Vermont Advance Directive for Health Care

• 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 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.
  
  
• 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 and go directly to Part Five to sign this in the presence of appropriate witnesses. 
  
  
• You are also free to use a different form as long as it is properly signed and witnessed. 

Instructions and Explanations

Part One of this form lets you name a person as your “agent” to make health care decisions for you if you become unable to make your own decisions, or earlier if you indicate when you want the Agent's authority to start, including when your Advance Directive is signed.  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.  They should know you and be guided by your values in making choices for you. 

You should notify your agent and alternates 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 you are unable to make your own decisions, unless you specify an earlier time or condition that gives your Agent authority to make health care decisions for you.

If you do not appoint an agent, and then become unable to make your own decisions, someone may be found 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 specific wishes based on your values, health condition or beliefs.

Part Three of this form lets you express your wishes about organ or tissue donation.

Part Four is for you to express your wishes about disposition of your remains.                                                                                    

Part Five of this form is for signatures. You must sign and date the form in the presence of two witnesses. The following persons may not serve as witnesses: your agent and alternate agents, your spouse or partner or your heirs.

You should give copies of the completed form to your agent and alternate agent, to your physician(s), your family and to any health care facility where you reside or at which you are likely to receive care. You should keep a list of those who have copies in case you revoke or revise the document in the future.  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 should be destroyed.

You should also file your Advance Directive with the Vermont Advance Directive Registry (VADR) to access it go to the VT Health Department's website: http://healthvermont.gov/vadr/

You may wish to read the booklet Taking Steps by the Vermont Ethics Network to help you think about and discuss different choices and situations with your agent or loved ones. You can reach them by calling 802-828-2909 or by e-mail vtethicsnetwork@silicondairy.net. Forms may also be downloaded from their website, www.vtehticsnetwork.org.

Download your own Advance Directive for Healthcare (pdf)

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