The following form may be used to create an Advance Health-Care Directive. Sections 41-41-201 through 41-41-207 and 41-41-211 through 41-41-229 govern the effect of this or any other writing used to create an advanced health-care directive. An individual may complete or modify all or any part of the following form:
ADVANCE HEALTH-CARE DIRECTIVE
Explanation
You have the right to give instructions about your own health care. You also have the right to name someone else to make health-care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.
Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health-care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator, or employee of a residential long-term health-care institution at which you are receiving care.
Unless the form you sign limits the authority of your agent, your agent may make all health-care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health-care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to:
Part 2 of this form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration, as well as the provision of pain relief. Space is provided for you to add to the choices you have made or for you to write out any additional wishes.
Part 3 of this form lets you designate a physician to have primary responsibility for your health care.
Part 4 of this form lets you authorize the donation of your organs at your death, and declares that this decision will supersede any decision by a member of your family.
After completing this form, sign and date the form at the end and have the form witnessed by one of the two alternative methods listed below. Give a copy of the signed and completed form to your physician, to any other health-care providers you may have, to any health-care institution at which you are receiving care, and to any health-care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility.
You have the right to revoke this advance health-care directive or replace this form at any time.
PART 1
POWER OF ATTORNEY FOR HEALTH CARE
____________________
(name of individual you choose as agent)
____________________
(address) (city) (state) (zip code)
____________________
(home phone) (work phone)
OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health-care decision for me, I designate as my first alternate agent:
____________________
(name of individual you choose as first alternate agent)
____________________
(address) (city) (state) (zip code)
____________________
(home phone) (work phone)
OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a health-care decision for me, I designate as my second alternate agent:
____________________
____________________
(name of individual you choose as second alternate agent)
____________________
(address) (city) (state) (zip code)
____________________
(home phone) (work phone)
____________________
____________________
____________________
(Add additional sheets if needed.)
PART 2
INSTRUCTIONS FOR HEALTH CARE
If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out this part of the form. If you do fill out this part of the form, you may strike any wording you do not want.
[ ] (a) Choice Not To Prolong Life
I do not want my life to be prolonged if (i) I have an incurable and irreversible condition that will result in my death within a relatively short time, (ii) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (iii) the likely risks and burdens of treatment would outweigh the expected benefits, or
[ ] (b) Choice To Prolong Life
I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
____________________
____________________
____________________
____________________
(Add additional sheets if needed.)
PART 3
PRIMARY PHYSICIAN
(OPTIONAL)
____________________
(name of physician)
____________________
(address) (city) (state) (zip code)
____________________
(phone)
OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I designate the following physician as my primary physician:
____________________
(name of physician)
____________________
(address) (city) (state) (zip code)
____________________
(phone)
____________________ ____________________
(date) (sign your name)
____________________ ____________________
(address) (print your name)
____________________
(city) (state)
PART 4
CERTIFICATE OF AUTHORIZATION FOR ORGAN DONATION
(OPTIONAL)
I, the undersigned, this ____________________ day of ____________________, 20____________________, desire that my ____________________ organ(s) be made available after my demise for:
____________________ (address).
I authorize a licensed physician or surgeon to remove and preserve for use my ____________________ for that purpose.
I specifically provide that this declaration shall supersede and take precedence over any decision by my family to the contrary.
Witnessed this ____________________ day of ____________________, 20____________________.
____________________
(donor)
____________________
(address)
____________________
(telephone)
____________________
(witness)
____________________
(witness)
ALTERNATIVE NO. 1
Witness
I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code of 1972, that the principal is personally known to me, that the principal signed or acknowledged this power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as agent by this document, and that I am not a health-care provider, nor an employee of a health-care provider or facility. I am not related to the principal by blood, marriage or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.
____________________ ____________________
(date) (signature of witness)
____________________ ____________________
(address) (printed name of witness)
____________________
(city) (state)
Witness
I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code of 1972, that the principal is personally known to me, that the principal signed or acknowledged this power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as agent by this document, and that I am not a health-care provider, nor an employee of a health-care provider or facility.
________________________________________
(date) (signature of witness)
____________________ ____________________
(address) (printed name of witness)
____________________
(city) (state)
ALTERNATIVE NO. 2
State of ____________________
County of ____________________
On this ____________________ day of ____________________, in the year ____________________, before me, ____________________ (insert name of notary public) appeared ____________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it. I declare under the penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud or undue influence.
Notary Seal
____________________
(Signature of Notary Public)
Miss. Code § 41-41-209