initials) I nominate the person serving as my health care

agent under PART ONE to serve as my guardian.

OR

(B) (Initials) I nominate the following person to serve as my

guardian:

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

PART FOUR: EFFECTIVENESS AND SIGNATURES

This advance directive for health care will become effective only if I am

unable or choose not to make or communicate my own health care decisions.

This form revokes any advance directive for health care, durable power of

attorney for health care, health care proxy, or living will that I have

completed before this date.

Unless I have initialed below and have provided alternative future dates or

events, this advance directive for health care will become effective at the

time I sign it and will remain effective until my death (and after my death

to the extent authorized in Section (5) of PART ONE).

(Initials) This advance directive for health care will become

effective on or upon and will terminate on or upon .

[You must sign and date or acknowledge signing and dating this form in the

presence of two witnesses.

Both witnesses must be of sound mind and must be at least 18 years of age,

but the witnesses do not have to be together or present with you when you sign

this form.

A witness:

-- Cannot be a person who was selected to be your health care agent or

back-up health care agent in PART ONE;

-- Cannot be a person who will knowingly inherit anything from you or

otherwise knowingly gain a financial benefit from your death; or

-- Cannot be a person who is directly involved in your health care.

Only one of the witnesses may be an employee, agent, or medical staff

member of the hospital, skilled nursing facility, hospice, or other health

care facility in which you are receiving health care (but this witness cannot

be directly involved in your health care).]

By signing below, I state that I am emotionally and mentally capable of

making this advance directive for health care and that I understand its

purpose and effect.

(Signature of Declarant) (Date)

The declarant signed this form in my presence or acknowledged signing this

form to me. Based upon my personal observation, the declarant appeared to

be emotionally and mentally capable of making this advance directive for

health care and signed this form willingly and voluntarily.

(Signature of First Witness) (Date)

Print Name:

Address:

(Signature of Second Witness) (Date)

Print Name:

Address:

[This form does not need to be notarized.]"