A Wyoming advance directive is a form an individual can use to express preferences for medical care and treatment and designate a trusted person to ensure those preferences are honored. This is used in the event of an emergency that causes the mental incapacitation of the principal. The form should be reviewed periodically.
Statutory Form
- Statute: § 35-22-405
- Download: Adobe PDF
PART 1
POWER OF ATTORNEY FOR HEALTH CARE
(1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me:
[NAME]
(2) AGENT’S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to provide, withhold or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:
[EXCEPTIONS]
(3) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority becomes effective when my supervising health care provider determines that I lack the capacity to make my own health care decisions unless I initial the following box.
If I initial this box [◻], my agent’s authority to make health care decisions for me takes effect immediately.
(4) AGENT’S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.
PART 2
INSTRUCTIONS FOR HEALTH CARE
(5) END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with the choice I have initialed below:
[◻] (a) Choice Not To Prolong Life
[◻] (b) Choice To Prolong Life
(6) ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutrition and hydration must be provided, withheld or withdrawn in accordance with the choice I have made in paragraph (6) unless I initial the following box.
If I initial this box [◻], artificial nutrition must be provided regardless of my condition and regardless of the choice I have made in paragraph (6).
If I initial this box [◻], artificial hydration must be provided regardless of my condition and regardless of the choice I have made in paragraph (6).
(7) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort be provided at all times: [EXCEPTIONS]
EFFECT OF COPY: A copy of this form has the same effect as the original.
SIGNATURES: Sign and date the form here:
Signature: ________________________________
Date: [DAY] day of [MONTH], 20[XX]
Adobe PDF