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Oregon ________________ (Signature of Alternate Health Care Representative/Date) _______________________________________________ (Printed name) -8- own to me. _______________________________________________ (Signature of Health Care Representative/Date) _______________________________________________ (Printed name) _______________________________o. I understand that the person who appointed me may revoke this appointment. If I learn that this document has been suspended or revoked, I will inform the person's current health care provider if kn a duty to act in what I believe in good faith to be that person's best interest. I understand that this document allows me to decide about that person's health care only while that person cannot do sI must act consistently with the desires of the person I represent, as expressed in this advance directive or otherwise made known to me. If I do not know the desires of the person I represent, I havealth care facility where the person is a patient or resident. PART E: ACCEPTANCE BY HEALTH CARE REPRESENTATIVE I accept this appointment and agree to serve as health care representative. I understand n) of the person signing this advance directive. That witness must also not be entitled to any portion of the person's estate upon death. That witness must also not own, operate or be employed at a he________________________________ (Signature of Witness/Date) -7- ___________________________________ (Printed Name of Witness) NOTE: One witness must not be a relative (by blood, marriage or adoptio a patient for whom either of us is attending physician. Witnessed By: ___________________________________ (Signature of Witness/Date) ___________________________________ (Printed Name of Witness) ___presence; (c) Appears to be of sound mind and not under duress, fraud or undue influence; (d) Has not appointed either of us as health care representative or alternative representative; and (e) Is notre that the person signing this advance directive: (a) Is personally known to us or has provided proof of identity; (b) Signed or acknowledged that person's signature on this advance directive in our DO NOT have a health care power of attorney. ___________________________________ (Date) SIGN HERE TO GIVE INSTRUCTIONS ___________________________ (Signature) PART D: DECLARATION OF WITNESSES We declant it to remain in effect unless I appointed a health care representative after signing the health care power of attorney. ________ I have a health care power of attorney, and I REVOKE IT. ________ I orney" is any document you may have signed to appoint a representative to make health care decisions for you. INITIAL ONE: -6- ________ I have previously signed a health care power of attorney. I wa_____________________________ ______________________________________________________________________________ (Insert description of what you want done.) 7. Other Documents. A "health care power of attlisted in Items 1 to 4 above. 6. Additional Conditions or Instructions. ______________________________________________________________________________ _________________________________________________fe support. I also do not want tube feeding as life support. I want my doctors to allow me to die naturally if my doctor and another knowledgeable doctor confirm I am in any of the medical conditions ly. ________ I want life support only as my physician recommends. ________ I want NO life support. 5. General Instruction. INITIAL IF THIS APPLIES: ________ I do not want my life to be prolonged by li_ I want to receive tube feeding. ________ I want tube feeding only as my physician recommends. ________ I DO NOT WANT tube feeding. B. INITIAL ONE: ________ I want any other life support that may appends. -5- ________ I want NO life support. 4. Extraordinary Suffering. If life support would not help my medical condition and would make me suffer permanent and severe pain: A. INITIAL ONE: _______ng only as my physician recommends. ________ I DO NOT WANT tube feeding. B. INITIAL ONE: ________ I want any other life support that may apply. ________ I want life support only as my physician recommself and recognize my family and other people, and it is very unlikely that my condition will substantially improve: A. INITIAL ONE: ________ I want to receive tube feeding. ________ I want tube feediss. If I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and permanently unable to communicate by any means, swallow food and water safely, care for mying. B. INITIAL ONE: ________ I want any other life support that may apply. ________ I want life support only as my physician recommends. ________ I want NO life support. 3. Advanced Progressive Illnenlikely that I will ever become conscious again: A. INITIAL ONE: ________ I want to receive tube feeding. ________ I want tube feeding only as my physician recommends. ________ I DO NOT WANT tube feedt any other life support that may apply. ________ I want life support only as my physician recommends. ________ I want NO life support. 2. Permanently Unconscious. If I am unconscious and it is very u death: A. INITIAL ONE: ________ I want to receive tube feeding. ________ I want tube feeding only as my physician recommends. ________ I DO NOT WANT tube feeding. B. INITIAL ONE: -4- ________ I wan if my doctor and another knowledgeable doctor confirm that I am in a medical condition described below: 1. Close to Death. If I am close to death and life support would only postpone the moment of myces you make. You may either give specific instructions by filling out Items 1 to 4 below, or you may use the general instruction provided by Item 5. · · · · Here are my desires about my health caren Part B above. If you refuse tube feeding, you should understand that malnutrition, dehydration and death will probably result. You will get care for your comfort and cleanliness, no matter what choiician to try life support if your physician believes it could be helpful and then discontinue it if it is not helping your health condition or symptoms. "Life support" and "tube feeding" are defined if person making appointment) PART C: HEALTH CARE INSTRUCTIONS NOTE: In filling out these instructions, keep the following in mind: · The term "as my physician recommends" means that you want your physhen your representative MAY NOT decide about tube feeding.) -3- __________________________ (Date) SIGN HERE TO APPOINT A HEALTH CARE REPRESENTATIVE ____________________________________ (Signature ond water supplied artificially by medical device, known as tube feeding. INITIAL IF THIS APPLIES: __________ My representative MAY decide about tube feeding for me. (If you don't initial this space, t representative MAY decide about life support for me. (If you don't initial this space, then your representative MAY NOT decide about life support.) 3. Tube Feeding. One sort of life support is food aintaining life, including procedures, devices and medications. If you refuse life support, you will still get routine measures to keep you clean and comfortable. INITIAL IF THIS APPLIES: __________ MyL IF THIS APPLIES: __________ I have executed a Health Care Instruction or Directive to Physicians. My representative is to honor it. 2. Life Support. "Life support" refers to any medical means for ma___________________________________ ______________________________________________________________________________ ______________________________________________________________________________ INITIAblood, marriage or adoption or that person was appointed before your admission into the health care facility. 1. Limits. Special Conditions or Instructions: ___________________________________________re when I can't do so. -2- NOTE: You may not appoint your doctor, an employee of your doctor, or an owner, operator or employee of your health care facility, unless that person is related to you by resentative. My alternate's address is _____________________________________ and telephone number is ______________________________. I authorize my representative (or alternate) to direct my health caepresentative's address is ____________________________________ and telephone number is ________________________________. I appoint ____________________________________ as my alternate health care rep________ My entire life __________ Other period (__Years) PART B: APPOINTMENT OF HEALTH CARE REPRESENTATIVE I appoint ___________________________________________ as my health care representative. My rthdate) _______________________________________________ _______________________________________________ (Address) Unless revoked or suspended, this advance directive will continue for: INITIAL ONE: __xpress your wishes. Witnesses must sign PART D. Print your NAME, BIRTHDATE AND ADDRESS here: _______________________________________________ (Name) _______________________________________________ (Biris document that you do not understand, ask a lawyer to explain it to you. You may sign PART B, PART C, or both parts. You may cross out words that don't express your wishes or add words that better eresentative and your health care provider of the revocation. -1- Despite this document, you have the right to decide your own health care as long as you are able to do so. If there is anything in tho direct your health care before that date, this advance directive will not expire until you are able to make those decisions again. You may revoke this document at any time. To do so, notify your repan advance directive, you do not have to sign this form. Unless you have limited the duration of this advance directive, it will not expire. If you have set an expiration date, and you become unable t direct your care. You can do this by using Part C of this form. Facts About Completing This Form This form is valid only if you sign it voluntarily and when you are of sound mind. If you do not want our representative can resign at any time. Facts About Part C (Giving Health Care Instructions) You also have the right to give instructions for health care providers to follow if you become unable toions for you. Your representative must follow your desires as stated in this document or otherwise made known. If your desires are unknown, your representative must try to act in your best interest. You can do this by using Part B of this form. Your representative must accept on Part E of this form. You can write in this document any restrictions you want on how your representative will make decis About Part B (Appointing a Health Care Representative) You have the right to name a person to direct your health care when you cannot do so. This person is called your "health care representative." Y IMPORTANT INFORMATION ABOUT THIS ADVANCE DIRECTIVE This is an important legal document. It can control critical decisions about your health care. Before signing, consider these important facts: Factshe purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -4- ADVANCE HEALTH CARE DIRECTIVE YOU DO NOT HAVE TO FILL OUT AND SIGN THIS FORM PART A: You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] Tnt for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation.ct or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting poi26a; 1993 c.767 §12] [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effe those documents are inconsistent, the document last executed governs to the extent of the inconsistency. (9) Any reinstatement of an advance directive must be in writing. [1989 c.914 §9; 1993 c.571 §he appointment in writing after the filing of the petition. (8) If the principal has both a valid health care instruction and a valid power of attorney for health care, and the directions reflected inact have withdrawn; or (b) If the power of attorney names the principal's spouse as attorney-in-fact, a petition for dissolution or annulment of marriage is filed and the principal does not reaffirm tive. (7) Unless the power of attorney for health care expressly provides otherwise, a power of attorney for health care is suspended: (a) If both the attorney-in-fact and the alternative attorney-in-f(a) Any power of a guardian or other person appointed by a court to make health care decisions for the protected person; and (b) Any other prior appointment or designation of a health care representat expression of desires with respect to health care decisions. (6) Unless the power of attorney for health care provides otherwise, valid appointment of an attorney-in-fact for health care supersedes: e directions as to health care decisions in a valid advance directive supersede: (a) Any directions contained in a previous court appointment or advance directive; and -3- (b) Any prior inconsistent. Unless the health care instruction provides otherwise, execution of a valid health care instruction revokes any prior health care instruction. (5) Unless the advance directive provides otherwise, thhysician shall cause the revocation to be made a part of the principal's medical records. (4) Execution of a valid power of attorney for health care revokes any prior power of attorney for health careive, the health care representative must promptly inform the attending physician or health care provider of the revocation. (3) Upon learning of the revocation, the health care provider or attending por to the health care representative. If the communication is to the health care representative, and the principal is incapable and is under the care of a health care provider known to the representat to revoke; or (b) Be revoked at any time and in any manner by a capable principal. (2) Revocation is effective upon communication by the principal to the attending physician or health care provider, withhold or withdraw life-sustaining procedures or artificially administered nutrition and hydration, be revoked at any time and in any manner by which the principal is able to communicate the intent revocation effective; effect of executing power of attorney for health care. (1) An advance directive or a health care decision by a health care representative may: (a) If it involves the decision toincipal is effective to indicate the principal's intent. (2) An advance directive shall be in the following form (see form below): 127.545 Revocation of advance directive or health care decision; whence directive executed by an Oregon resident must be the same as the form set forth in this section to be valid. In any place in the form that requires the initials of the principal, any mark by the pr principal, and who is aware of that disqualification, may not make health care decisions for the principal. [1989 c.914 §4; 1993 c.767 §5] 127.531 Form of advance directive. (1) The form of an advanho has actual knowledge of a disqualification may not accept a health care decision from a disqualified individual. -2- (5) A person who has been disqualified from making health care decisions for aqualification must specifically designate those persons who are disqualified. (3) A health care representative whose authority has been revoked by a court is disqualified. (4) A health care provider w facility. (2) A capable adult may disqualify any other person from making health care decisions for the capable adult. The disqualification must be in writing and signed by the capable adult. The disb) An owner, operator or employee of a health care facility in which the principal is a patient or resident, unless the health care representative was appointed before the principal's admission to thehe following persons may not serve as health care representatives if unrelated to the principal by blood, marriage or adoption: (a) The attending physician or an employee of the attending physician. (127.520 Persons not eligible to serve as attorney-in-fact; manner of disqualifying persons for service as attorney-in-fact. (1) Except as provided in ORS 127.635 or as may be allowed by court order, tis validly executed for the purposes of ORS 127.505 to 127.660 and 127.995 and may be given effect in accordance with its provisions, subject to the laws of this state. [1989 c.914 §3; 1993 c.767 §4] er state, in compliance with the formalities of execution required by the laws of that state, the laws of the state where the principal was located at the time of execution or the laws of this state, ecified by the Department of Human Services by rule. (5) Notwithstanding subsections (2) to (4) of this section, an advance directive executed by an adult who at the time of execution resided in anotha patient in a long term care facility at the time the advance directive is executed, one of the witnesses must be an individual designated by the facility and having any qualifications that may be spact for health care or alternative attorney-in-fact may not be a witness. The principal's attending physician at the time the advance directive is signed may not be a witness. (e) If the principal is he principal upon death under any will or by operation of law; or -1- (C) An owner, operator or employee of a health care facility where the principal is a patient or resident. (d) The attorney-in-fbe a person who is not: (A) A relative of the principal by blood, marriage or adoption; (B) A person who at the time the advance directive is signed would be entitled to any portion of the estate of t the principal's acknowledgment of the signature of the principal. (b) Each witness shall make the written declaration as set forth in the form provided in ORS 127.531. (c) One of the witnesses shall he principal's signature. To be valid, an advance directive must be witnessed by at least two adults as follows: (a) Each witness shall witness either the signing of the instrument by the principal orn the form provided by Part C of the advance directive form set forth in ORS 127.531, or must be in the form provided by ORS 127.610 (1991 Edition). (4) An advance directive must reflect the date of tre must be in the form provided by Part B of the advance directive form set forth in ORS 127.531, or must be in the form provided by ORS 127.530 (1991 Edition). (3) A health care instruction must be i of state. (1) An advance directive may be executed by a resident or nonresident adult of this state in the manner provided by ORS 127.505 to 127.660 and 127.995. (2) A power of attorney for health catatutes relating to the Advance Health Care Directive (Power of Attorney for Health Care and Living Will) Form. 127.515 Manner of executing advance directive; forms; witnesses; directives executed outlth Care Directive (Power of Attorney for Health Care and Living Will) Form is based on Chapter 127 Section 127.005 et. Seq. of the Oregon Statutes. The following are useful excerpts from the Oregon SCare Directive (Power of Attorney for Health Care and Living Will) Form; (2) Oregon Advance Health Care Directive (Power of Attorney for Health Care and Living Will) Form Form. This Oregon Advance HeaInformation and Instructions Oregon Advance Directive for Health Care (Power of Attorney for Health Care & Living Will) This package contains (1) Information and Instruction for Oregon Advance Health Oregon