Vermont Advance Directive For Health Care

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Vermont Advance Directive
for Health Care
Prepared by the Vermont Ethics Network
Explanation and Instructions
• You have the right to give instructions about what types
of health care you want or do not want.
• You also have the right to name someone else to make health care decisions
for you when you are unable to make them yourself. You may also have that person’s
authority begin immediately or on the occurrence of an event or condition.
• You may do either of these by telling your family or your doctor, but it is generally better
for you and your family if you write down your wishes in an Advance Directive.
• You may use this form in its entirety or you may use any part of it.
For example, if you simply want to choose an agent in Part One, you may do so
Part One, you may do so
Part One
and go directly to Part Five to sign this in the presence of appropriate witnesses.
Part Five to sign this in the presence of appropriate witnesses.
Part Five
• You are also free to use a diff erent form as long as it is properly signed and witnessed.
Part One of this form lets you name a person as your
Part One of this form lets you name a person as your
Part One
“agent” to make health care decisions
for you if you become unable or unwilling to make your own decisions. You may also name co-
agents or alternate agents. You should choose as your agent (and alternates) people you trust,
who are going to be comfortable making what might be hard decisions on your behalf. Th ey
should know you and be guided by your values in making choices for you.
You should notify your agents that you have named them, and they need to agree to act as your
agent if asked to do so. Your agent does not have authority to make decisions for you until the
time you specify or when you are unable to make your own decisions.
If you do not appoint an agent, and then become unable to make your own decisions, someone
else will need to make health care decisions for you.
Part Two of this form lets you state Treatment Wishes. Choices are provided for you to express
your wishes about having, not having, or stopping treatment necessary to keep you alive under
certain circumstances. Space is also provided for you to write out any additional or specifi c
wishes based on your values, health condition, or beliefs.

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