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Vermont _______ _______________________________________________________ 18 V.S.A. § 5253. ___________________________________________________ Copies of this request have been given to: _______________________________________________________ ______________________________________________________________________________________________________ Date:__________________________________________________________ Witness:________________________________________________________ Witness:___________________________ __________________________________________________________________________________ __________________________________________________________________________________ Signed: __se to whom this will is addressed will regard themselves as morally bound by these provisions. Other directions (optional ­ or write none): ____________________________________________________________ordance with my strong convictions and beliefs. I want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are not legally enforceable, I hope that thoo, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life. This statement is made after careful consideration and is in accwhich I am in a terminal state and there is no reasonable expectation of my recovery, I direct that I be allowed to die a natural death and that my life not be prolonged by extraordinary measures. I d_____________________ , can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes, while I am still of sound mind. If the situation should arise in ecome responsible for my health, welfare or affairs. Death is as much a reality as birth, growth, matur ity and old age- it is the one certainty of life. If the time comes when I, ____________________ound at findlegalforms.com Terminal Care Document (Living Will) To my family, my physician, my lawyer, my clergyman. To any medical facility in whose care I happen to be. To any individual who may batters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use fshould not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning mess. [_]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 point for you and ath. [_] 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 effect or completenegardless of the application of life-saving procedures would, within reasonable medical judgment, produce death and where application of life-sustaining procedures would only postpone the moment of desion-making process. (4) "Physician" means a medical doctor licensed to practice in the state of Vermont. (5) "Terminal state" means an incurable condition caused by injury, disease or illness which rction that no extraordinary measures be taken when the person executing said document is in a terminal state, without hope of recovery from such state and is unable to actively participate in the decit of death and where, in the judgment of the attending physician, the patient is in a terminal state. (3) "Terminal care document" means a document which, when duly executed, contains the express direr artificial means to sustain, restore, or supplant a vital function which, in the judgment of the attending physician, when applied to the patient, would serve only to artificially postpone the momenned to the patient, who has primary responsibility for the treatment and care of the patient. (2) "Extraordinary measures" means any medical procedure or intervention which utilizes mechanical or otheprovided herein. 18 V.S.A. § 5252. (Definitions) The following definitions shall be applicable in the construction of this chapter: (1) "Attending physician" means the physician selected by, or assigthe same or by causing the same to be done by some other person Living Will Information & Instructions ­ Page 2 at his direction and in his presence. A terminal care document may be revoked only as y revoke the same orally in the presence of two or more witnesses, at least one of whom shall not be a spouse or a relative as specified in 15 V.S.A. §§ 1 or 2, or by burning, tearing or obliterating ereof any claims against the estate of the person. 18 V.S.A. § 5257. (Revocation) A person who has validly executed a document consistent with the provisions of sections 5253 and 5254 of this title marson's spouse, heir, reciprocal beneficiary, attending physician or person acting under the direction or control of the attending physician or any other person who has at the time of the witnessing thn and witnesses) The document set forth in section 5253 of this title shall be executed by the person making the same in the presence of two or more subscribing witnesses, none of whom shall be the perolong his life when he is in a terminal state. The document shall only be effective in the event that the person is incapable of participating in decisions about his care. 18 V.S.A. § 5254. (Executiore document) A person of sound mind who is 18 years of age or older may execute at any time a document commonly known as a terminal care document, directing that no extraordinary measures be used to pas a fundamental right to determine whether or not life-sustaining procedures which would cause prolongation of life beyond natural limits, should be used or withdrawn. 18 V.S.A. § 5253. (Terminal cathat his physical state reaches such a point of deterioration that he is in a terminal state and there is no reasonable expectation that life can be continued with dignity and without pain. A person hS.A. § 5251. (Purpose and policy) The state of Vermont recognizes that a person as a matter of right may rationally make an election as to the extent of medical treatment he will receive in the event Terminal Care Document is based on Vermont Statutes Title 18 Chapter 111 Section 5253. For your convenience, we have included useful excerpts from the Vermont Statutes relating to Living Wills. 18 V.re Document (Living Will) This package contains (1) Information and Instruction for Vermont Terminal Care Document (a.k.a. Living Will); (2) Vermont Terminal Care Document (Living Will). This Vermont __ Date: _________________________________________ Address: ______________________________________ Print Name: ____________________________________ 3 Information and Instructions Vermont Terminal Cae that I have personally explained the nature and effect of this durable power of attorney to the principal and that the principal understands the same. Signature: ___________________________________tatement of ombudsman, hospital representative or other authorized person (to be signed only if the principal is in or is being admitted to a hospital, nursing home or residential care home): I declar__________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Sthe nature of the document and is signing it freely and voluntarily. _____________________________________________ (Witness Signature) Print Name: ___________________________________ 2 Address: ____ that the principal appears to be of sound mind and free from duress at the time the durable power of attorney for health care is signed and that the principal has affirmed that he or she is aware of ___________________________ In witness whereof, I have hereunto signed my name this ________. day of ______________, 20 ____ . ___________________________________________________ Signature I declarened copies: _______________________________________________________________________ _______________________________________________________________________ ____________________________________________rstand the information contained in the disclosure statement. The original of this document will be kept at ___________________________________ and the following persons and institutions will have sig____________ (address and telephone numbers) as alternate agent. I hereby acknowledge that I have been provided with a disclosure statement explaining the effect of this document. I have read and undent above is unable, unwilling or unavailable to act as my health care agent, I hereby appoint __________________________________________. (name of Agent) of ___________________________________________t the primary purpose of which is to prolong my life. ____________ (initial) I want my life sustained by any reasonable medical measures, regardless of my condition. In the event the person I appoithe ability to think and act for myself, I want care directed to my comfort and dignity and also want artificial nutrition and hydration if needed, but authorize my agent to decline all other treatmening artificial nutrition and hydration) the primary purpose of which is to prolong my life. 1 ____________ (initial) If I suffer a condition from which there is no reasonable prospect of regaining which there is no reasonable prospect of regaining my ability to think and act for myself, I want only care directed to my comfort and dignity, and authorize my agent to decline all treatment (includSTATEMENTS, YOU MAY IINITIAL THE STATEMENT APPROPRIATE STATEMENT IN THE SPACE PROVIDED (you should delete or cross-out the inapplicable statements): ____________ (initial) If I suffer a condition fromANCE. For your convenience in dealing with that subject, some general statements concerning the withholding or removal of life-sustaining treatment are set forth below. IF YOU AGREE WITH ONE OF THESE ___________________ _______________________________________________________________________ (attach additional pages as necessary) (b) THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR IMPORTon. _______________________________________________________________________ _______________________________________________________________________ ____________________________________________________or discontinue artificial nutrition and hydration; or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs or unacceptable to you for any other reas HEALTH CARE DECISIONS. Here you may include any specific desires or limitations you deem appropriate, such as when or what life-sustaining measures should be withheld; directions whether to continue durable power of attorney for health care shall take effect in the event I become unable to make my own health care decisions. (a) STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS REGARDING of Agent) of _______________________________ (address and telephone numbers)as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. Thisu. 2 Durable Power Of Attorney For Health Care I , ________________________________________________________ (name of Principal) hereby appoint ________________________________________________. (nameent; your health or residential care provider or one of their employees; your spouse; your lawful heirs or beneficiaries named in your will or a deed; creditors or persons who ha ve a claim against yo2) OR MORE QUALIFIED WITNESSES WHO MUST BOTH BE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES: · · · · · the person you have designated as your ag your agent. Any alternate agent you designate will have the same authority to make health care decisions for you. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO (d. If you want to make changes in the document you must make an entirely new one. You may wish to designate an alternate agent in the event that your agent is unwilling, unable or ineligible to act as your objection. You have the right to revoke the authority granted to your agent by informing him or her or your health care provider orally or in writing. This document may not be changed or modifier behalf. Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped overa signed copy. You should indicate on the document itself the people and 1 institutions who will have signed copies. Your agent will not be liable for health care decisions made in good faith on youoth at the same time. You should inform the person you appoint that you want him or her to be your health care agent. You should discuss this document with your agent and your physician and give each or residential care home, other than a relative), that person will have to choose between acting as your agent or as your health or residential care provider; the law does not permit a person to do beone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your physician, or an employee of a home health agency, hospital, nursing home, assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. The person you appoint as agent should be soms which may be made on your behalf. If you do not have a physician, yo u should talk with someone else who is knowledgeable about these issues and can answer your questions. You do not need a lawyer'su would have had. It is important that you discuss this document with your physician or other health care providers before you sign it to make sure that you understand the nature and range of decisiont will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent will have the same authority to make decisions about your health care as yos authority will begin when your doctor certifies that you lack the capacity to make health care decisions. You may attach additional pages if you need more space to complete your statement. Your agen may make decisions about withdrawing or withholding life-sustaining treatment. You may state in this document any treatment you do not desire or treatment you want to be sure you receive. Your agent'ental condition. Your agent therefore can have the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and and all health care decisions for you when you are no longer capable of making them yourself. "Health care" means any treatment, service or procedure to maintain, diagnose or treat your physical or mDOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make anymers and Terms of Use found at findlegalforms.com 3 Vermont Durable Power Of Attorney for Health Care INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY FOR HEALTH CARE THIS IS AN IMPORTANT LEGAL with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaiting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealinggal effect 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 staral's care of the revocation. [_] 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 le durable power of attorney for health care shall immediately record the revocation in the principal's medical record and notify the agent, the attending physician and staff responsible for the principr (3) by the divorce of the principal and spouse, where the spouse is the principal's agent. (b) A principal's health or residential care provider who is informed of or provided with a revocation of aare provider orally, or in writing, or by any other act evidencing a specific intent to revoke the power; (2) by execution by the principal of a subsequent durable power of attorney for health care; o express direction. 14 V.S.A. § 3457. (Revocation) (a) A durable power of attorney for health care shall be revoked: 2 (1) by notification by the principal to the agent or a health or residential cncipal is physically unable to sign, the durable power of attorney for health care may be signed by the principal's name written by some other person in the principal's presence and at the principal'se time the durable power of attorney for health care was signed and that the principal affirmed that he or she was aware of the nature of the documents and signed it freely and voluntarily. If the priny other person who has, at the time of execution, any claims against the estate of the principal. The witnesses shall affirm that the principal appeared to be of sound mind and free from duress at thal's spouse, heir, or reciprocal beneficiary, a person entitled to any part of the estate of the principal upon the death of the principal under a will or deed in existence or by operation of law or af at least two or more subscribing witnesses, neither of whom shall, at the time of execution, be the agent, the principal's health or residential care provider or the provider's employee, the princip an employee of the principal's residential care provider. 14 V.S.A. § 3456. (Execution and witnesses) The durable power of attorney for health care shall be signed by the principal in the presence oare provider; (2) a nonrelative of the principal who is an employee of the principal's health care provider; (3) the principal's residential care provider; or (4) a nonrelative of the principal who is2 of Title 18. 14 V.S.A. § 3455. (Restrictions on who can act as agent) A person may not exercise the authority of agent while serving in one of the following capacities: (1) the principal's health cder" means an individual or facility licensed, certified or otherwise authorized or permitted by law to operate, for profit or otherwise, a residential care home as that term is defined in section 200in the office on aging pursuant to the Older Americans Act of 1965, as amended. (8) "Principal" means an adult who has executed a durable power of attorney for health care. (9) "Residential care proviare, for profit or otherwise, in the ordinary course of business or professional practice. 1 (7) "Ombudsman" means a person appointed as a long-term care ombudsman under the program established withor treat an individual's physical or mental condition. (6) "Health care provider" means an individual or facility licensed, certified or otherwise authorized or permitted by law to administer health ccordance with the provisions of this chapter. (5) "Health care decision" means consent, refusal to consent, or withdrawal of consent to any care, treatment, service or procedure to maintain, diagnose reasonable alternatives to any proposed health care. (4) "Durable power of attorney for health care" means a document delegating to an agent the authority to make health care decisions executed in ac. (3) "Capacity to make health care decisions" means the ability to understand and appreciate the nature and consequences of a health care decision, including the significant benefits and harms of anddurable power of attorney for health care. (2) "Attending physician" means the physician, selected by or assigned to a patient, who has primary responsibility for the treatment and care of the patient make health care decisions on their beha lf. 14 V.S.A. § 3452. (Definitions) As used in this chapter: (1) "Agent" means an adult to whom authority to make health care decisions is delegated under a 451. (Statement of purpose) The purpose of this chapter is to enable adults to retain control over their own medical care during periods of incapacity through the prior designation of an individual totutes Title 14 Chapter 121 Section 3466. For your convenience, we have included useful excerpts from the Vermont Statutes relating to the Durable Power Of Attorney For Health Care Form. 14 V.S.A. § 3lating to the Durable Power Of Attorney For Health Care Form; (2) Vermont Durable Power Of Attorney For Health Care Form. This Vermont Durable Power Of Attorney For Health Care is based on Vermont Sta Durable Power Of Attorney For Health Care This package contains (1) Informa tion and Instruction for Vermont Durable Power Of Attorney For Health Care, including excerpts from the Vermont Statutes rent should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Vermontt to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this documer legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney firsress warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute folth Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Terminal Care Document (Living Will). [_] These forms are provided "as is" and no implied or expVermont Advance Health Care Directive This package contains both a Vermont Power of Attorney for Health Care and a Vermont Living Will. Together these forms are also sometimes known as an Advance Hea Vermont