Vermont Advance Health Care Directive(Living Will) Form

The Vermont advance health care directive(living will) is  is an “Advance Directive” document that would allow an individual,(Principal), while of sound mind, may plan in advance, how they wish to direct their physicians and health care representative(s) with information pertaining to their end of life choices.

In the event the Principal hasn’t appointed a health care agent,this document will allow the Principal to select someone they trust to assist their health care providers with decision making processes, when they are no longer able to competently communicate their own decisions. This document must be witnessed before it would be effective. The Principal may revoke this document at any time.

Laws – Title 18, Chapter 231 (Advance Directives For Health Care And Disposition Of Remains)

How to Write

Step 1 – Download the document – The Principal must read pages 1 through 3

Step 2 – Begin the completion of the form on page four (4) by submitting the following:

  • The Principal’s name
  • Date of Birth in mm/dd/yyyy format
  • Date of execution of the document
  • Street Address
  • City, State, Zip Code
  • Phone number
  • E mail address

Step 3 – Health Care Agent –

  • Read statements 1 through 4 and respond accordingly
  • Be certain to include all of the information required for each agent appointed

Step 4 – Appointment of Co-Agents – If the Principal would like to have agents who will act together in their health care decisions:

  • The Principal may appoint the agents in number 5
  • By entering 1,2 or 3 arrange the order in how the agents would act
  • If the Principal has other instructions for their agent(s) enter them into the lines provided

Step 5 – Part 2 – Other’s involved in the care of the Principal

  • Begin this section by reading the first page of Part 2
  • Place the Principal’s name, date of birth and date of the document at the top of the page
  • Enter the Doctor(s) following information
  • Doctor’s name
  • Address
  • Phone
  • AND
  • Other people who may be consulted about the principal’s medical decisions
  • AND
  • Names of those who should  not  be consulted by agents
  • AND
  • Enter the names of those the the physicians and/or health care agent may release the principal’s medical information to
  • AND
  • Enter the name(s) of those who may not bring legal action on behalf of the Principal – Name and Address
  • AND
  • If a guardian must be appointed by order of the courts, initial one of the choices and place their name, address and phone numbers in the spaces provided
  • The Principal may also enter other preferred guardians OR Persons the Principal will not wish to be their guardians

Step 6 – Statement of Value and Goals –

  • Read the first page in this section
  • Read each statement and respond in the lines below the statements

Step 7 – End of Life Treatment Wishes –

  • Read the first page of this section
  • Read the statement at the top of the next page
  • Select and initial all of the statements that apply
  • At the end of the page, enter any other wishes and instructions

Step 8 – Other Treatment Wishes –

  • Begin by carefully reading the 1st page of part 5
  • Read all statements in numbers 1 through 9-B. Select and initial from the responses provided

Step 9 – Waiver of Right to Request or Object to Future Treatment –

  • Begin by entering the name of the Agent into the first paragraph
  • Read statements 1 through 4 and respond according to the Principal’s wishes
  • At the bottom of this page, the Principal must provide their signature and date of their signature in mm/dd/yyyy format

Step 10 – Acknowledgements – The following people must read the statement and complete the information under each:

  • Agent’s acknowledgement
  • Principal’s Clinician’s acknowledgement
  • Acknowledgement of the person(s) who explain the document’s sections

Step 11 – Organ and Tissue Donations –

  • The Principal must read the first page of the section
  • Read the statement
  • Initial all of the selections that apply
  • Should the Principal choose not to donate simply initial the last line on the page only

Step 12 – Disposition of Body After Death (Optional) – If the Principal has made arrangements and chooses not to complete this section, leave it blank, otherwise

  • Read the statements in 1 through 4 and respond accordingly

Step 13  – Signatures and Witnesses – Before proceeding in this section, carefully read “Instructions for Part 9”  –

  • The Principal must read the bold statement at the top of the page, if in agreement:
  • Provide Principal’s signature
  • Date the signature in mm/dd/yyyy format
  • AND
  • Read the optional statements. If agreed, provide the principal’s signature and date the signature in mm/dd/yyyy format

Acknowledgement of Witnesses –

  • Witnesses must read the statement. If in agreement, enter the following:
  • Witnesses Signatures
  • Date of Signatures in mm/dd/yyyy format

Acknowledgement of the Person Who Explained the Document:

  • Read the statements, if in agreement enter the following
  • Name
  • Title or Position
  • Address
  • Telephone Number
  • Date of Signature in mm/dd/yyyy format

Step 14 – Enter the names of the persons who will possess copies of the document

  • Name
  • Address
  • Physician’s name and address
  • If there are other individuals or locations list them on the lines

 

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