GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE

By: [NAME]

Date of Birth: [DAY] day of [MONTH], [YEAR]

(1) Health Care Agent

I select the following person as my health care agent to make health care decisions for me:

Name: [NAME]

Address: [ADDRESS, CITY, STATE, ZIP CODE]

Telephone Numbers: ([HOME PHONE, WORK PHONE, and MOBILE PHONE])

(2) General Powers of Health Care Agent

My health care agent will make health care decisions for me when I am unable to communicate my health care decisions or I choose to have my health care agent communicate my health care decisions. My health care agent will be my personal representative for all purposes of federal or state law related to privacy of medical records (including the Health Insurance Portability and Accountability Act of 1996) and will have the same access to my medical records that I have and can disclose the contents of my medical records to others for my ongoing health care.

(3) Guidance for Health Care Agent

When making health care decisions for me, my health care agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in this document, my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then my health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.

(4) Powers of Health Care Agent After Death

(A) My health care agent will have the power to authorize an autopsy of my body unless I have limited my health care agent’s power by initialing below. (Initials) My health care agent will not have the power to authorize an autopsy of my body (unless an autopsy is required by law).

(B) My health care agent will have the power to make a disposition of any part or all of my body for medical purposes pursuant to the Georgia Revised Uniform Anatomical Gift Act, unless I have limited my health care agent’s power by initialing below.

• • ([INITIALS]) My health care agent will not have the power to make a disposition of my body for use in a medical study program.
  • ([INITIALS]) My health care agent will not have the power to donate any of my organs.

(C) My health care agent will have the power to make decisions about the final disposition of my body unless I have initialed below.

• • ([INITIALS]) I want the following person to make decisions about the final disposition of my body:
    Name: Address: Telephone Numbers: (Home, Work, and Mobile)
  • I wish for my body to be: ([INITIALS]) Buried OR ([INITIALS]) Cremated

(5) Conditions

Effective if I am in any of the following conditions:

• ([INITIALS]) A terminal condition, which means I have an incurable or irreversible condition that will result in my death in a relatively short period of time.
• ([INITIALS]) A state of permanent unconsciousness, which means I am in an incurable or irreversible condition in which I am not aware of myself or my environment and I show no behavioral response to my environment.

(7) Treatment Preferences

If I am in any condition that I initialed in Section (5) above and I can no longer communicate my treatment preferences after reasonable and appropriate efforts have been made to communicate with me about my treatment preferences, then:

(A) ([INITIALS]) Try to extend my life for as long as possible, using all medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means.

(B) ([INITIALS]) Allow my natural death to occur. I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication.

(C) ([INITIALS]) I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me, except as follows:

• • ([INITIALS]) If I am unable to take nutrition by mouth, I want to receive nutrition by tube or other medical means.
  • ([INITIALS]) If I am unable to take fluids by mouth, I want to receive fluids by tube or other medical means.
  • ([INITIALS]) If I need assistance to breathe, I want to have a ventilator used.
  • ([INITIALS]) If my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR) used.

EFFECTIVENESS AND SIGNATURES

This advance directive for health care will become effective only if I am unable or choose not to make or communicate my own health care decisions. This form revokes any advance directive for health care, durable power of attorney for health care, health care proxy, or living will that I have completed before this date.

([INITIALS]) This advance directive for health care will become effective on or upon and will terminate on or upon [DAY] day of [MONTH], 20[XX].

By signing below, I state that I am emotionally and mentally capable of making this advance directive for health care and that I understand its purpose and effect.

Signature of Declarant: ____________________________
[DAY] day of [MONTH], 20[XX]

The declarant signed this form in my presence or acknowledged signing this form to me. Based upon my personal observation, the declarant appeared to be emotionally and mentally capable of making this advance directive for health care and signed this form willingly and voluntarily.

Signature of First Witness: __________________________
[DAY] day of [MONTH], 20[XX]
Print Name: ____________________________________
Address: ______________________________________

Signature of Second Witness: ________________________
[DAY] day of [MONTH], 20[XX]
Print Name: ____________________________________
Address: ______________________________________