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Utah Advance Health Care 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)
. 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.
. My Agent
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
| ____ | YES | __X__ | NO | Get copies of my medical records at any time, even when I can speak for myself. |
| __X__ | YES | ____ | NO | Get copies of my medical records at any time, even when I can speak for myself. |
| _________________ |
| (Initial) |
| ____ | YES | __X__ | NO | Admit me to a licensed health care facility, such as a hospital, nursing home, assisted living, or other facility for long-term |
| __X__ | YES | ____ | NO | Admit me to a licensed health care facility, such as a hospital, nursing home, assisted living, or other facility for long-term placement other than convalescent or recuperative care. |
| _________________ |
| (Initial) |
I wish to limit or expand the powers of my health care agent as follows:
I do not wish to include additional limits or expansions of my health care agent.
| ____ | YES | __X__ | NO |
| __X__ | YES | ____ | NO | _________________ |
| (Initial) |
| ____ | YES | __X__ | NO | I authorize my agent to consent to my participation in medical research or clinical trials, even if I may not benefit from the results. |
| __X__ | YES | ____ | NO | I authorize my agent to consent to my participation in medical research or clinical trials, even if I may not benefit from the results. |
| _________________ |
| (Initial) |
| ____ | YES | __X__ | NO | If I have not otherwise agreed to organ donation, my agent may consent to the donation of my organs for the purpose of organ transplantation. |
| __X__ | YES | ____ | NO | If I have not otherwise agreed to organ donation, my agent may consent to the donation of my organs for the purpose of organ transplantation. |
| _________________ |
| (Initial) |
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.
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.
| _______ | (Initial) |
| Additional Comments: |
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.
| _______ | (Initial) |
| Other: |
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.
| _______ | (Initial) |
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: |
| _______ | (Initial) | I have a progressive illness that will cause death. |
| _______ | (Initial) | I am close to death and am unlikely to recover. |
| _______ | (Initial) | I cannot communicate and it is unlikely that my condition will improve. |
| _______ | (Initial) | I do not recognize my friends or family and it is unlikely that my condition will improve. |
| _______ | (Initial) | I am in a persistent vegetative state. |
| Other: |
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.
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]
| _____ | (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 quick and easy to outline your medical preferences with a free Utah Living Will template from Rocket Lawyer:
This route will often end up being much less time-consuming than finding and working with a traditional law firm. If necessary, you may fill out this Living Will on behalf of your spouse or another family member, and then help that person sign it when ready. Keep in mind that for a Living Will to be considered valid, the principal must be mentally competent at the time of signing. In the event that the principal has already been declared incompetent, a court-appointed conservatorship generally will be necessary. When facing such a situation, it's a good idea to speak to an attorney .
Every adult should have a Living Will. Even though it's challenging to acknowledge, a day may come when you are no longer able to make your own healthcare decisions. Here are some common occasions in which it may be helpful to make or update your Living Will:
Whether your Utah Living Will is being produced in response to a recent change in your health or as part of a long-term plan, notarization and witnesses are strongly recommended as a best practice for protecting this document and/or your agent if their privileges are questioned by a third party. Please note that a Living Will is not valid during pregnancy in Utah.
Making a Living Will is typically simple to do; however, you or your agent(s) might need legal advice. Finding an attorney to check your Utah Living Will could be time-intensive and fairly expensive. An easier and more cost-effective alternative would be via Rocket Lawyer attorney services. As a Premium member, you can get your documents looked at by an Rocket Lawyer network attorney with relevant experience. You can rest assured that Rocket Lawyer will be here to support you.
The fees associated with working with a law firm to make a Living Will could range between $200 and $1,000. When you use Rocket Lawyer, you aren't just filling out a Living Will template. In case you ever need help from a lawyer, your Rocket Lawyer membership offers up to 40% in savings when you hire an attorney from our Rocket Lawyer attorney network.
Attached to your Utah Living Will form, you will find a series of next steps you should take after your document is completed. Feel free to interact with your PoA in all of these ways: editing it, downloading it in PDF format or as a Word file, printing it out, and/or signing it. Finally, you will need to send a final copy of the fully signed document to your agent(s) and care providers.
The specific requirements and restrictions for Living Wills will be different by state; however, in Utah, your document needs to be signed by one witness. 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. As a basic standard, your witness will need to be over the age of 18 and should not simultaneously be your healthcare agent.
