Mississippi Advance Health Care Directive(Living Will) Form

Explanation

MississippiAdvanceHealth-CareDirective

(LivingWill)

Youhavetherighttogiveinstructionsaboutyourownhealthcare.Youalsohavetherighttonamesomeoneelsetomakehealth-caredecisionsforyou.Thisformletsyoudoeitherorbothofthesethings.Italsoletsyouexpressyourwishesregardingthedesignationofyourprimaryphysician.Ifyouusethisform,youmaycompleteormodifyalloranypartofit.Youarefreetouseadifferentform.

Part1ofthisformisapowerofattorneyforhealthcare.Part1letsyounameanotherindividualasagenttomakehealth-caredecisionsforyouifyoubecomeincapableofmakingyourowndecisionsorifyouwantsomeoneelsetomakethosedecisionsforyounoweventhoughyouarestillcapable.Youmaynameanalternateagenttoactforyouifyourfirstchoiceisnotwilling,ableorreasonablyavailabletomakedecisionsforyou.Unlessrelatedtoyou,youragentmaynotbeanowner,operator,oremployeeofaresidentiallong-termhealth-careinstitutionatwhichyouarereceivingcare.

Unlesstheformyousignlimitstheauthorityofyouragent,youragentmaymakeallhealth-caredecisionsforyou.Thisformhasaplaceforyoutolimittheauthorityofyouragent.Youneednotlimittheauthorityofyouragentifyouwishtorelyonyouragentforallhealth-caredecisionsthatmayhavetobemade.Ifyouchoosenottolimittheauthorityofyouragent,youragentwillhavetherightto:

(a)Consentorrefuseconsenttoanycare,treatment,service,orproceduretomaintain,diagnose,orotherwiseaffectaphysicalormentalcondition;

(b)Selectordischargehealth-careprovidersandinstitutions;

(c)Approveordisapprovediagnostictests,surgicalprocedures,programsofmedication,andordersnottoresuscitate;and

(d)Directtheprovision,withholding,orwithdrawalofartificialnutritionandhydrationandallotherformsofhealthcare.

Part2ofthisformletsyougivespecificinstructionsaboutanyaspectofyourhealthcare.Choicesareprovidedforyoutoexpressyourwishesregardingtheprovision,withholding,orwithdrawaloftreatmenttokeepyoualive,includingtheprovisionofartificialnutritionandhydration,aswellastheprovisionofpainrelief.Spaceisprovidedforyoutoaddtothechoicesyouhavemadeorforyoutowriteoutanyadditionalwishes.

Part3ofthisformletsyoudesignateaphysiciantohaveprimaryresponsibilityforyourhealthcare.

Aftercompletingthisform,signanddatetheformattheendandhavetheformwitnessedbyoneofthetwoalternativemethodslistedbelow.Giveacopyofthesignedandcompletedformtoyourphysician,toanyotherhealth-careprovidersyoumayhave,toanyhealth-careinstitutionatwhichyouarereceivingcare,andtoanyhealth-careagentsyouhavenamed.Youshouldtalktothepersonyouhavenamedasagenttomakesurethatheorsheunderstandsyourwishesandiswillingtotaketheresponsibility.

Youhavetherighttorevokethisadvancehealth-caredirectiveorreplacethisformatanytime.

Thematerialcontained inthisdocument isprovidedbythestatutes oftheStateofMississippiintheMSCode1972Annotated.Thisdocumentisbeingprovidedasaserviceanddoesnotconstitute legaladvice. Wemakenoclaimastotheaccuracyorcompletenessoftheinformationcontained inthisdocument. Theinformationcontained hereinisnotasubstituteforprofessionallegalcounsel.

PARTI

POWER OFATTORNEY FORHEALTH CARE

(1)DESIGNATIONOFAGENT:Idesignatethefollowingindividualasmyagenttomakehealth-caredecisionsforme:

(nameofindividualyouchooseasagent)

(address)(city)(state)(zipcode)

(homephone)(workphone)

OPTIONAL:IfIrevokemyagent'sauthorityorifmyagentisnotwilling,able,orreasonablyavailabletomakeahealth-caredecisionforme,Idesignateasmyfirstalternateagent:

(nameofindividualyouchooseasfirstalternateagent)

(address)(city)(state)(zipcode)

(homephone)(workphone)

OPTIONAL:IfIrevoketheauthorityofmyagentandfirstalternateagentorifneitheriswilling,able,orreasonablyavailabletomakeahealth-caredecisionforme,Idesignateasmysecondalternateagent:

(nameofindividualyouchooseasfirstalternateagent)

(address)(city)(state)(zipcode)

(homephone)(workphone)

(2)AGENT'SAUTHORITY:Myagentisauthorizedtomakeallhealth-caredecisionsforme,includingdecisionstoprovide,withhold,orwithdrawartificialnutritionandhydration,andallotherformsofhealthcaretokeepmealive,exceptasIstatehere:

(Addadditionalsheetsifneeded.)

(3)WHENAGENT'SAUTHORITYBECOMESEFFECTIVE:Myagent'sauthoritybecomeseffectivewhenmyprimaryphysiciandeterminesthatIamunabletomakemyownhealth-caredecisionsunlessImarkthefollowingbox.IfImarkthisbox[ ],myagent'sauthoritytomakehealth-caredecisionsformetakeseffectimmediately.

(4)AGENT'SOBLIGATION:Myagentshallmakehealth-caredecisionsformeinaccordancewiththispowerofattorneyforhealthcare,anyinstructionsIgiveinPart2ofthisform,andmyotherwishestotheextentknowntomyagent.Totheextentmy

wishesareunknown,myagentshallmakehealth-caredecisionsformeinaccordancewithwhatmyagentdeterminestobeinmybestinterest.Indeterminingmybestinterest,myagentshallconsidermypersonalvaluestotheextentknowntomyagent.

(5)NOMINATIONOFGUARDIAN:Ifaguardianofmypersonneedstobeappointedformebyacourt,Inominatetheagentdesignatedinthisform.Ifthatagentisnot

willing,able,orreasonablyavailabletoactasguardian,Inominatethealternateagents

whomIhavenamed,intheorderdesignated.

PART2

INSTRUCTIONSFORHEALTHCARE

Ifyouaresatisfiedtoallowyouragenttodeterminewhatisbestforyouinmaking

end-of-lifedecisions,youneednotfilloutthispartoftheform.Ifyoudofilloutthispartoftheform,youmaystrikeanywordingyoudonotwant.

(6)END-OF-LIFEDECISIONS:Idirectthatmyhealth-careprovidersandothersinvolvedinmycareprovide,withholdorwithdrawtreatmentinaccordancewiththechoiceIhavemarkedbelow:

[ ](a)ChoiceNotToProlongLife

Idonotwantmylifetobeprolongedif(i)Ihaveanincurableandirreversibleconditionthatwillresultinmydeathwithinarelativelyshorttime,(ii)Ibecomeunconsciousand,

toareasonabledegreeofmedicalcertainty,Iwillnotregainconsciousness,or(iii)thelikelyrisksandburdensoftreatmentwouldoutweightheexpectedbenefits,or

[ ](b)ChoiceToProlongLife

Iwantmylifetobeprolongedaslongaspossiblewithinthelimitsofgenerallyacceptedhealth-carestandards.

(7)ARTIFICIALNUTRITIONANDHYDRATION:Artificialnutritionandhydrationmustbeprovided,withheldorwithdrawninaccordancewiththechoiceIhavemadeinparagraph(6)unlessImarkthefollowingbox.IfImarkthisbox[ ],artificialnutritionandhydrationmustbeprovidedregardlessofmyconditionandregardlessofthechoiceIhavemadeinparagraph(6).

(8)RELIEFFROMPAIN:ExceptasIstateinthefollowingspace,Idirectthattreatmentforalleviationofpainordiscomfortbeprovidedatall

times,evenifithastensmydeath:

(9)OTHERWISHES:(Ifyoudonotagreewithanyoftheoptionalchoicesaboveandwishtowriteyourown,orifyouwishtoaddtotheinstructionsyouhavegivenabove,youmaydosohere.)Idirectthat:

(Addadditionalsheetsifneeded.)

PART3

PRIMARYPHYSICIANOPTIONAL

(10)Idesignatethefollowingphysicianasmyprimaryphysician:

(nameofphysician)

(address)(city)(state)(zipcode)

(phone)

OPTIONAL:IfthephysicianIhavedesignatedaboveisnotwilling,able,orreasonablyavailabletoactasmyprimaryphysician,Idesignatethefollowingphysicianasmyprimaryphysician:

(nameofphysician)

(address)(city)(state)(zipcode)

(phone)

(11)EFFECTOFCOPY:Acopyofthisformhasthesameeffectastheoriginal.

(12)SIGNATURES:Signanddatetheformhere:

(date)(signyourname)

(address)(printyourname)

(city) (state)

(13)WITNESSES:Thispowerofattorneywillnotbevalidformakinghealth-caredecisionsunlessitiseither(a)signedbytwo(2)qualifiedadultwitnesseswhoarepersonallyknowntoyouandwhoarepresentwhenyousignoracknowledgeyoursignature;or(b)acknowledgedbeforeanotarypublicinthestate.

ALTERNATIVENO.1

Witness

IdeclareunderpenaltyofperjurypursuanttoSection97-9-61,MississippiCodeof

1972,thattheprincipalispersonallyknowntome,thattheprincipalsignedoracknowledgedthispowerofattorneyinmypresence,thattheprincipalappearstobeofsoundmindandundernoduress,fraudorundueinfluence,thatIamnotthepersonappointedasagentbythisdocument,andthatIamnotahealth-careprovider,noranemployeeofahealth-careproviderorfacility.Iamnotrelatedtotheprincipalbyblood,marriageoradoption,andtothebestofmyknowledge,Iamnotentitledtoanypartoftheestateoftheprincipaluponthedeathoftheprincipalunderawillnowexistingorbyoperationoflaw.

(date)(signatureofwitness)

(address)(printednameofwitness)

(city)(state)

Witness

IdeclareunderpenaltyofperjurypursuanttoSection97-9-61,MississippiCodeof

1972,thattheprincipalispersonallyknowntome,thattheprincipalsignedoracknowledgedthispowerofattorneyinmypresence,thattheprincipalappearstobeofsoundmindandundernoduress,fraudorundueinfluence,thatIamnotthepersonappointedasagentbythisdocument,andthatIamnotahealth-careprovider,noranemployeeofahealth-careproviderorfacility.

(date)(signatureofwitness)

(address)(printednameofwitness)

(city)(state)

ALTERNATIVENO.2

Stateof

Countyof

Onthis dayof ,intheyear ,beforeme,

appeared personallyknowntome(orprovedtomeonthebasisofsatisfactoryevidence)tobethepersonwhosenameissubscribedtothisinstrument,andacknowledgedthatheorsheexecutedit.Ideclareunderthepenaltyofperjurythatthepersonwhosenameissubscribedtothisinstrumentappearstobeofsoundmindandundernoduress,fraudorundueinfluence.

NotarySeal

(SignatureofNotaryPublic)

Mycommissionexpires: