Fillable Vermont Advance Directive For Health Care (Page 2 of 8) in pdf

Vermont Advance Directive For Health Care Page 2

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Vermont Advance Directive Explanation and Instructions

treatment unless they have a signed DNR/COLST

order specifying some limitation of treatment. If there

is no DNR/COLST order the emergency medical

team will perform CPR as they will not have time to

consult an Advance Directive, your family, agent, or

physician.

Part FOUR of this form allows you to express your

wishes related to organ/tissue donation & prefer-

ences for funeral, burial and disposition of your

remains.

Taking Steps

Part FIVE is for signatures. You must sign and date

Planning for Critical

the form in the presence of two adult witnesses. The

Health Care Decisions

following persons may not be witnesses: your agent

Vermont Advance Directive

and alternate agents; your spouse or partner; parents;

for Health Care included

siblings; reciprocal beneficiary; children or grand-

A Publication of the

children.

Vermont Ethics Network

You should give copies of the completed form to your

agent and alternate agent(s), to your physician, your

You may wish to read the booklet Taking Steps

family and to any health care facility where you reside

to help you think about and discuss different

or at which you are likely to receive care. Please note

choices and situations with your agent(s) or

who has a copy of your Advance Directive so it may

loved ones.

be updated if your preferences change.

Copies of Taking Steps can be purchased from:

You are also encouraged to send a copy of your

Vermont Ethics Network

Advance Directive to the Vermont Advance Directive

61 Elm Street

Registry with the Registration Agreement Form found

Montpelier, VT 05602.

at the end of this document.

Tel: (802) 828-2909

Fax: (802) 828-2646

You have the right to revoke all or part of this

Advance Directive for Health Care or replace this

form at any time. If you do revoke it, all old copies

For information about the Vermont Advance

should be destroyed. If you make changes and have

Directive Registry visit:

sent a copy of your original document to the Vermont

VEN website:

Advance Directive Registry, be sure to send them a

new copy or a notification of change form with infor-

Registry website at the Vermont Department

mation needed to update your Advance Directive

of Health:

there.

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Vermont Advance Directive For Health Care Page 2

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