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ADVANCE MEDICAL DIRECTIVE
Declaration made this _____ day of _______________, _____. I, , willingly and voluntarily make known my wishes in the event that I am incapable of making an informed decision, as follows:
I understand that my advance directive may include the selection of an agent as well as set forth my choices regarding health care. The term "health care" means the furnishing of services to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical disability, including but not limited to, medications; surgery; blood transfusions; chemotherapy; radiation therapy; admission to a hospital, nursing home, assisted living facility, or other health care facility; psychiatric or other mental health treatment; and life-prolonging procedures and palliative care.
The phrase "incapable of making an informed decision" means unable to understand the nature, extent and probable consequences of a proposed health care decision or unable to make a rational evaluation of the risks and benefits of a proposed health care decision as compared with the risks and benefits of alternatives to that decision, or unable to communicate such understanding in any way.
The determination that I am incapable of making an informed decision shall be made by my attending physician and a capacity reviewer, if certification by a capacity reviewer is required by law, after a personal examination of me and shall be certified in writing. Such certification shall be required before health care is provided, continued, withheld or withdrawn, before any named agent shall be granted authority to make health care decisions on my behalf, and before, or as soon as reasonably practicable after, health care is provided, continued, withheld or withdrawn and every 180 days thereafter while the need for health care continues.
If, at any time, I am determined to be incapable of making an informed decision, I shall be notified, to the extent I am capable of receiving such notice, that such determination has been made before health care is provided, continued, withheld, or withdrawn. Such notice shall also be provided, as soon as practical, to my named agent or person authorized by Section 54.1-2986 to make health care decisions on my behalf. If I am later determined to be capable of making an informed decision by a physician, in writing, upon personal examination, any further health care decisions will require my informed consent.
To consent to or refuse or withdraw consent to any type of medical care, treatment, surgical procedure, diagnostic procedure, medication and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, artificially administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the power to consent to the administration of dosages of pain relieving medication in excess of standard dosages in an amount sufficient to relieve pain, even if such medication carries the risk of addiction or inadvertently hastens my death.
To request, receive, and review any information, verbal or written, regarding my physical or mental health, including but not limited to, medical and hospital records, and to consent to the disclosure of this information.
To employ and discharge my health care providers.
To authorize my admission to or discharge (including transfer to another facility) from any hospital, hospice, nursing home, adult home or other medical care facility. If I have authorized admission to a health care facility for treatment of mental illness, that authority is stated elsewhere in this advance directive.
To authorize my admission to a health care facility for the treatment of mental illness for no more than 10 calendar days provided I do not protest the admission and a physician on the staff of or designated by the proposed admitting facility examines me and states in writing that I have a mental illness and I am incapable of making an informed decision about my admission, and that I need treatment in the facility; and to authorize my discharge (including transfer to another facility) from the facility;
To authorize my admission to a health care facility for the treatment of mental illness for no more than 10 calendar days, even over my protest, if a physician on the staff of or designated by the proposed admitting facility examines me and states in writing that I have a mental illness and I am incapable of making an informed decision about my admission, and that I need treatment in the facility; and to authorize my discharge (including transfer to another facility) from the facility. [My physician or licensed clinical psychologist hereby attests that I am capable of making an informed decision and that I understand the consequences of this provision of my advance directive: ______________(INITIAL)];
To continue to serve as my agent even in the event that I protest the agent's authority after I have been determined to be incapable of making an informed decision.
To authorize my participation in any health care study approved by an institutional review board or research review committee according to applicable federal or state law that offers the prospect of direct therapeutic benefit to me.
To authorize my participation in any health care study approved by an institutional review board or research review committee pursuant to applicable federal or state law that aims to increase scientific understanding of any condition that I may have or otherwise to promote human well-being, even though it offers no prospect of direct benefit to me.
To make decisions regarding visitation during any time that I am admitted to any health care facility, consistent with the following directions:
To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers.
________________________________________.
A. I specifically direct that I receive the following health care if it is medically appropriate under the circumstances as determined by my attending physician:
B. I specifically direct that the following health care not be provided to me under the following circumstances (you may specify that certain health care not be provided under any circumstances):
Anatomical Gifts. I do not desire to make an anatomical gift.
Anatomical Gifts. Upon my death, I direct that an anatomical gift of all or any part of my body may be made pursuant to Article 2 (Section 32.1-289.2 et seq.) of Chapter 8 of Title 32.1 and in accordance with my directions, if any. I hereby appoint as my agent to make any such anatomical gift following my death.
End of Life Instructions
If at any time my attending physician should determine that I have a terminal condition where the application of life-prolonging procedures would serve only to artificially prolong the dying process,
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this advance directive shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal.
This advance directive shall not terminate in the event of my disability.
By signing below, I indicate that I am emotionally and mentally competent to make this advance directive and that I understand the purpose and effect of this document. I understand I may revoke all or any part of this document at any time (i) with a signed, dated writing; (ii) by physical cancellation or destruction of this advance directive by myself or by directing someone else to destroy it in my presence; or (iii) by my oral expression of intent to revoke.
Date Signed: _______________ _____, _____.
| Declarant Signature: | ______________________________________ |
| Name: |
| Address: |
The Declarant signed the foregoing advance directive in my presence. I am not the spouse or blood relative of the Declarant.
| Witness Signature: | ________________________________________ |
| Witness Signature: | ________________________________________ |
| _____ | (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 set forth your medical wishes with a free Virginia Living Will template from Rocket Lawyer:
This solution, in many cases, would be much less time-consuming than finding and hiring a conventional provider. If necessary, you can start this Living Will on behalf of your spouse or another relative, and then have that person sign it when ready. Please remember that for this document to be accepted as valid, the principal must be an adult who is mentally competent when they sign. In the event that the principal is already unable to make their own decisions, a conservatorship could be required. When dealing with such a situation, it's important for you to speak with an attorney .
Every adult should have a Living Will. Even though it is difficult to acknowledge, there could come a time when you are no longer able to make important decisions on your own. Here are a few typical occasions in which it might be helpful to make or update your Living Will:
Regardless of whether this Virginia Living Will is being made in response to a change in your health or as part of a forward-looking plan, notarization and witnesses are highly recommended for protecting your document if a third party challenges its lawfulness.
Making a Living Will is generally easy to do; however, you might still have legal questions. Hiring a lawyer to double-check your Living Will could take a long time if you do it by yourself. An easier approach would be through Rocket Lawyer attorney services. Rocket Lawyer Premium members can ask for feedback from an experienced lawyer or send other questions. As always, you can Live Confidently® knowing that Rocket Lawyer is by your side.
The fees associated with meeting and hiring your average legal provider to draft a Living Will can total anywhere from $200 to $1,000, depending on where you are. When you use Rocket Lawyer, you aren't just filling out a Living Will template. In case you ever need assistance from a lawyer, your Premium membership offers up to a 40% discount when you hire an Rocket Lawyer network attorney.
With a Premium membership, you will be able to edit it, save it in PDF format or as a Word file, and/or print it. In order to finish up your Virginia Living Will form, it will need to be signed. Be sure that your agent(s) and care providers get a copy of your fully executed document.
The guidelines for Living Wills are different by state; however, in Virginia, your document must be signed by two witnesses. As a general standard, your witnesses should be over 18 years old, and none should also be your agent.
