Fill and Sign the Advance Health Care Directive Wyoming 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 donation of organs and the designation of your supervising health care provider. 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 also 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 or community care facility 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 also 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 express an intention to donate your bodily organs and tissues following your death. After completing this form, sign and date the form at the end. This form must be signed before a notary public and witnessed by two (2) witnesses. 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 b becomes effective when my supervising health care provider determines that I lack the capacity to make my own health care decisions unless I initial the following box. If I initial 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, (please initial one): I nominate the agent(s) whom I named in this form in the order designated to act as guardian. I nominate the following to be guardian in the order designated: I do not nominate anyone to be guardian. PART 2 INSTRUCTIONS FOR HEALTH CARE Please strike any wording that 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 initialed 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 initial the following box. If I initial this box , artificial nutrition must be provided regardless of my condition and regardless of the choice I have made in paragraph (6). If I initial this box , artificial 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: (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 DONATION OF ORGANS AT DEATH (OPTIONAL) (10) Upon my death (initial applicable box): (a) I give my body, or (b) I give any needed organs, tissues or parts, or (c) I give the following organs, tissues or parts only (d) My gift is for the following purposes (strike any of the following you do not want): (i) Any purpose authorized by law; (ii) Transplantation; (iii) Therapy; (iv) Research; (v) Medical education. (11) I designate the following physician as my primary physician: (name of physician) ________________________________________________________ (address) (city) (state) (zip code) __________________ (phone) If the physician I have designated above is not willing, able or reasonably available to act as my primary physician, I designate the following as my primary physician: ________________________________________________________ (name of physician) ________________________________________________________ (address) (city) (state) (zip code) __________________ (phone) (12) EFFECT OF COPY: A copy of this form has the same effect as the original. (13) SIGNATURES: Sign and date the form here: __________________ (date) ___________________________________ (sign your name) ________________________________________________________ (print your name) ________________________________________________________ (address) ________________________________________________________ (city) (state) SIGNATURES OF WITNESSES: I declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is known to me to be the principal, and the principal signed or acknowledged this document in my presence. First witness ________________________________________________________ (print name) (address) __________________________________ (signature of witness) __________________ (date) Second witness ________________________________________________________ (print name) (address) __________________________________ (signature of witness) __________________ (date) STATE OF WYOMING COUNTY OF __________________ The foregoing instrument was acknowledged before me by __________________________________ this       day of __________________ , 20       . Witness my hand and official seal. (Seal) ______________________________ Notary Public My Commission Expires: