make your free utah medical power of attorney

utah advance healthcare directive

(pursuant to utah code section 75-2a-117)

my personal information

name:

street address:

city, state, zip code: ,

cell phone:

birth date:

part i: my agent (health care power of attorney)

a. no agent

if you do not want to name an agent: initial the line below, then go to part ii; do not name an agent in b or c below. no one can force you to name an agent.

b. my agent

c. my alternate agent

this person will serve as your agent if your agent, named above, is unable or unwilling to serve.

d. agent's authority

if i cannot make decisions or speak for myself (in other words, after my physician or another authorized provider finds that i lack health care decision making capacity under section 75-2a-104 of the advance health care directive act), my agent has the power to make any health care decision i could have made such as, but not limited to:

-- consent to, refuse, or withdraw any health care. this may include care to prolong my life such as food and fluids by tube, use of antibiotics, cpr (cardiopulmonary resuscitation), and dialysis, and mental health care, such as convulsive therapy and psychoactive medications. this authority is subject to any limits in paragraph f of part i or in part ii of this directive.

-- hire and fire health care providers.

-- ask questions and get answers from health care providers.

-- consent to admission or transfer to a health care provider or health care facility, including a mental health facility, subject to any limits in paragraphs e and f of part i.

-- get copies of my medical records.

-- ask for consultations or second opinions.

my agent cannot force health care against my will, even if a physician has found that i lack health care decision making capacity.

e. other authority

my agent has the powers below only if i initial the "yes" option that precedes the statement. i authorize my agent to:

f. limits/expansion of authority

g. nomination of guardian

even though appointing an agent should help you avoid a guardianship, a guardianship may still be necessary. initial the "yes" option if you want the court to appoint your agent or, if your agent is unable or unwilling to serve, your alternate agent, to serve as your guardian, if a guardianship is ever necessary.

i, being of sound mind and not acting under duress, fraud, or other undue influence, do hereby nominate my agent, or if my agent is unable or unwilling to serve, i hereby nominate my alternate agent, to serve as my guardian in the event that, after the date of this instrument, i become incapacitated.

h. consent to participate in medical research

i. organ donation

part ii: my health care wishes (living will)

i want my health care providers to follow the instructions i give them when i am being treated, even if my instructions conflict with these or other advance directives. my health care providers should always provide health care to keep me as comfortable and functional as possible.

choose only one of the following options, numbered option 1 through option 4, by placing your initials before the numbered statement. do not initial more than one option. if you do not wish to document end-of-life wishes, initial option 4. you may choose to draw a line through the options that you are not choosing.

option 1

additional comments:

_____________________________________________________________________

option 2

other:

_____________________________________________________________________

option 3

if you choose this option, you must also choose either (a) or (b), below.

if you selected (a), above, do not choose any options under (b).

_____ i have a progressive illness that will cause death.

_____ i am close to death and am unlikely to recover.

_____ i cannot communicate and it is unlikely that my condition will improve.

_____ i do not recognize my friends or family and it is unlikely that my condition will improve.

_____ i am in a persistent vegetative state.

other:

_____________________________________________________________________

option 4

additional instructions about your health care wishes:

if you do not want emergency medical service providers to provide cpr or other life sustaining measures, you must work with a physician or aprn to complete an order that reflects your wishes on a form approved by the utah department of health.

part iii: revoking or changing a directive

part iv: making my directive legal

my signature on this form revokes any living will or power of attorney form, naming a health care agent, that i have completed in the past.

date:____________________

if the witness is signing to confirm an oral directive, describe below the circumstances under which the directive was made. [utah code ann. a7 75-2a-117]