§ 23-06.5-17 — Optional health care directive form

North Dakota § 23-06.5-17

• Jurisdiction: North Dakota
• Title 23: Health and Safety
• Ch. 23-06.5: Health Care Directives

Text

The following is an optional form of a health care directive and is not a required form:
HEALTH CARE DIRECTIVE
I_________________________________, understand this document allows me to do ONE
OR ALL of the following:
PART I: Name another individual (called the health care agent) to make health care
decisions for me if I am unable to make and communicate health care decisions for myself. My
health care agent must make health care decisions for me based on the instructions I provide in
this document (Part II), if any, the wishes I have made known to him or her, or my agent must
act in my best interest if I have not made my health care wishes known.
AND/OR
PART II: Give health care instructions to guide others making health care decisions for me.
If I have named a health care agent, these instructions are to be used by the agent. These
instructions may also be used by my health care providers, others assisting with my health care,
and my family, in the event I cannot make and communicate decisions for myself.
AND/OR
PART III: Allows me to make an organ and tissue donation upon my death by signing a
document of anatomical gift.
PART I: APPOINTMENT OF HEALTH CARE AGENT
THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS
FOR ME IF I AM UNABLE TO MAKE AND COMMUNICATE
HEALTH CARE DECISIONS FOR MYSELF
(I know I can change my agent or alternate agent at any time
and I know I do not have to appoint an agent or an alternate agent)
NOTE: If you appoint an agent, you should discuss this health care directive with your agent
and give your agent a copy. If you do not wish to appoint an agent, you may leave Part I blank

and go to Part II and/or Part III. None of the following may be designated as your agent: your
treating health care provider, a nonrelative employee of your treating health care provider, an
operator of a long-term care facility, or a nonrelative employee of a long-term care facility.
When I am unable to make and communicate health care decisions for myself, I trust and
appoint______________________________ to make health care decisions for me. This
individual is called my health care agent.
Relationship of my health care agent to me: _________________________________
Telephone number of my health care agent: _________________________________
Address of my health care agent: __________________________________________
(OPTIONAL) APPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If my
health care agent is not reasonably available, I trust and appoint _____________________
to be my health care agent instead.
Relationship of my alternate health care agent to me: ________________________
Telephone number of my alternate health care agent: ________________________
Address of my alternate health care agent: _________________________________
THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO DO
IF I AM UNABLE TO MAKE AND COMMUNICATE HEALTH CARE DECISIONS
FOR MYSELF
(I know I can change these choices)
My health care agent is automatically given the powers listed below in (A) through (D). My
health care agent must follow my health care instructions in this document or any other
instructions I have given to my agent. If I have not given health care instructions, then my agent
must act in my best interest.
Whenever I am unable to make and communicate health care decisions for myself, my
health care agent has the power to:
(A) Make any health care decision for me. This includes the power to give, refuse, or
withdraw consent to any care, treatment, service, or procedures. This includes deciding whether
to stop or not start health care that is keeping me or might keep me alive and deciding about
mental health treatment.
(B) Choose my health care providers.
(C) Choose where I live and receive care and support when those choices relate to my
health care needs.
(D) Review my medical records and have the same rights I would have to give my medical
records to other people.
If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR
if I want to LIMIT any power in (A) through (D), I MUST say that here:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
My health care agent is NOT automatically given the powers listed below in (1) and (2). If I
WANT my agent to have any of the powers in (1) and (2), I must INITIAL the line in front of the
power; then my agent WILL HAVE that power.
____(1) To decide whether to donate any parts of my body, including organs, tissues, and
eyes, when I die.
____(2) To decide what will happen with my body when I die (burial, cremation).
If I want to say anything more about my health care agent's powers or limits on the powers,
I can say it here:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
PART II: HEALTH CARE INSTRUCTIONS
NOTE: Complete this Part II if you wish to give health care instructions. If you appointed an
agent in Part I, completing this Part II is optional but would be very helpful to your agent.
However, if you chose not to appoint an agent in Part I, you MUST complete, at a minimum,
Part II (B) if you wish to make a valid health care directive.

These are instructions for my health care when I am unable to make and communicate
health care decisions for myself. These instructions must be followed (so long as they address
my needs).
(A) THESE ARE MY BELIEFS AND VALUES ABOUT MY HEALTH CARE
(I know I can change these choices or leave any of them blank)
I want you to know these things about me to help you make decisions about my health care:
My goals for my health care:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
My fears about my health care:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
My spiritual or religious beliefs and traditions:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
My beliefs about when life would be no longer worth living:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
My thoughts about how my medical condition might affect my family:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
(B) THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE
(I know I can change these choices or leave any of them blank)
Many medical treatments may be used to try to improve my medical condition or to prolong
my life. Examples include artificial breathing by a machine connected to a tube in the lungs,
artificial feeding or fluids through tubes, attempts to start a stopped heart, surgeries, dialysis,
antibiotics, and blood transfusions. Most medical treatments can be tried for a while and then
stopped if they do not help.
I have these views about my health care in these situations:
(Note: You can discuss general feelings, specific treatments, or leave any of them blank).
If I had a reasonable chance of recovery and were temporarily unable to make and
communicate health care decisions for myself, I would want:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
If I were dying and unable to make and communicate health care decisions for myself, I
would want:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
If I were permanently unconscious and unable to make and communicate health care
decisions for myself, I would want:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
If I were completely dependent on others for my care and unable to make and communicate
health care decisions for myself, I would want:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

In all circumstances, my health care providers will try to keep me comfortable and reduce
my pain. This is how I feel about pain relief if it would affect my alertness or if it could shorten
my life:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
There are other things that I want or do not want for my health care, if possible:
Who I would like to be my health care provider:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Where I would like to live to receive health care:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Where I would like to die and other wishes I have about dying:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
My wishes about what happens to my body when I die (cremation, burial, whole body
donation):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Any other things:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
PART III: MAKING AN ANATOMICAL GIFT
(A) I WANT TO BE AN ORGAN DONOR
[ ] I would like to be an organ donor at the time of my death. I have told my family my
decision and ask my family to honor my wishes. I wish to donate the following (initial one
statement):
[ ] Any needed organs and tissue.
[ ] Only the following organs and tissue:___________________________
(B) I DO NOT WANT TO BE AN ORGAN DONOR
[ ] I do not want to be an organ donor at the time of my death. I have told my family my decision
and ask my family to honor my wishes.
PART IV: MAKING THE DOCUMENT LEGAL
EARLIER DESIGNATIONS REVOKED. I revoke any earlier health care directive.
DATE AND SIGNATURE OF PRINCIPAL
(YOU MUST DATE AND SIGN THIS HEALTH CARE DIRECTIVE)
I sign my name to this Health Care Directive Form on_____________ at
(date)
_______________________________________
(city)
________________________________________
(state)
________________________________________________
(you sign here)
(THIS HEALTH CARE DIRECTIVE WILL NOT BE VALID UNLESS IT IS NOTARIZED OR
SIGNED BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR
ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES
TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE
SAME TIME YOU DATE AND SIGN THIS HEALTH CARE DIRECTIVE.)
NOTARY PUBLIC OR STATEMENT OF WITNESSES

This document must be (1) notarized or (2) witnessed by two qualified adult witnesses. The
individual notarizing this document may be an employee of a health care or long-term care
provider providing your care. At least one witness to the execution of the document may not be
a health care or long-term care provider providing you with direct care or an employee of the
health care or long-term care provider providing you with direct care. None of the following may
be used as a notary or witness:
1. An individual you designate as your agent or alternate agent;
2. Your spouse;
3. An individual related to you by blood, marriage, or adoption;
4. An individual entitled to inherit any part of your estate upon your death; or
5. An individual who has, at the time of executing this document, any claim against your
estate.
Option 1: Notary Public
State of _________________
County of ________________
In my presence on __________ (date), ________________ (name of declarant) acknowledged
the declarant's signature on this document or acknowledged that the declarant directed the
individual signing this document to sign on the declarant's behalf.
_________________________
(Signature of Notary Public)
My commission expires __________________________, 20__.
Option 2: Two Witnesses
Witness One:
(1) In my presence on _________ (date), _____________________ (name of
declarant) acknowledged the declarant's signature on this document or
acknowledged that the declarant directed the individual signing this document to
sign on the declarant's behalf.
(2) I am at least eighteen years of age.
(3) If I am a health care provider or an employee of a health care provider giving
direct care to the declarant, I must initial this box: [ ].
I certify that the information in (1) through (3) is true and correct.
_________________________
(Signature of Witness One)
_________________________
(Address)
Witness Two:
(1) In my presence on__________(date), ___________________ (name of
declarant) acknowledged the declarant's signature on this document or
acknowledged that the declarant directed the individual signing this document to
sign on the declarant's behalf.
(2) I am at least eighteen years of age.
(3) If I am a health care provider or an employee of a health care provider giving
direct care to the declarant, I must initial this box: [ ].
I certify that the information in (1) through (3) is true and correct.
_________________________
(Signature of Witness Two)
_________________________
(Address)
PRINCIPAL'S STATEMENT
I have read a written explanation of the nature and effect of an appointment of a health care
agent which is attached to my health care directive.
Dated this _____ day of ________, 20 _____. _______________________
(Signature of Principal)