2017 Mississippi Code
Title 41 - Public Health
Chapter 41 - Surgical or Medical Procedures; Consents
Uniform Health-Care Decisions Act
§ 41-41-209. Form for Advance Health-Care Directive

Universal Citation: MS Code § 41-41-209 (2017)
  • The following form may be used to create an Advance Health-Care Directive. Sections 41-41-201 through 41-41-207 and 41-41-211 through 41-41-229 govern the effect of this or any other writing used to create an advanced health-care directive. An individual may complete or modify all or any part of the following form:
    • ADVANCE HEALTH-CARE DIRECTIVE

      Explanation

      You have the right to give instructions about your own health care. You

      also have the right to name someone else to make health-care decisions for

      you. This form lets you do either or both of these things. It also lets you

      express your wishes regarding the designation of your primary physician. If

      you use this form, you may complete or modify all or any part of it. You are

      free to use a different form.

      Part 1 of this form is a power of attorney for health care. Part 1 lets you

      name another individual as agent to make health-care decisions for you if you

      become incapable of making your own decisions or if you want someone else to

      make those decisions for you now even though you are still capable. You may

      name an alternate agent to act for you if your first choice is not willing,

      able or reasonably available to make decisions for you. Unless related to you,

      your agent may not be an owner, operator, or employee of a residential

      long-term health-care institution at which you are receiving care.

      Unless the form you sign limits the authority of your agent, your agent may

      make all health-care decisions for you. This form has a place for you to limit

      the authority of your agent. You need not limit the authority of your agent if

      you wish to rely on your agent for all health-care decisions that may have to

      be made. If you choose not to limit the authority of your agent, your agent

  • will have the right to:
    • (a) Consent or refuse consent to any care, treatment, service, or

      procedure to maintain, diagnose, or otherwise affect a physical or mental

      condition;

    • (b) Select or discharge health-care providers and institutions;
    • (c) Approve or disapprove diagnostic tests, surgical procedures,

      programs of medication, and orders not to resuscitate; and

    • (d) Direct the provision, withholding, or withdrawal of artificial

      nutrition and hydration and all other forms of health care.

      Part 2 of this form lets you give specific instructions about any aspect of

      your health care. Choices are provided for you to express your wishes

      regarding the provision, withholding, or withdrawal of treatment to keep you

      alive, including the provision of artificial nutrition and hydration, as well

      as the provision of pain relief. Space is provided for you to add to the

      choices you have made or for you to write out any additional wishes.

      Part 3 of this form lets you designate a physician to have primary

      responsibility for your health care.

      Part 4 of this form lets you authorize the donation of your organs at your

      death, and declares that this decision will supersede any decision by a member

      of your family.

      After completing this form, sign and date the form at the end and have the

      form witnessed by one of the two alternative methods listed below. Give a copy

      of the signed and completed form to your physician, to any other health-care

      providers you may have, to any health-care institution at which you are

      receiving care, and to any health-care agents you have named. You should talk

      to the person you have named as agent to make sure that he or she understands

      your wishes and is willing to take the responsibility.

      You have the right to revoke this advance health-care directive or replace

      this form at any time.

  • PART 1 POWER OF ATTORNEY FOR HEALTH CARE
    • (1) DESIGNATION OF AGENT: I designate the following individual as my
      • agent to make health-care decisions for me:
        • ____

          (name of individual you choose as agent)

          ____

          (address) (city)

          (state)

          (zip code)

          ____

          (home phone)

          (work phone)

          OPTIONAL: If I revoke my agent's authority or if my agent is not willing,

          able, or reasonably available to make a health-care decision for me, I

      • designate as my first alternate agent:
        • ____

          (name of individual you choose as first alternate agent)

          ____

          (address) (city)

          (state)

          (zip code)

          ____

          (home phone)

          (work phone)

          OPTIONAL: If I revoke the authority of my agent and first alternate agent

          or if neither is willing, able, or reasonably available to make a health-care

      • decision for me, I designate as my second alternate agent:
        • ____

          (name of individual you choose as second alternate agent)

          ____

          (address) (city)

          (state)

          (zip code)

          ____

          (home phone)

          (work phone)

    • (2) AGENT'S AUTHORITY: My agent is authorized to make all health-care
      • decisions for me, including decisions to provide, withhold, or withdraw

        artificial nutrition and hydration, and all other forms of health care to keep

        me alive, except as I state here:

        • ____

          ____

          ____

          (Add additional sheets if needed.)

    • (3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority

      becomes effective when my primary physician determines that I am unable to

      make my own health-care decisions unless I mark the following box. If I mark

      this box [ ], my agent's authority to make health-care decisions for me takes

      effect immediately.

    • (4) AGENT'S OBLIGATION: My agent shall make health-care decisions for me

      in accordance with this power of attorney for health care, any instructions I

      give in Part 2 of this form, and my other wishes to the extent known to my

      agent. To the extent my wishes are unknown, my agent shall make health-care

      decisions for me in accordance with what my agent determines to be in my best

      interest. In determining my best interest, my agent shall consider my personal

      values to the extent known to my agent.

    • (5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be

      appointed for me by a court, I nominate the agent designated in this form. If

      that agent is not willing, able, or reasonably available to act as guardian, I

      nominate the alternate agents whom I have named, in the order designated.

  • PART 2 INSTRUCTIONS FOR HEALTH CARE

    If you are satisfied to allow your agent to determine what is best for you

    in making end-of-life decisions, you need not fill out this part of the form.

    If you do fill out this part of the form, you may strike any wording you do

    not want.

    • (6) END-OF-LIFE DECISIONS: I direct that my health-care providers and
      • others involved in my care provide, withhold or withdraw treatment in

        accordance with the choice I have marked below:

        • [ ] (a) Choice Not To Prolong Life

          I do not want my life to be prolonged if (i) I have an incurable and

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

          time, (ii) I become unconscious and, to a reasonable degree of medical

          certainty, I will not regain consciousness, or (iii) the likely risks and

          burdens of treatment would outweigh the expected benefits, or

          [ ] (b) Choice To Prolong Life

          I want my life to be prolonged as long as possible within the limits of

          generally accepted health care standards.

    • (7) ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutrition and

      hydration must be provided, withheld or withdrawn in accordance with the

      choice I have made in paragraph (6) unless I mark the following box. If I mark

      this box [ ], artificial nutrition and hydration must be provided regardless

      of my condition and regardless of the choice I have made in paragraph (6).

    • (8) RELIEF FROM PAIN: Except as I state in the following space, I direct
      • that treatment for alleviation of pain or discomfort be provided at all times,

        even if it hastens my death:

        • ____

          ____

    • (9) OTHER WISHES: (If you do not agree with any of the optional choices
      • above and wish to write your own, or if you wish to add to the instructions

        you have given above, you may do so here.) I direct that:

        • ____

          ____

          (Add additional sheets if needed.)

  • PART 3 PRIMARY PHYSICIAN

    (OPTIONAL)

    • (10) I designate the following physician as my primary physician:
      • ____

        (name of physician)

        ____

        (address) (city)

        (state)

        (zip code)

        ____

        (phone)

        OPTIONAL: If the physician I have designated above is not willing, able, or

        reasonably available to act as my primary physician, I designate the following

      • physician as my primary physician:
        • ____

          (name of physician)

          ____

          (address) (city)

          (state)

          (zip code)

          ____

          (phone)

    • (11) EFFECT OF COPY: A copy of this form has the same effect as the

      original.

    • (12) SIGNATURES: Sign and date the form here:
      • ____ ____

        (date)

        (sign your name)

        ____ ____

        (address)

        (print your name)

        ____

        (city) (state)

  • PART 4
    • CERTIFICATE OF AUTHORIZATION FOR ORGAN DONATION

      (OPTIONAL)

      I, the undersigned, this ____ day of ____, 20____, desire that my

      ____ organ(s) be made available after my demise for:

      • (a) Any licensed hospital, surgeon or physician, for medical education,

        research, advancement of medical science, therapy or transplantation to

        individuals;

      • (b) Any accredited medical school, college or university engaged in

        medical education or research, for therapy, educational research or medical

        science purposes or any accredited school of mortuary science;

      • (c) Any person operating a bank or storage facility for blood, arteries,

        eyes, pituitaries, or other human parts, for use in medical education,

        research, therapy or transplantation to individuals;

      • (d) The donee specified below, for therapy or transplantation needed by

        him or her, do donate my ____ for that purpose to ____ (name) at

        ____ (address).

        I authorize a licensed physician or surgeon to remove and preserve for use

        my ____ for that purpose.

        I specifically provide that this declaration shall supersede and take

        precedence over any decision by my family to the contrary.

        Witnessed this ____ day of ____, 20____.

        ____

        (donor)

        ____

        (address)

        ____

        (telephone)

        ____

        (witness)

        ____

        (witness)

        • (13) WITNESSES: This power of attorney will not be valid for making
    • health-care decisions unless it is either (a) signed by two (2) qualified

      adult witnesses who are personally known to you and who are present when you

      sign or acknowledge your signature; or (b) acknowledged before a notary public

      in the state.

      ALTERNATIVE NO. 1

      Witness

      I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi

      Code of 1972, that the principal is personally known to me, that the principal

      signed or acknowledged this power of attorney in my presence, that the

      principal appears to be of sound mind and under no duress, fraud or undue

      influence, that I am not the person appointed as agent by this document, and

      that I am not a health-care provider, nor an employee of a health-care

      provider or facility. I am not related to the principal by blood, marriage or

      adoption, and to the best of my knowledge, I am not entitled to any part of

      the estate of the principal upon the death of the principal under a will now

      existing or by operation of law.

      ____ ____

      (date)

      (signature of witness)

      ____ ____

      (address)

      (printed name of witness)

      ____

      (city) (state)

      Witness

      I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi

      Code of 1972, that the principal is personally known to me, that the principal

      signed or acknowledged this power of attorney in my presence, that the

      principal appears to be of sound mind and under no duress, fraud or undue

      influence, that I am not the person appointed as agent by this document, and

      that I am not a health-care provider, nor an employee of a health-care

      provider or facility.

      ____ ____

      (date)

      (signature of witness)

      ____ ____

      (address)

      (printed name of witness)

      ____

      (city) (state)

      ALTERNATIVE NO. 2

      State of ____

      County of ____

      On this ____ day of ____, in the year ____, before me, ____ (insert name of

      notary public) appeared ____, personally known to me (or proved to me on the

      basis of satisfactory evidence) to be the person whose name is subscribed to

      this instrument, and acknowledged that he or she executed it. I declare under

      the penalty of perjury that the person whose name is subscribed to this

      instrument appears to be of sound mind and under no duress, fraud or undue

      influence.

      Notary Seal

      ____

      (Signature of Notary Public)

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