Docstoc Legal Agreements
This Advanced Health Care Directive (Living Will and Health Care Proxy) is intended to be
used by an individual located in Vermont to express his or her directions regarding whether
or not life-sustaining procedures are to be utilized in the event of the individual's incapacity.
The directive provides for the appointment of a Health Care Proxy in case the individual is
unable to speak for him or herself due to terminal illness, injury, or permanent
unconsciousness. This document contains both standard provisions commonly found in
advanced health care directives and opportunities for customization to address the specific
directions of the individual.
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ADVANCED HEALTH CARE DIRECTIVE
(Living Will and Health Care Proxy)
1. LIVING WILL
I, ________________ [Instruction: Insert the name of person making the direction],
being of sound mind, would like to make and express the following wishes known. I direct
that my family, my doctors and health care workers, and all others follow such directions I
am writing down in this document. I know that at any time I can change my mind about these
directions by tearing up this form and writing a new one. I can also do away with these
directions by tearing them up and by telling some adult person of my wishes and asking him/
her to write them down as per my instructions.
I understand that these directions will only be used in case I am not being able to speak for
myself.
a. If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a
condition that cannot be cured and that I will likely die in the near future from this
condition.
i. Life sustaining treatment.
Life sustaining treatment includes drugs, machines, or medical procedures that would
keep me alive, but would not cure me. I know that even if I choose not to have life
sustaining treatment, I will still get medicines and treatments that ease my pain and
keep me comfortable.
[Instruction: Insert your initial by either “Yes” or “No” in the appropriate box]
I want to have life sustaining treatment if I am terminally ill or injured.
____ Yes
____ No
ii. Artificially provided Food and Hydration (food and water through a tube). I
understand that if I am terminally ill or injured I may need to be given food and water
through a tube to keep me alive if I can no longer chew or swallow on my own or
with someone helping me.
[Instruction: Insert your initial by either “Yes” or “No” in the appropriate box]
I want to have food and water provided through a tube if I am terminally ill or
injured.
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____ Yes
____ No
b. If I Become Permanently Unconscious.
Permanent unconsciousness is when my doctor and another doctor agree that within a
reasonable degree of medical certainty, I can no longer think, feel anything, knowingly
move, or be aware of being aliv