An Idaho advance directive is a form that allows a person to legally document their medical preferences and to designate someone to make medical decisions on their behalf. In Idaho, the document is bundled into a living will. The document is often useful in case of mental incapacitation or serious illness.
Signing Requirements (§ 39-4510) – Only the principal.
Statutory Form
LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE
Date of Directive: [DAY] day of [MONTH], 20[XX]
Name of person executing Directive: [NAME]
Address of person executing Directive: [ADDRESS, CITY, STATE, ZIP CODE]
A LIVING WILL
I willfully and voluntarily make known my desire that my life shall not be prolonged artificially under the circumstances set forth below. This Directive shall only be effective if I am unable to communicate my instructions and:
- I have an incurable or irreversible injury, disease, illness or condition, and a medical doctor who has examined me has certified:
- That such injury, disease, illness or condition is terminal; and
- That the application of artificial life-sustaining procedures would serve only to prolong artificially my life; and
- That my death is imminent, whether or not artificial life-sustaining procedures are utilized; or
- I have been diagnosed as being in a persistent vegetative state. In such event, I direct that the following marked expression of my intent be followed, and that I receive any medical treatment or care that may be required to keep me free of pain or distress.
- □ I direct that all medical treatment, care and procedures necessary to restore my health and sustain my life be provided to me. Nutrition and hydration, whether artificial or nonartificial, shall not be withheld or withdrawn from me if I would likely die primarily from malnutrition or dehydration rather than from my injury, disease, illness or condition.
- □ I direct that all medical treatment, care and procedures, including artificial life-sustaining procedures, be withheld or withdrawn, except that nutrition and hydration, whether artificial or nonartificial shall not be withheld or withdrawn from me if, as a result, I would likely die primarily from malnutrition or dehydration rather than from my injury, disease, illness or condition, as follows:
- □ Only hydration of any nature, whether artificial or nonartificial, shall be administered;
- □ Only nutrition, of any nature, whether artificial or nonartificial, shall be administered;
- □ Both nutrition and hydration, of any nature, whether artificial or nonartificial shall be administered.
- □ I direct that all medical treatment, care and procedures be withheld or withdrawn, including withdrawal of the administration of artificial nutrition and hydration.
If I have been diagnosed as pregnant, this Directive shall have no force during the course of my pregnancy.
I understand the full importance of this Directive and am mentally competent to make this Directive. No participant in the making of this Directive or in its being carried into effect shall be held responsible in any way for complying with my directions.
- □ I have discussed these decisions with my physician, advanced practice professional nurse or physician assistant and have also completed a Physician Orders for Scope of Treatment (POST) form that contains directions that may be more specific than, but are compatible with, this Directive. I hereby approve of those orders and incorporate them herein as if fully set forth.
- □ I have not completed a Physician Orders for Scope of Treatment (POST) form. If a POST form is later signed by my physician, advanced practice professional nurse or physician assistant, then this living will shall be deemed modified to be compatible with the terms of the POST form.
A DURABLE POWER OF ATTORNEY FOR HEALTH CARE
1. DESIGNATION OF HEALTH CARE AGENT. None of the following may be designated as your agent: (1) your treating health care provider; (2) a nonrelative employee of your treating health care provider; (3) an operator of a community care facility; or (4) a nonrelative employee of an operator of a community care facility.
I do hereby designate and appoint the following individual as my attorney in fact (agent) to make health care decisions for me as authorized in this Directive.
Name of Health Care Agent: [NAME]
Address of Health Care Agent: [ADDRESS, CITY, STATE, ZIP CODE]
Telephone Number of Health Care Agent: [PHONE]
2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this portion of this Directive, I create a durable power of attorney for health care. This power of attorney shall not be affected by my subsequent incapacity. This power shall be effective only when I am unable to communicate rationally.
3. GENERAL STATEMENT OF AUTHORITY GRANTED. I hereby grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this Directive or otherwise made known to my agent.
4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. In exercising the authority under this durable power of attorney for health care, my agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated in my Physician Orders for Scope of Treatment (POST) form, a living will, or similar document executed by me, if any.
5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH.
General Grant of Power and Authority. Subject to any limitations in this Directive, my agent has the power and authority to do all of the following: (1) Request, review and receive any information, verbal or written, regarding my physical or mental health including, but not limited to, medical and hospital records; (2) Execute on my behalf any releases or other documents that may be required in order to obtain this information; (3) Consent to the disclosure of this information; and (4) Consent to the donation of any of my organs for medical purposes.
6. SIGNING DOCUMENTS, WAIVERS AND RELEASES. Where necessary to implement the health care decisions that my agent is authorized by this Directive to make, my agent has the power and authority to execute on my behalf all of the following: (a) Documents titled, or purporting to be, a “Refusal to Permit Treatment” and/or a “Leaving Hospital Against Medical Advice”; and (b) Any necessary waiver or release from liability required by a hospital or physician.
7. DESIGNATION OF ALTERNATE AGENTS. If the person designated as my agent in paragraph 1 is not available or becomes ineligible to act as my agent to make a health care decision for me or loses the mental capacity to make health care decisions for me, or if I revoke that person’s appointment or authority to act as my agent to make health care decisions for me, then I designate and appoint the following persons to serve as my agent to make health care decisions for me as authorized in this Directive, such persons to serve in the order listed below:
Alternate Agent:
Name [NAME]
Address [ADDRESS, CITY, STATE, ZIP CODE]
Telephone Number [PHONE NUMBER]
8. PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney for health care.
I sign my name to this Statutory Form Living Will and Durable Power of Attorney for Health Care on the date set forth at the beginning of this Form at [CITY], [STATE] (City, State).
I sign my name to this Statutory Form Living Will and Durable Power of Attorney for Health Care on the date set forth at the beginning of this Form at [CITY], [STATE] (City, State).
_______________________________________ [DAY] day of [MONTH], 20[XX]
Signature
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