A Vermont advance directive is a form that allows someone to designate someone else to make healthcare decisions on their behalf. The designated person, known as a healthcare agent, is authorized by the form to direct the type of healthcare desired or not desired by the principal. The agent can make decisions about everything ranging from ending life-sustaining treatment to organ donation.
Sample
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Appointment of a Health Care Agent
Vermont Advance Directive for Health Care Decisions
YOUR NAME [NAME]
AGENT NAME [NAME]
ALTERNATE AGENT NAME [NAME]
Your health care agent can make health care decisions for you when you are unable or unwilling to make decisions for yourself. You should pick someone that you trust, who understands your wishes and agrees to act as your agent. Your health care provider may NOT be your agent unless they are a relative. Your agent may NOT be the owner, operator, employee or contractor of a residential care facility, health care facility or correctional facility where you reside at the time your advance directive is completed. I appoint this person to be my health care AGENT:
[NAME]
If this agent is unavailable, unwilling or unable to act as my agent, I appoint this person as my ALTERNATE AGENT:
[NAME]
SIGNATURE: ________________________________________________________
DECLARATION OF WISHES
You must sign this before TWO adult witnesses. The following people may not sign as witnesses: your agent(s), spouse, parents, siblings, children or grandchildren. I declare that this document reflects my health care wishes and that I am signing this Advance Directive of my own free will. I affirm that the signer appeared to understand the nature of this advance directive and to be free from duress or undue influence at the time this was signed.
(Please sign and print)
If the person signing this document is being admitted to or is a current patient in a hospital, one of the following must sign and affirm that they have explained the nature and effect of the advance directive and the patient appeared to understand and be free from duress or undue influence at the time of signing: designated hospital explainer, ombudsman, mental health patient representative, recognized member of the clergy, Vermont attorney, or Probate Court designee. If the person signing this document is being admitted to or is a resident in a nursing home or residential care facility, one of the following must sign and affirm that they have explained the nature and effect of the advance directive and the resident appeared to understand and be free from duress or undue influence at the time of signing: an ombudsman, recognized member of the clergy, Vermont attorney, Probate Court designee, designated hospital explainer, mental health patient representative, clinician not employed by the facility, or appropriately trained nursing home/residential care facility volunteer. The explainer as outlined above may also serve as one of the two required witnesses.
FIRST WITNESS: _____________________________________________________
SECOND WITNESS: ___________________________________________________
Adobe PDF