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Fill in Your Vermont Directive Health Care Form

The Vermont Directive Health Care form is a legal document that allows individuals to outline their healthcare preferences in advance. It empowers you to appoint someone you trust to make medical decisions on your behalf if you become unable to do so. By clearly expressing your treatment goals and wishes, this form helps ensure that your healthcare aligns with your values and desires, even when you cannot communicate them yourself.

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Fill in Your Vermont Directive Health Care Form

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The Vermont Directive Health Care form is a crucial tool for individuals wishing to express their health care preferences in advance. This form empowers individuals to appoint a trusted person, known as an agent, to make health care decisions on their behalf if they become unable to do so. It allows for the specification of treatment goals and wishes, enabling individuals to communicate their desires regarding life-sustaining measures, such as CPR and feeding tubes. Additionally, the form provides a section to outline limitations on treatment, ensuring that health care providers understand the individual’s specific wishes in critical situations. Beyond medical preferences, the form also addresses organ and tissue donation and allows individuals to express their wishes regarding the disposition of their remains. Completing the form requires signatures from two adult witnesses, ensuring that the document is legally valid. It is essential for individuals to discuss their choices with family members and health care providers, fostering clarity and understanding. Furthermore, the form can be updated or revoked at any time, allowing individuals to maintain control over their health care decisions throughout their lives.

⇩ Vermont Directive Health Care PDF Form

Dos and Don'ts

When filling out the Vermont Directive Health Care form, consider the following important dos and don'ts:

Do choose someone you trust as your health care agent. This person should understand your wishes and be comfortable making decisions on your behalf.
Do communicate your goals and preferences clearly. Discuss your wishes with your agent, family, and healthcare providers.
Do ensure that the form is signed in the presence of two adult witnesses who are not related to you or involved in your care.
Do keep copies of the completed form. Distribute it to your agent, family, and healthcare providers to ensure everyone is informed.

Don't leave sections of the form blank. If you have specific wishes, make sure to express them clearly.
Don't appoint your healthcare provider as your agent unless they are a relative. This ensures there is no conflict of interest.
Don't assume that your next-of-kin will make decisions for you if you are unable to do so. Appoint someone in advance.
Don't forget to update the form if your preferences change. Notify the Vermont Advance Directive Registry if you make any updates.

Similar forms

The Vermont Advance Directive for Health Care form shares similarities with the Durable Power of Attorney for Health Care (DPOA). Both documents allow individuals to appoint someone to make medical decisions on their behalf when they are unable to do so. The DPOA typically focuses solely on health care decisions, while the Vermont form encompasses treatment preferences, goals, and limitations. This ensures that the appointed agent not only has the authority to make decisions but also understands the individual's specific wishes regarding medical treatment. In both cases, clear communication with the chosen agent is essential to ensure that the individual’s values and preferences are respected.

Another document similar to the Vermont Advance Directive is the Living Will. A Living Will outlines an individual's preferences regarding medical treatment in specific situations, particularly at the end of life. While the Vermont form provides a broader scope by allowing for the appointment of an agent and detailing treatment goals, the Living Will serves as a direct expression of a person's wishes concerning life-sustaining measures. Both documents aim to ensure that a person's health care preferences are honored, even when they cannot communicate those wishes themselves.

The Do Not Resuscitate (DNR) order is also comparable to the Vermont Advance Directive. A DNR specifically instructs medical personnel not to perform CPR in the event of cardiac arrest. While the Vermont form includes the option to refuse CPR, it also allows for a more comprehensive discussion of treatment preferences and appointing an agent. The DNR is a critical document for those who wish to avoid aggressive life-saving measures, emphasizing the importance of understanding and documenting one’s wishes regarding end-of-life care.

In similar fashion to other health care directives, the Arizona Transfer-on-Death Deed form is vital for ensuring that property is passed on smoothly to beneficiaries without the complications of probate. Property owners can benefit significantly from understanding this tool, which simplifies the process and honors the owner’s intentions after their passing. For more details, visit arizonapdf.com/transfer-on-death-deed.

Lastly, the Physician Orders for Life-Sustaining Treatment (POLST) form bears resemblance to the Vermont Advance Directive. The POLST is a medical order that translates a patient's wishes regarding treatment into actionable orders for healthcare providers. Like the Vermont form, it includes preferences for resuscitation and other life-sustaining treatments. However, the POLST is typically used for patients with serious illnesses or those nearing the end of life, making it more immediate in nature. Both documents serve to communicate and uphold an individual's treatment preferences, ensuring that their values are respected in critical health situations.

Common mistakes

Not Naming an Agent: Failing to appoint a health care agent can lead to confusion about who will make decisions on your behalf when you are unable to do so. It's essential to choose someone you trust.
Choosing the Wrong Agent: Selecting an agent who does not understand your wishes or values can result in decisions that do not align with your preferences. Make sure your agent is someone comfortable making difficult choices.
Inadequate Discussion: Not discussing your goals and preferences with your agent and family can lead to misunderstandings. Open conversations are vital to ensure everyone is on the same page.
Incomplete Form: Filling out only parts of the form without completing all relevant sections can leave important decisions unaddressed. Take the time to fill out each section thoroughly.
Ignoring Treatment Limitations: Failing to specify your wishes regarding limitations of treatment can result in unwanted interventions. Clearly state your preferences for treatments like CPR and feeding tubes.
Not Following Up: After completing the form, neglecting to share copies with your agent, family, and health care providers can lead to situations where your wishes are not honored. Distribute copies to all relevant parties.
Forgetting to Update: Failing to keep your Advance Directive current can lead to outdated preferences being followed. Regularly review and update your document as your wishes change.

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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

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
	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

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

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:

(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.

Documents used along the form

The Vermont Directive Health Care form is an essential document for expressing health care preferences and appointing a decision-maker. Several other forms and documents complement this directive, ensuring clarity and adherence to individual wishes regarding medical treatment.

DNR/COLST Order: This document specifies a person's wish not to receive cardiopulmonary resuscitation (CPR) or other life-sustaining treatments in emergencies. It is crucial for ensuring that emergency medical personnel respect a patient's treatment preferences.
Doctor's Excuse Note: This official documentation is crucial for verifying health-related absences from work or school, providing validation from a medical professional. For more information, visit OnlineLawDocs.com.
Health Care Proxy: Similar to the Advance Directive, this form appoints a specific person to make health care decisions on behalf of someone who is unable to do so. It is essential for ensuring that medical choices align with the individual's values and preferences.
Living Will: A living will outlines specific medical treatments a person does or does not want in the event of a terminal condition. This document serves to guide health care providers in making treatment decisions that reflect the individual's wishes.
Organ Donation Registration: This document allows individuals to express their wishes regarding organ donation after death. It ensures that medical personnel are aware of the individual's desire to donate organs, which can save lives.
Power of Attorney for Health Care: This legal document grants another person the authority to make health care decisions on behalf of someone else. It is often used in conjunction with an Advance Directive to ensure comprehensive decision-making authority.
Patient Advocate Form: This form designates a patient advocate who can assist in navigating the healthcare system and ensuring that the patient's wishes are communicated and respected during treatment.
Spiritual Care Preferences: This document outlines an individual's spiritual or religious wishes regarding care at the end of life. It provides guidance to health care providers about the importance of spiritual support during treatment.
Funeral Planning Document: This document specifies preferences for funeral arrangements, burial, or cremation. It ensures that the individual's wishes are honored and can relieve family members from making difficult decisions during a challenging time.
Vermont Advance Directive Registry Registration: This form registers the Advance Directive with the Vermont Advance Directive Registry, ensuring that it is accessible to health care providers when needed. It helps maintain updated records of an individual's health care preferences.

These documents work together to ensure that an individual's health care preferences are respected, especially in critical situations. Proper planning and communication can significantly ease the burden on family members and health care providers during challenging times.

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