2017 Georgia Code
Title 31 - Health
Chapter 32 - Advance Directives for Health Care
§ 31-32-4. Form

By: ____ Date of Birth:____

(Print Name)

(Month/Day/Year)

This advance directive for health care has four parts:

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

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

Using this form of advance directive for health care is completely

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

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

• (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 will be effective only if you are unable to communicate your

• (6) 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.

• (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)

• 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.]"