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HEALTH CARE DIRECTIVE
Notice:
This is an important legal document. Before signing this document, you should know these important facts:
| (a) This document gives your health care providers or your designated proxy the power and guidance to make health care decisions according to your wishes when you are in a terminal condition and cannot do so. This document may include what kind of treatment you want or do not want and under what circumstances you want these decisions to be made. You may state where you want or do not want to receive any treatment. |
| (b) If you name a proxy in this document and that person agrees to serve as your proxy, that person has a duty to act consistently with your wishes. If the proxy does not know your wishes, the proxy has the duty to act in your best interests. If you do not name a proxy, your health care providers have a duty to act consistently with your instructions or tell you that they are unwilling to do so. |
| (c) This document will remain valid and in effect until and unless you amend or revoke it. Review this document periodically to make sure it continues to reflect your preferences. You may amend or revoke the living will at any time by notifying your health care providers. |
| (d) Your named proxy has the same right as you have to examine your medical records and to consent to their disclosure for purposes related to your health care or insurance unless you limit this right in this document. |
| (e) If there is anything in this document that you do not understand, you should ask for professional help to have it explained to you. |
TO MY FAMILY, DOCTORS, AND ALL THOSE CONCERNED WITH MY CARE:
I, , understand this document allows me to do ONE OR BOTH of the following:
Name another person (called the health care agent) to make health care decisions for me. My health care agent must make health care decisions for me based on the instructions I provide in this document, if any, the wishes I have made known to him or her, or must act in my best interest if I have not made my health care wishes known.
AND/OR
Give health care instructions to guide others making health care decisions for me. If I have named a health care agent, these instructions are to be used by the agent. These instructions may also be used by my health care providers, others assisting with my health care and my family, in the event I cannot make decisions for myself.
I.
I do not have an attending physician because in good faith I generally select and depend upon spiritual means or prayer for the treatment or care of disease or remedial care. Therefore, I appoint the following individual to determine my decision-making capacity:
| Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
I understand that the limitations regarding the eligibility of a health care provider attending the principal or the provider's employee to act as an agent or witness apply to the individual designated above.
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
However, if a guardian or conservator of my person is to be appointed for me, I nominate
| Name: |
| Address: |
| , |
to serve as my guardian or conservator.
II. If at any time I should have an incurable injury, disease, illness, or condition certified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining treatment is used, and where the application of life-sustaining treatment would serve only to artificially prolong the dying process, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care. It is my preference Upon my death, I hereby make an anatomical gift of any needed organs or tissues for any purpose authorized by law.I do not wish to donate my organs or tissues upon my death.However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining treatment, it is my preference that this document be given effect at that point. If life-sustaining treatment will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
(YOU MUST DATE AND SIGN THIS DOCUMENT)
I am thinking clearly, I agree with everything that is written in this document, and I have made this document willingly.
Signed on _____ day of ____________________, _____.
| Signature: | ________________________________________ |
| Address: |
| County |
If I cannot sign my name, I can ask someone to sign this document for me.
____________________________________ Signature of the person who I asked to sign this document for me.
____________________________________ Printed name of the person who I asked to sign this document for me.
(Sign and date here in the presence of two adult witnesses, one of whom is not your health care provider or an employee of your health care provider on the date you sign this document.)
(Sign and date here in the presence of two adult witnesses, neither of whom has been appointed as your agent or alternate agents in this document, and one of whom is not your health care provider or an employee of your health care provider on the date you sign this document.)
In my presence on ______________ (date), acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. I am at least eighteen (18) years of age.
In my presence on ______________ (date), acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. I am at least eighteen (18) years of age. I am not named as 's health care agent or alternate agent.
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
Date: _________________________
In my presence on ______________ (date), acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. I am at least eighteen (18) years of age.
In my presence on ______________ (date), acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. I am at least eighteen (18) years of age. I am not named as 's health care agent or alternate agent.
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
Date: _________________________
I am not a health care agent or alternative health care agent appointed in the foregoing instrument.
A notary public
two witnesses who then sign the document in your presence and in each other's presence.a notary who then notarizes the document.| _____ | (your Agent) |
You should discuss the document and your wishes with any person you want to designate as an Agent before doing so to assure they agree to act on your behalf.
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It is very easy to outline your medical wishes with a free Minnesota Living Will template from Rocket Lawyer:
This method will often end up being notably more affordable than meeting and hiring the average lawyer. If needed, you can fill out a Living Will on behalf of your spouse or another relative, and then have them sign it once you've drafted it. Please remember that for this document to be considered valid, the principal must be mentally competent at the time of signing. If the principal has already been declared legally incompetent, a conservatorship could be necessary. When managing this scenario, it's a good idea for you to work with an attorney .
Every adult ought to have a Living Will in place. While it may be difficult to acknowledge, a time could come when you aren't able to make healthcare decisions on your own. Here are a few typical situations where it might be helpful to make or update your Living Will:
Regardless of whether this Minnesota Living Will is being prepared as part of a long-term plan or created in response to a recent change in your health, notarization and/or witnesses are highly encouraged for protecting your document if its authenticity is challenged by a third party. That said, Living Wills are not valid during pregnancy in Minnesota.
Making a Living Will is usually easy to do, but you or your agent could need legal advice. Depending on whom you contact, some lawyers will not even agree to review your document if they weren't the author. An easier approach would be via the On Call network. When you become a Premium member, you will be able to request advice from an Rocket Lawyer network attorney with relevant experience or ask other legal questions related to your Living Will. We're here for you.
The fees associated with meeting and hiring a legal provider to write a Living Will might be between $200 and $1,000, depending on where you are located. Rocket Lawyer isn't your average Living Will template provider. With our service, anyone under a Rocket Lawyer Premium membership can take advantage of up to a 40% discount when hiring an attorney from our Rocket Lawyer attorney network.
Alongside your Minnesota Living Will form, there's a set of instructions for what you should do next. With a membership, you can make edits, save it as a PDF document or Word file, and/or sign it. Finally, your agent(s), care providers, and other impacted parties should receive copies of the final document.
The requirements for Living Wills vary by state; however, in Minnesota, your document must be acknowledged by a notary public or signed by two witnesses. Only one of the witnesses to your Living Will can be your healthcare provider. As a basic principle, your witnesses should not be under 18 years old, and none of them should also be named as your healthcare agent.
