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Utah Advance Healthcare Directive
(Pursuant to Utah Code Section 75-2a-117)
| Part I: | Allows you to name another person to make health care decisions for you when you cannot make decisions or speak for yourself. |
| Part II: | Allows you to record your wishes about health care in writing. |
| Part III: | Tells you how to revoke or change this directive. |
| Part IV: | Makes your directive legal. |
My Personal Information
Name:
Street Address:
City, State, Zip Code: ,
| Telephone: |
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
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
C. My Alternate Agent
This person will serve as your agent if your agent, named above, is unable or unwilling to serve.
| Alternate Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
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
| _______ | (Initial) I choose to let my agent decide. I have chosen my agent carefully. I have talked with my agent about my health care wishes. I trust my agent to make the health care decisions for me that I would make under the circumstances. |
Additional Comments:
_____________________________________________________________________
Option 2
| _______ | (Initial) I choose to prolong life. Regardless of my condition or prognosis, I want my health care team to try to prolong my life as long as possible within the limits of generally accepted health care standards. |
Other:
_____________________________________________________________________
Option 3
| _______ | (Initial) I choose not to receive care for the purpose of prolonging life, including food and fluids by tube, antibiotics, CPR, or dialysis being used to prolong my life. I always want comfort care and routine medical care that will keep me as comfortable and functional as possible, even if that care may prolong my life. |
If you choose this option, you must also choose either (a) or (b), below.
| _______ | (Initial) | (a) I put no limit on the ability of my health care provider or agent to withhold or withdraw life-sustaining care. |
If you selected (a), above, do not choose any options under (b).
| _______ | (Initial) | (b) My health care provider should withhold or withdraw life-sustaining care if at least one of the following initialed conditions is met: |
_____ 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
| _______ | (Initial) I do not wish to express preferences about health care wishes in this directive. |
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
| I may revoke or change this directive by: |
| 1. Writing "void" across the form, or burning, tearing, or otherwise destroying or defacing this document or directing another person to do the same on my behalf; |
| 2. Signing a written revocation of the directive, or directing another person to sign a revocation on my behalf; |
| 3. Stating that I wish to revoke the directive in the presence of a witness who: is 18 years of age or older; will not be appointed as my agent in a substitute directive; will not become a default surrogate if the directive is revoked; and signs and dates a written document confirming my statement; or |
| 4. Signing a new directive. (If you sign more than one Advance Health Care Directive, the most recent one applies.) |
Part IV: Making My Directive Legal
| I sign this directive voluntarily. I understand the choices I have made and declare that I am emotionally and mentally competent to make this directive. |
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:____________________
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
| I have witnessed the signing of this directive, I am 18 years of age or older, and I am not: |
| 1. related to the declarant by blood or marriage; |
| 2. entitled to any portion of the declarant's estate according to the laws of intestate succession of any state or jurisdiction or under any will or codicil of the declarant; |
| 3. a beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transfer on death deed that is held, owned, made, or established by, or on behalf of, the declarant; |
| 4. entitled to benefit financially upon the death of the declarant; |
| 5. entitled to a right to, or interest in, real or personal property upon the death of the declarant; |
| 6. directly financially responsible for the declarant's medical care; |
| 7. a health care provider who is providing care to the declarant or an administrator at a health care facility in which the declarant is receiving care; or |
| 8. the appointed agent or alternate agent. |
| Witness Signature: | ________________________________________ |
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]
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It's quick and easy to give or receive the support you need with a free Utah Medical Power of Attorney template from Rocket Lawyer:
This method will often end up being notably less expensive than finding and working with a traditional provider. If needed, you can start a Medical PoA on behalf of your spouse or another relative, and then have that person sign it once you've drafted it. Please remember that for this document to be accepted as legally valid, the principal must be a mentally competent adult when they sign. In the event that the principal is already incapacitated and unable to make their own decisions, a court-appointed conservatorship generally will be necessary. When dealing with this situation, it's best for you to connect with a lawyer .
Every person over 18 years old should have a Medical Power of Attorney. Although it is painful to acknowledge, there could come a day when you cannot make important decisions on your own. Here are a few typical situations in which you might consider power of attorney to be useful:
Regardless of whether your Utah Medical Power of Attorney has been made in response to an unexpected issue or as part of a long-term plan, witnesses and notarization can help to protect your agent if their privileges are doubted.
Sometimes, in the process of researching the topics of elder care or estate planning, you may see the terms "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" used together or interchangeably. In reality, they're the same. That said, it's absolutely possible to have agency over affairs that aren't related to medical care, in which case, "proxy" is not usually used.
Utah Medical PoA forms are typically straightforward; however, you or your agent might still have questions. Depending on whom you approach, some lawyers will not even agree to review documents that they didn't author. An easier approach to consider is to get help via attorney services at Rocket Lawyer. If you sign up for a Premium membership, you have the ability to ask for a document review from an attorney with relevant experience or get answers to additional legal questions about your Medical Power of Attorney. As always, Rocket Lawyer is here to support you.
The fees associated with hiring a legal provider to draft a Medical Power of Attorney might total anywhere from two hundred to five hundred dollars. Unlike the other sites you might stumble upon, Rocket Lawyer offers more than a Power of Attorney template. If you ever require support from a lawyer, your membership offers up to 40% in savings when you hire an attorney from our Rocket Lawyer attorney network.
After completing a Healthcare PoA on Rocket Lawyer, you will be able to view it anytime, anywhere. As a Rocket Lawyer member, you may make edits, save it in PDF format or as a Word file, or sign it. Alongside your Power of Attorney, you will find a list of proposed actions to take after your document is completed. Your agent(s), care providers, and other impacted parties should receive a copy of the fully executed document.
The specifications for PoA forms vary in each state; however, in Utah, your document will typically need one witness. If your agent is granted the authority to direct your burial or cremation, then two witnesses are required. Your chosen witness must not be anyone who is financially responsible for your medical care or any healthcare provider or administrator of a facility where you are receiving care. It also should not be your spouse or another family member, heir, or beneficiary, nor can it be the person who signed the document for you, if you were unable to sign it yourself. As a basic standard, witnesses must be over 18 years old, and none of them should also be acting as your PoA agent.
See Utah Medical/Healthcare Power of Attorney law: Title 75, Chapter 2a, Section 107
