2006 Code of Virginia § 54.1-2984 - Suggested form of written advance directives

54.1-2984. Suggested form of written advance directives.

An advance directive executed pursuant to this article may, but need not, bein the following form, and may (i) direct a specific procedure or treatmentto be provided, such as artificially administered hydration and nutrition;(ii) direct a specific procedure or treatment to be withheld; or (iii)appoint an agent to make health care decisions for the declarant as specifiedin the advance directive if the declarant is determined to be incapable ofmaking an informed decision, including the decision to make, after thedeclarant's death, an anatomical gift of all of the declarant's body or anorgan, tissue or eye donation pursuant to Article 2 ( 32.1-289 et seq.) ofChapter 8 of Title 32.1 and in compliance with any directions of thedeclarant. Should any other specific directions be held to be invalid, suchinvalidity shall not affect the advance directive. If the declarant appointsan agent in an advance directive, that agent shall have the authority to makehealth care decisions for the declarant as specified in the advance directiveif the declarant is determined to be incapable of making an informed decisionand shall have decision-making priority over any individuals authorized under 54.1-2986 to make health care decisions for the declarant. In no case shallthe agent refuse or fail to honor the declarant's wishes in relation toanatomical gifts or organ, tissue or eye donation.

ADVANCE MEDICAL DIRECTIVE

I,..........,willfullyandvoluntarilymakeknownmydesireanddohereby
declare:
IfatanytimemyattendingphysicianshoulddeterminethatIhaveaterminal
conditionwheretheapplicationoflife-prolongingprocedureswouldserveonly
toartificiallyprolongthedyingprocess,Idirectthatsuchproceduresbe
withheldorwithdrawn,andthatIbepermittedtodienaturallywithonlythe
administrationofmedicationortheperformanceofanymedicalprocedure
deemednecessarytoprovidemewithcomfortcareortoalleviatepain(OPTION:
Ispecificallydirectthatthefollowingproceduresortreatmentsbeprovided
tome:....................)

In the absence of my ability to give directions regarding the use of suchlife-prolonging procedures, it is my intention that this advance directiveshall be honored by my family and physician as the final expression of mylegal right to refuse medical or surgical treatment and accept theconsequences of such refusal.

OPTION: APPOINTMENT OF AGENT (CROSS THROUGH IF YOU DO NOT WANT TO APPOINT ANAGENT TO MAKE HEALTH CARE DECISIONS FOR YOU.)

Iherebyappoint.......(primaryagent),of.......(addressandtelephone
number),asmyagenttomakehealthcaredecisionsonmybehalfasauthorized
inthisdocument.If.......(primaryagent)isnotreasonablyavailableor
isunableorunwillingtoactasmyagent,thenIappoint.......(successor
agent),of.......(addressandtelephonenumber),toserveinthatcapacity.

I hereby grant to my agent, named above, full power and authority to makehealth care decisions on my behalf as described below whenever I have beendetermined to be incapable of making an informed decision about providing,withholding or withdrawing medical treatment. The phrase "incapable ofmaking an informed decision" means unable to understand the nature, extentand probable consequences of a proposed medical decision or unable to make arational evaluation of the risks and benefits of a proposed medical decisionas compared with the risks and benefits of alternatives to that decision, orunable to communicate such understanding in any way. My agent's authorityhereunder is effective as long as I am incapable of making an informeddecision.

The determination that I am incapable of making an informed decision shall bemade by my attending physician and a second physician or licensed clinicalpsychologist after a personal examination of me and shall be certified inwriting. Such certification shall be required before treatment is withheld orwithdrawn, and before, or as soon as reasonably practicable after, treatmentis provided, and every 180 days thereafter while the treatment continues.

In exercising the power to make health care decisions on my behalf, my agentshall follow my desires and preferences as stated in this document or asotherwise known to my agent. My agent shall be guided by my medical diagnosisand prognosis and any information provided by my physicians as to theintrusiveness, pain, risks, and side effects associated with treatment ornontreatment. My agent shall not authorize a course of treatment which heknows, or upon reasonable inquiry ought to know, is contrary to my religiousbeliefs or my basic values, whether expressed orally or in writing. If myagent cannot determine what treatment choice I would have made on my ownbehalf, then my agent shall make a choice for me based upon what he believesto be in my best interests.

OPTION: POWERS OF MY AGENT (CROSS THROUGH ANY LANGUAGE YOU DO NOT WANT ANDADD 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 useof mechanical or other procedures that affect any bodily function, including,but not limited to, artificial respiration, artificially administerednutrition and hydration, and cardiopulmonary resuscitation. Thisauthorization specifically includes the power to consent to theadministration of dosages of pain-relieving medication in excess ofrecommended dosages in an amount sufficient to relieve pain, even if suchmedication 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, medicaland 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 anotherfacility) from any hospital, hospice, nursing home, adult home or othermedical care facility for services other than those for treatment of mentalillness requiring admission procedures provided in Article 1 ( 37.2-800 etseq.) of Chapter 8 of Title 37.2; and

E. To take any lawful actions that may be necessary to carry out thesedecisions, including the granting of releases of liability to medicalproviders.

Further, my agent shall not be liable for the costs of treatment pursuant tohis authorization, based solely on that authorization.

OPTION: APPOINTMENT OF AN AGENT TO MAKE AN ANATOMICAL GIFT OR ORGAN, TISSUEOR EYE DONATION (CROSS THROUGH IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKEAN ANATOMICAL GIFT OR ANY ORGAN, TISSUE OR EYE DONATION FOR YOU.)

Uponmydeath,Idirectthatananatomicalgiftofallofmybodyorcertain
organ,tissueoreyedonationsmaybemadepursuanttoArticle2(32.1-289
etseq.)ofChapter8ofTitle32.1andinaccordancewithmydirections,if
any.Iherebyappoint.......asmyagent,of.......(addressandtelephone
number),tomakeanysuchanatomicalgiftororgan,tissueoreyedonation
followingmydeath.Ifurtherdirectthat:.......(declarant'sdirections
concerninganatomicalgiftororgan,tissueoreyedonation).
Thisadvancedirectiveshallnotterminateintheeventofmydisability.

By signing below, I indicate that I am emotionally and mentally competent tomake this advance directive and that I understand the purpose and effect ofthis document.

________________________________________
(Date)(SignatureofDeclarant)
Thedeclarantsignedtheforegoingadvancedirectiveinmypresence.
(Witness)________________________________________
(Witness)________________________________________

(1983, c. 532, 54-325.8:4; 1988, c. 765; 1989, c. 592; 1991, c. 583; 1992,cc. 748, 772; 1997, c. 609; 1999, c. 814; 2000, c. 810; 2005, c. 186.)