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Embarking on the journey of preparing for future healthcare decisions is met with the creation of an essential document, known as the Vermont Advance Directive for Health Care. Crafted with care by the Vermont Ethics Network, this directive serves as a comprehensive guide, empowering individuals to make preemptive choices about their medical care and appoint a trusted agent, or substitute decision-maker, in times when they may not be able to articulate their desires directly. It doesn't merely stop at naming an agent; the form delves into the specifics, allowing individuals to express their healthcare objectives, be it aggressively pursuing all forms of treatment or opting for comfort care in the final stages of life. With thoughtful sections dedicated to treatment goals, spiritual wishes, and limitations, such as CPR, mechanical ventilation, and feeding tubes, the document respects the spectrum of personal values and health beliefs. The directive even addresses the matter of post-life decisions, including organ donation and funeral arrangements, ensuring individuals' wishes are honored in their entirety. Additionally, by making provisions for these preferences to be legally recognized, the form necessitates witnessing by two unrelated adults to underscore its validity, thereby encouraging discussions around these often sensitive topics with family, healthcare providers, and appointed agents. This dialogue ensures that when the directive takes effect—be it immediately upon signing or only when the individual is incapacitated—there exists a clear path forward that honors the person's values and medical care preferences.

Preview - Vermont Directive Health Care Form

Vermont Advance Directive for Health Care

Prepared by the Vermont Ethics Network

EXPLANATION & INSTRUCTIONS

■You have the right to:

1.Name someone else to make health care decisions for you when or if you are unable to make them yourself.

2.Give instructions about what types of health care you want or do not want.

■It is important to talk with those people closest to you and with your health care providers about your goals, wishes and preferences for treatment.

■You may use this form in its entirety or you may use any part of it. For example, if you only want to choose an agent in Part One, you may fill out just that section and then go to Part Five to sign in the presence of appropriate witnesses.

■You are free to use another form so long as it is properly witnessed. More detailed forms providing greater options and information regarding mental health care preference can be found on the VEN website at www.vtethicsnetwork.org.

Part ONE of this form allows you to name a person as your “agent” to make health care decisions for you if you become unable or unwilling to make your own decisions. You may also name alternate agents. You should choose someone you trust, who will be com- fortable making what might be hard decisions on your behalf. They should be guided by your values in making choices for you and agree to act as your agent. You may fill out the Advance Directive form stating your medical preferences even if you do not identify an agent. Medical providers will follow your directions in the Advance Directive without an agent to their best ability, but having a person designated as your agent to make decisions for you will help medical providers and those who care for you make the best decisions in situ- ations that may not have been detailed in your Advance Directive. According to Vermont law, next-of-kin will not automatially make decisions on your behalf if you are unable to do so. That is why it is best to appoint some- one of your choosing in advance.

Part TWO of this form lets you state Treatment Goals & Wishes. Choices are provided for you to express your wishes about having, not having, or stopping treatment under certain circumstances. Space is also provided for you to write out any additional or specific wishes based on your values, health condition or beliefs.

Part THREE of this form lets you express your wishes about Limitations of Treatment. These treatments include CPR, breathing machines, feeding tubes, and antibiotics. There is space for you to write any addition- al wishes. NOTE: If you DO NOT want CPR, a breathing machine, a feeding tube, or antibiotics, please discuss this with your doctor, who can complete a DNR/COLST order (Do Not Resuscitate/Clinician Order for Life Sustaining Treatment) to ensure that you do not receive treatments you do not want, especially in an emer- gency. Emergency Medical Personnel are required to provide you with life-saving treatment unless they have a signed DNR/COLST order specifying some limitation

Vermont Advance Directive Explanation and Instructions

of treatment. If there is no DNR/COLST order the emer- gency medical team will perform CPR as they will not have time to consult an Advance Directive, your family, agent, or physician.

Part FOUR of this form allows you to express your wish- es related to organ/tissue donation & preferences for funeral, burial and disposition of your remains.

Part FIVE is for signatures. You must sign and date the form in the presence of two adult witnesses. The fol- lowing persons may not be witnesses: your agent and alternate agents; your spouse or partner; parents; sib- lings; children or grandchildren.

You should give copies of the completed form to your agent and alternate agent(s), to your physician, your family and to any health care facility where you reside or at which you are likely to receive care. Please note who has a copy of your Advance Directive so it may be updated if your preferences change.

You are also encouraged to send a copy of your Advance Directive to the Vermont Advance Directive Registry with the Registration Agreement Form found at the end of this document.

You have the right to revoke all or part of this Advance Directive for Health Care or replace this form at any time. If you do revoke it, all old copies should be destroyed. If you make changes and have sent a copy of your original document to the Vermont Advance Directive Registry, be sure to send them a new copy or a notification of change form with information needed to update your Advance Directive there.

You may wish to read the booklet Taking Steps to help you think about and discuss different choices and situations with your agent(s) or loved ones.

Copies of Taking Steps can be purchased from:

Vermont Ethics Network

61 Elm Street

Montpelier, VT 05602.

Tel: (802) 828-2909

Fax: (802) 828-2646

www.vtethicsnetwork.org

For information about the Vermont Advance Directive Registry visit:

VEN website: www.vtethicsnetwork.org

or

Registry website at the Vermont Department of Health: www.healthvermont.gov/vadr

Vermont Advance Directive for Health Care

YOUR NAME

ADDRESS

CITY

 

DATE OF BIRTH

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART ONE: YOUR HEALTH CARE AGENT

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:

AGENT NAME

ADDRESS

EMAIL

HOME PHONE

 

WORK PHONE

 

 

 

(If you appoint CO-AGENTS, list them on a separate sheet of paper)

CELL PHONE

If this agent is unavailable, unwilling or unable to act as my agent, I appoint this person as my ALTERNATE AGENT:

ALTERNATE AGENT NAME

EMAIL

ADDRESS

HOME PHONE

WORK PHONE

CELL PHONE

Others who may be consulted about medical decisions on my behalf include:

Primary care provider (Physician, PA or Nurse Practitioner):

NAME

PHONE

ADDRESS

NAME

PHONE

ADDRESS

Those who should NOT be consulted include:

(PART ONE CONTINUED NEXT PAGE)

12/18

 

ADVANCE DIRECTIVE, PAGE 2

NAME

DOB

DATE

I want my Advance Directive to start:

When I cannot make my own decisions

Now

When this happens:

PART TWO: HEALTH CARE GOALS AND SPIRITUAL WISHES

My overall health care goals include:

I want to have my life sustained as long as possible by any medical means.

I want treatment to sustain my life only if I will:

be able to communicate with friends and family. be able to care for myself.

live without incapacitating pain.

be conscious and aware of my surroundings.

I only want treatment directed toward my comfort.

Additional Goals, Wishes, or Beliefs I wish to express include:

People to notify if I have a life-threatening illness:

If I am dying it is important for me to be (check choice):

At home

In the hospital

Other:

No preference

My Spiritual Care Wishes include:

My Religion/Faith:

PLACE OF WORSHIP

PHONE

ADDRESS

The following items or music or readings would be a comfort to me:

12/18

ADVANCE DIRECTIVE, PAGE 3

NAME

DOB

DATE

PART THREE: LIMITATIONS OF TREATMENT

You can decide what kind of treatment you want or don't want if you become seriously ill or are dying. Regardless of the treatment limitations expressed, you have the right to have your pain and symptoms (nausea, fatigue, shortness of breath) managed. Unless treatment limitations are stated, the medical team is required and expected to do everything possible to save your life.

1. If my heart stops (choose one):

I DO want CPR done to try to restart my heart.

I DON’T want CPR done to try to restart my heart.

CPR means cardio (heart)-pulmonary (lung) resuscitation, including vigorous compressions of the chest, use of electrical stimulation, medications to support or restore heart function, and rescue breaths (forcing air into your lungs).

2. If I am unable to breathe on my own (choose one):

I DO want a breathing machine

I want to have a breathing

without any time limit.

machine for a short time to see

 

if I will survive or get better.

I DO NOT want a breathing machine for ANY length of time.

“Breathing machine” refers to a device that mechanically moves air into and out of your lungs such as a ventilator.

3. If I am unable to swallow enough food or water to stay alive (choose one):

I DO want a feeding tube

I want to have a feeding tube

without any time limits

for a short time to see if I will

 

survive or get better.

I DO NOT want a feeding tube for any length of time.

NOTE: If you are being treated in another state your agent may not automatically have the authority to withhold or withdraw a feeding tube. If you wish to have your agent decide about feeding tubes please check the box below.

I authorize my agent to make decisions about feeding tubes.

4. If I am terminally ill or so ill that I am unlikely to get better (choose one):

I DO want antibiotics or other medication to fight infection.

I DON’T want antibiotics or other medication to fight infection.

If you have stated you DO NOT want CPR, a breathing machine, a feeding tube, or antibiotics under any circum- stances, please discuss this with your doctor who can complete a DNR/COLST form to ensure you don’t receive treatments you don’t want, particularly in an emergency situation. A DNR/COLST order will be honored outside of the hospital setting.

Additional Limitations of Treatment I wish to include:

12/18

ADVANCE DIRECTIVE, PAGE 4

NAME

DOB

DATE

PART FOUR: ORGAN/TISSUE DONATION & BURIAL/DISPOSITION OF REMAINS

My wishes for organ & tissue donation (check your choices):

I consent to donate the following organs & tissues:

Any needed organs

Any needed tissue (skin, bone, cornea)

I do not wish to donate the following organs and tissues:

I do not want to donate any organs or tissues

I want my health care agent to decide

I wish to donate my body to research or educational program(s). (Note: you will have to make your own arrangements with a medical school or other program in advance.)

My Directions for Burial/Disposition of My Remains after I Die (check & complete):

I have a Pre-Need Contract for Funeral Arrangements:

NAME

ADDRESS

PHONE

I want the following individuals to decide about my burial or disposition of my remains (check your choices):

Agent

NAME

ADDRESS

Other:

Alternate Agent

Family:

PHONE

NAME

PHONE

ADDRESS

Specific Wishes (check your choices): I want a Wake/Viewing

I prefer a Burial — If possible at the following location: (cemetery, address, phone number)

I prefer Cremation — With my ashes kept or scattered as follows:

I want a Funeral Ceremony with a burial or cremation to follow

I prefer only a Graveside Ceremony

I prefer only a Memorial Ceremony with burial or cremation preceding

Other Details: (such as music, readings, Officiant)

12/18

ADVANCE DIRECTIVE, PAGE 5

NAME

DOB

DATE

PART FIVE: SIGNED 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.

SIGNED

DATE

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)

FIRST WITNESS (PRINT NAME)

SIGNATURE

DATE

SECOND WITNESS (PRINT NAME)

SIGNATURE

DATE

If the person signing this document is being admitted to or is a current patient in a hospital, one of the follow- ing 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 hospi- tal 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 sign- ing: an ombudsman, recognized member of the clergy, Vermont attorney, Probate Court designee, des- ignated 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.

NAME

TITLE/POSITION

ADDRESS

SIGNATURE

PHONE

DATE

12/18

ADVANCE DIRECTIVE, PAGE 6

NAME

DOB

DATE

The following have a copy of my Advance Directive (please check):

Vermont Advance Directive Registry

Date registered:

 

 

Health care agent

 

 

 

Alternate health care agent

 

 

 

 

 

 

 

 

Doctor/Provider(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital(s):

 

 

 

 

 

 

 

 

 

Family Member(s): Please list:

 

 

 

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

Other:

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

12/18

Vermont Advance Directive Registry

REGISTRATION AGREEMENT

VERMONT DEPARTMENT OF HEALTH SOURCE CODE: 53101301

Registry Use Only

Received:

Confirmed:

1.Read the Registration Policy, and complete this Registration Agreement. Please type or print clearly. Be sure to sign and date the form.

2.Attach either a copy of your advance directive, or optionally, an Advance Directive Locator form which indicates only the physical location of your advance directive so that it can be retrieved.

3.Registrations MUST include a completed and signed Registration Agreement form, and a copy of your advance

 

directive document.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. MAIL to:

Vermont Advance Directive Registry (VADR)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PO Box 2789

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Westfield, NJ 07091-2789

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. OR FAX to:

908- 654-1919

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For additional information visit: http://healthvermont.gov/vadr/ or call 1-888-548-9455

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Registrant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name: First

 

 

 

 

Middle

 

 

 

Last

 

 

 

 

 

 

 

 

 

 

 

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender: Male

_

Female

 

 

 

Date of Birth (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Mailing Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt #

 

 

City/Town:

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

Zip:

 

 

Phone: Home

 

 

 

 

 

Work

 

 

 

 

 

 

 

 

Other

 

 

Secondary Mailing Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt #

 

 

City/Town:

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

Zip:

 

 

Emergency Contacts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary: Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to Registrant:

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/Town:

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

Zip:

 

 

Phone: Home

 

 

 

 

 

 

Work/Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Secondary: Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to Registrant:

 

 

Phone: Home

 

 

 

 

 

 

Work/Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I,

 

 

 

 

 

 

 

 

 

 

 

(print name) request that my advance directive be registered in the

Vermont Advance Directive Registry, and authorize its access as allowed by Vermont law. By signing below, I acknowledge and affirm that: the information provided is accurate; I have read, understand, and agree to the terms of the Registry Registration Policy; I will safeguard my registrant identification number and wallet card from unauthorized access; and I will immediately notify the Registry in writing of changes to my registration information or advance directive. I execute this agreement voluntarily and without coercion, duress, or undue influence by any party. I understand that anyone who has access to my wallet card can use it to gain access to my documents and personal information. This authorization remains in effect until I revoke it.

Signature of Registrant:

 

Date:

VERMONT ADVANCE DIRECTIVE REGISTRY

REGISTRATION POLICY

An advance directive is a legal document that conveys a person’s wishes regarding their health care treatment and end of life choices should they become incapacitated or otherwise unable to make those decisions. The Vermont Advance Directive Registry is a database that allows people to electronically store a copy of their advance directive document in a secure database. That database may be accessed when needed by authorized health care providers, health care facilities, residential care facilities, funeral directors, and crematory operators. For more information, visit: http://healthvermont.gov/vadr/.

1.To register an advance directive, the registrant must complete and send the Registration Agreement form along with a copy of the advance directive to:

The Vermont Advance Directive Registry

PO Box 2789

Westfield, New Jersey 07091-2789

2.Upon receipt of the Registration Agreement and attachments, the Registry will scan the advance directive and store it in the database along with registrant identifying information from

the Registration Agreement. The Registry will send a confirmation letter to the registrant along with a registration number, instructions for using the registration number to access documents at the Registry website, a wallet card, and stickers to affix to a driver’s license or insurance card. The registration is not effective until receipt of the confirmation letter and registration materials is made by registrant.

3.Registrants should share the registration number from the wallet card with anyone that should have access to their advance directives: for example, the registrant’s agent, family members, or physician. Anyone may access a person’s advance directive using the registration number. Additionally, when the registration number is not readily available, an authorized health care provider can search the Registry for a specific person’s advance directive using a registrant’s personal identifying information.

4.The registrant is responsible for ensuring that:

a.The advance directive is properly executed in accordance with the laws of the state of Vermont.

b.The copy of the advance directive sent to the Registry, if a photocopy of the original, is correct and readable.

c.The information in both the Registration Agreement and advance directive documents is accurate and up to date.

d.The Registry is notified as soon as possible of any changes to the advance directive or registration information by completing and submitting an Authorization to Change form with the changes appended, or preferably, with an updated copy of the advance directive to the Registry.

5.Initial registration as well as subsequent changes and updates to the registration information or the advance directive documents are free of charge.

6.The Registration Agreement shall remain in effect until the Registry receives reliable information that the registrant is deceased, or the registrant requests in writing that the Registration Agreement be terminated. When the Agreement is terminated, the Registry will remove registrant’s advance directive from the Registry database, and the file will no longer be accessible to providers.

7.Only the Registry can change the terms of the Registration Agreement.

⇓ PDF File

File Overview

Fact Detail
1. Purpose of the Form Allows individuals to name an agent for health care decisions and specify care preferences.
2. Part One: Health Care Agent Enables naming an agent and alternate agents to make decisions if the individual is unable.
3. Agent Restrictions Your agent cannot be your health care provider unless they are a relative, or associated with a facility where you reside.
4. Part Two: Treatment Goals & Spiritual Wishes Lets individuals specify their treatment preferences in various circumstances and spiritual care wishes.
5. Part Three: Treatment Limitations Allows individuals to express wishes about CPR, mechanical ventilation, feeding tubes, and antibiotics.
6. DNR/COLST Orders Discusses the need for a separate order to ensure emergency personnel honor treatment limitations.
7. Part Four: Posthumous Wishes Enables specifying organ/tissue donation preferences and funeral arrangements.
8. Witness Requirements The form must be signed in the presence of two adult witnesses who are not the agent, family members, or care providers.
9. Revocation and Updates Advance Directives can be revoked or replaced at any time by the individual.
10. Vermont Advance Directive Registry Completed forms can be registered for added accessibility and to ensure wishes are honored.

Vermont Directive Health Care: Usage Guidelines

Filling out the Vermont Advance Directive for Health Care form is an important step in managing your future health care decisions. This process allows you to appoint a trusted individual as your health care agent, express your health care goals and spiritual wishes, and state your preferences regarding certain medical treatments and interventions. Additionally, you can outline your wishes concerning organ donation and the handling of your remains. It's critical to complete this form thoughtfully, ensuring your health care preferences are known and can be honored. Below are steps to guide you through filling out the Vermont Advance Directive for Health Care form.

  1. Part One: Your Health Care Agent
    • Choose a health care agent you trust to make decisions on your behalf if you're unable. Fill in their name, contact information, and relationship to you.
    • If desired, appoint an alternate agent by providing their details as well.
    • List any additional individuals or professionals who may be consulted about your medical care, excluding those you don't want involved.
  2. Part Two: Health Care Goals and Spiritual Wishes
    • Express your overarching health care goals, such as sustaining life as long as possible or prioritizing comfort care.
    • Indicate additional goals, wishes, or beliefs that are important to you.
    • State your preferences for where you would like to be if you are near the end of your life and specify any spiritual care wishes.
  3. Part Three: Limitations of Treatment
    • Make specific choices about life-sustaining treatments, such as CPR, breathing machines, feeding tubes, and the use of antibiotics in various scenarios.
    • If you strongly oppose certain treatments like CPR, discuss obtaining a DNR/COLST order with your doctor to ensure your wishes are respected in emergencies.
    • Add any additional treatment limitations or preferences.
  4. Part Four: Other Wishes
    • Document your wishes regarding organ/tissue donation and preferences for the handling of your remains, including funeral, burial, and disposition.
  5. Part Five: Signatures
    • Review your advance directive to ensure it accurately represents your wishes.
    • Sign and date the form in the presence of two adult witnesses who are not your agent, alternate agent, spouse, partner, parents, siblings, children, or grandchildren.
    • Distribute copies of the completed form to your health care agent, family members, primary care provider, and any health care facilities where you receive care. Also, consider registering your advance directive with the Vermont Advance Directive Registry.

Remember, this form can always be revoked or replaced if your preferences change. Just make sure to communicate any changes to your health care agent and update your documents accordingly. Having this directive in place is a proactive step in ensuring your health care wishes are followed, providing peace of mind for you and your loved ones.

Your Questions, Answered

Frequently Asked Questions about the Vermont Advance Directive for Health Care

  1. What is a Vermont Advance Directive for Health Care?

    An Advance Directive for Health Care is a legal document that allows you to name someone else (an agent) to make health care decisions on your behalf if you are unable to do so. It also allows you to specify your preferences for types of health care treatments you would want or refuse under certain conditions. This document ensures that your health care providers and loved ones are aware of your wishes and can make decisions that align with your values and beliefs.

  2. Who should I choose as my health care agent?

    Select someone you trust implicitly, such as a close family member or friend, who understands your health care goals and is willing to act on your behalf. This individual will need to make potentially difficult decisions under stressful conditions, so it’s crucial they are comfortable with this responsibility and are guided by your values. Your chosen agent cannot be your health care provider or affiliated with a residential care or health care facility where you are receiving care, unless they are related to you.

  3. Can I specify my treatment preferences without appointing an agent?

    Yes, Part TWO of the form allows you to document your treatment goals, wishes, and any specific medical preferences you have. Medical providers are instructed to follow these directives to the best of their ability in your care. However, appointing an agent can provide additional guidance for situations that may not be explicitly covered in the document.

  4. What happens if I do not have an Advance Directive or an appointed agent?

    In the absence of an Advance Directive, Vermont law does not automatically grant decision-making authority to next-of-kin. Healthcare providers may instead make decisions based on what they believe is in your best interest, which may not always reflect your personal preferences. To ensure your health care decisions align with your wishes, it’s advised to complete an Advance Directive.

  5. How can I make changes to my Advance Directive?

    You have the right to revise or revoke your Advance Directive at any time. To do so, it’s essential to destroy all copies of the old directive and inform anyone who has a copy, including your health care agent and providers. If you have registered your document with the Vermont Advance Directive Registry, send them a new copy or a notification form detailing the changes to update their records accordingly. It’s also a good practice to discuss any new wishes or alterations with your health care agent and family to ensure they are up to date with your preferences.

Common mistakes

When filling out the Vermont Advance Directive for Health Care form, it's crucial to get every detail right. This document is your voice when you cannot speak for yourself regarding your healthcare. Unfortunately, people often make mistakes during this process. Understanding these errors can help ensure your healthcare wishes are respected.

  1. Not discussing your wishes with your agent ahead of time. Before you appoint someone as your healthcare agent, it's vital to have a detailed conversation with them. They need to understand your healthcare goals, wishes, and preferences to make decisions that align with your values.

  2. Choosing an agent who is not willing or able to act on your behalf. Sometimes, people choose an agent based on familial obligations or emotions without ensuring the person is prepared for such responsibility. Confirm that your agent is ready and able to advocate for your wishes.

  3. Failing to specify treatment preferences clearly. The sections on treatment goals, spiritual wishes, and limitations of treatment require careful thought and clear articulation. Vague language or incomplete instructions can lead to confusion and misinterpretation.

  4. Ignoring the legal witness requirements. The signature page comes with specific instructions about who can and cannot be a witness. Overlooking these details can invalidate the entire directive. Always ensure your witnesses comply with the stated requirements.

  5. Not sharing the completed form with important parties. Completing the form is just one part of the process. For it to be effective, you must share it with your healthcare agent, alternate agents, physician, family, and any healthcare facility you might use. Keeping it to yourself defeats its purpose.

To avoid these mistakes:

  • Have open and honest discussions with your potential agent and family about your healthcare wishes.

  • Choose someone as your agent who understands your values and is committed to acting on your behalf.

  • Be clear and specific about your healthcare preferences, leaving no room for doubt.

  • Follow the signature and witness guidelines to ensure your document is legally valid.

  • Distribute copies of your completed form to your agent, alternate agents, physician, family, and healthcare facilities.

By being mindful of these common mistakes and taking steps to avoid them, you can better secure your healthcare wishes for the future.

Documents used along the form

Individuals preparing for future healthcare decisions with the Vermont Advance Directive for Health Care form should consider complementing this directive with other important documents to ensure comprehensive coverage of their health care and personal wishes. Below is an overview of key forms and documents often used alongside the Vermont Directive Health Care form to offer a complete and holistic approach to end-of-life planning.

  • Last Will and Testament: Specifies how a person's possessions and assets should be distributed after death.
  • Living Will: Details a person's wishes regarding medical treatment if they become incapable of communicating those decisions themselves.
  • Power of Attorney for Health Care: Designates a person to make health decisions on someone's behalf if they're unable to do so. Often included within the Vermont Advance Directive but might be drafted as a separate document in some cases.
  • Durable Financial Power of Attorney: Empowers another individual to manage financial affairs, ensuring that bills and expenses are paid even if the person becomes incapacitated.
  • Do Not Resuscitate (DNR)/Clinician Order for Life-Sustaining Treatment (COLST) Order: Indicates a person's wishes not to have CPR or other life-saving measures taken in the event of cardiac or respiratory arrest.
  • Organ and Tissue Donation Form: Indicates which organs and tissues may be donated after death. While part of the Advance Directive, registering separately with a donation registry is also common.
  • Funeral Planning Declaration: Specifies arrangements for funerals, burials, or cremation, including details about the type of service, location, and handling of remains.
  • HIPAA Release Form: Authorizes health care providers to share medical information with designated individuals, helping agents make informed decisions.
  • Letter of Intent: Provides detailed instructions and personal wishes that might not be legally binding but are meant to guide loved ones and health care agents.
  • Guardianship Designation: Names a guardian for making decisions on behalf of the person, typically focused on care provisions and living arrangements if they become unable to decide for themselves.

Integrating these documents with the Vermont Advance Directive for Health Care ensures that individuals retain control over their medical and personal affairs, provides clarity and guidance for loved ones, and facilitates the legal processes following incapacity or death. It is advisable to discuss these documents with a legal advisor to tailor them to your specific situation and to ensure they are executed in accordance with Vermont law.

Similar forms

The Vermont Advance Directive for Health Care form shares similarities with a Living Will, a document that allows individuals to express their preferences regarding the types of life-sustaining treatments they would like to receive, or not, if they become unable to communicate these decisions themselves. Similar to the Vermont form, a Living Will may include preferences about CPR, use of ventilators, feeding tubes, and other life-preserving measures. Both documents serve the vital function of guiding healthcare providers and loved ones in making care decisions that align with the person’s wishes.

Another similar document is the Health Care Proxy, where an individual appoints a trusted person to make health care decisions on their behalf if they are unable to do so. This parallels the Vermont Advance Directive's first part, which is designated for naming a health care agent. Both documents emphasize the importance of choosing someone who understands the person's values and desires about health care, ensuring decisions made are in the person’s best interest.

The Durable Power of Attorney for Health Care is also akin to the Vermont Directive. It grants a designated agent the authority to make a wide range of health decisions on behalf of the person, not just limited to end-of-life decisions. This is comparable to the comprehensive decision-making power granted to the agent in the Vermont Advance Directive, covering both specific treatment preferences and other health care decisions as needed.

The Medical Orders for Life-Sustaining Treatment (MOLST) form, similar to the specific instructions about treatment limitations found in the Vermont Advance Directive, details a patient’s preferences regarding treatments that are designed to extend life. Both aim to ensure that the patient’s wishes are followed by medical professionals, especially in emergency situations or towards the end of life, including decisions about CPR, ventilators, and other life-sustaining interventions.

Organ and Tissue Donation Forms, which allow individuals to specify their wishes about organ donation after death, share similarities with part four of the Vermont Directive. This section allows individuals to express their preferences concerning organ/tissue donation, along with decisions about funeral, burial, and the disposition of remains, emphasizing personal values in posthumous decisions.

Do Not Resuscitate (DNR) Orders are directives that prevent the administration of CPR in case the individual’s breathing stops or the heart stops beating. The Vermont Advance Directive includes an option for stating a preference not to receive CPR, which, like a DNR order, instructs health care providers not to perform life-sustaining procedures. Both documents play a crucial role in respect to a patient's autonomy and their right to refuse certain medical treatments.

Lastly, the POLST (Physician Orders for Life-Sustaining Treatment) parallels the Vermont Advance Directive in its approach to detailed medical orders. Similar to the Vermont Directive's sections on treatment and life support preferences, a POLST form provides specific instructions about medical care preferences in easily understandable medical orders. This ensures that a patient’s wishes are known and can be quickly understood and acted upon by medical personnel, even outside of hospital settings.

Dos and Don'ts

When filling out the Vermont Advance Directive for Health Care form, it's essential to approach the task with careful consideration and adherence to guidance for ensuring your health care wishes are respected and followed. Below are key practices to adopt and avoid during this process:

Things You Should Do:

  • Discuss your health care wishes with close family, friends, and your chosen health care agent to ensure they understand your preferences.

  • Choose a trusted person as your health care agent who is comfortable making decisions on your behalf and understands your values.

  • Give detailed instructions on what types of health care you want or do not want in the form's provided sections.

  • Consider a DNR/COLST discussion with your doctor if you do not wish for CPR, a breathing machine, feeding tubes, or antibiotics under certain circumstances.

  • Sign and date the form in the presence of two adult witnesses who are not your agent, alternate agents, spouse, partner, or direct relatives.

  • Distribute copies of the completed form to your health care agent, alternate agents, family, physician, and health care facilities involved in your care.

  • Update your Advance Directive as necessary, informing the Vermont Advance Directive Registry of any changes.

Things You Shouldn't Do:

  • Do not appoint your health care provider as your agent unless they are a relative, to avoid conflicts of interest.

  • Do not choose an agent who is involved in the operation of a health care or residential facility where you reside, to ensure unbiased decisions.

  • Avoid using witnesses who are your agent, alternate agents, spouse, partner, or direct relatives, to validate the signing process.

  • Do not leave sections incomplete if they apply to your wishes, as every part of the directive can help guide your care.

  • Do not forget to sign and date the document in the presence of appropriate witnesses, as this is crucial for its validity.

  • Avoid failing to communicate your wishes and the existence of your Advance Directive to relevant parties.

  • Do not refrain from reviewing and updating your directive, as your preferences may change over time.

Misconceptions

  • One common misconception is that you must fill out the entire Vermont Advance Directive for Health Care form for it to be valid. However, this is not the case. You may use the form in its entirety or only part of it depending on your needs, such as choosing only to appoint a health care agent or stating specific health care wishes without appointing an agent. This flexibility allows you to tailor the directive to your specific preferences.

  • Another misconception is that if you do not appoint a health care agent, your closest family member will automatically make health care decisions for you. According to Vermont law, this is not automatically the case. Without a designated health care agent, there may be no clear authority for someone to make decisions on your behalf, which is why it is crucial to appoint someone you trust as your agent.

  • Many believe that an advance directive is only used when you are at the end of your life. While it can guide care at the end of life, an advance directive is valuable in any situation where you cannot make decisions for yourself, whether temporarily or permanently. It ensures your preferences are known and respected, even if you are expected to recover fully.

  • Lastly, there's the misconception that once you have completed your Vermont Advance Directive, there’s nothing more you need to do with it. In fact, it is recommended to regularly review and possibly update your directive, especially if your health situation or preferences change. Additionally, it's important to make sure that your health care agent, family, physician, and any health care facility where you receive care have the most current copy of your directive. You are also encouraged to register your advance directive with the Vermont Advance Directive Registry to ensure it can be accessed by health care providers when needed.

Key takeaways

Filling out and using the Vermont Directive for Health Care form is a significant step in planning for future health care decisions. Here are four key takeaways that can guide you through the process:

  • The form allows you to appoint a health care agent. This person will make medical decisions on your behalf if you cannot do so. Choosing someone you trust and who understands your wishes is crucial. The form also permits the appointment of alternate agents, providing backup options if your primary agent is unable to serve.
  • Part Two of the form focuses on your health care goals and spiritual wishes, offering space to outline your desires for treatment in various situations. It's important to consider and communicate your values and beliefs about life-sustaining treatments, personal comfort, and how you wish to spend your final days.
  • Limits on medical treatment can also be specified. This includes decisions about CPR, use of a breathing machine, feeding tubes, and antibiotics in terminal or seriously ill conditions. Discussing your wishes with your doctor is recommended, especially if you decide against certain life-sustaining treatments. A DNR/COLST form can be completed by your doctor to ensure emergency personnel honor your wishes.
  • The importance of clear communication and documentation cannot be overstated. After completing the form, signing it in the presence of two adult witnesses who are not your agent or immediate family members is necessary. Copies should be shared with your health care agent, alternate agents, family members, physicians, and any health care facilities involved in your care. Additionally, registering your Advance Directive with the Vermont Advance Directive Registry ensures that your health care preferences are accessible when needed.

Understanding and completing the Vermont Advance Directive for Health Care form empowers you to make your health care wishes known and respected. It's an act of care for yourself and a gift of clarity for your loved ones.

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