Indiana Advance Directive Form

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An Indiana advance directive is a legal document used to choose a health care agent to take care of any decision in the chance a person cannot speak for themselves. The form is actually a collection of health-planning documents mainly for the elderly and those in high-risk situations that may not be able to make decisions for themselves. After the form is complete, it should be held by multiple family members and the agent to ensure it’s easily accessible in the time of an emergency.

Advance Directive Includes

Table of Contents

Laws

StatutesArticle 36, Chapter 4 (Living Wills and Life-Prolonging Procedures), Title 30, Article 5 (Powers of Attorney), Article 36, Chapter 1.7 (Psychiatric Advance Directives)

Signing Requirements (§ 16-36-4-11) – Two (2) Witnesses.

Versions (3)


AARP

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Indiana Dept. of Health

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Spanish (Español) Version

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How to Write

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Out Of Hospital Do Not Resuscitate Declaration: Patient Declaration

(1) Calendar Date Of Declaration. The advance directive packet will begin with the option of issuing a Do Not Resuscitate Order (this requires an Indiana Doctor’s approval). Begin the process of informing Indiana Medical Professionals that the Patient this order concerns does not wish to have CPR used to prolong his or her life by establishing the date of this declaration.

(2) Name Of Declarant. The full name of the Patient should be dispensed as well. Make sure the Patient’s name is recorded exactly as it appears on his or her identifying paperwork and medical records.

(3) Signature Of Declarant. The signature of the Declarant or Patient must be supplied to issue this order.

(4) Name And Location Of Declarant. The printed name of the Indiana Declarant issuing this order should be presented along with the city and the state where he or she maintains a home.

Witness Confirmation

(5) Signature Of Witness. The signature provided by the Indiana Declarant must be authentic and easy to prove as such. To this end, two Witnesses who have watched him or her sign this order and are not related to the Declarant or anyone working where the Declarant receives medical care should sign their names beneath the statement provided.

(6) Witness Printed Name.

(7) Date Of Witness Signature.

Out Of Hospital Do Not Resuscitate Order: Physician Declaration

(8) Physician Name. A licensed Physician recognized by Indiana State must oversee this declaration and support it by signature. This will aid in providing assurance that it contains appropriate treatment instructions for Indiana First Responders who encounter the Declarant undergoing cardiopulmonary failure (when the Patient’s lungs no longer function or the heart stops beating). Before the Physician approves this document, he or she should record his or her full name in the approval statement provided.

(9) Medical Facility. The Medical Facility, Office, or Institution where the Physician can be reached must be documented.

(10) Signature Of Attending Physician. The attending Indiana Physician can only approve of this order by signing his or her name and dispensing his or her printed name and credentials to the areas that follow.

(11) Printed Name Of Physician.

(12) Medical License Number.

(13) Physician Signature Date.

Life Prolonging Procedures Declaration

(14) Date Of Declaration. The Indiana Declarant discussing his or her medical preferences may formally request that his or her life be extended as long as medically possible when diagnosed with a fatal medical condition. Record the date when this declaration is made.

(15) Declarant’s Full Name. Identify the Declarant with his or her full name. This will be the Patient who wishes that Indiana Physicians are aware that informed consent has been given to all life support procedures including artificially delivered nourishment and air through a tube. This declaration will stand even if the Indiana Declarant is unconscious, incognizant, or otherwise unable to deliver this consent when needed to prolong his or her life beyond (or to prevent) life-threatening medical events.

(16) Signature Of Effect. The Indiana Declarant seeking to approve of all legal life-prolonging care through this order must sign his or her name and document the city, county, and state of his or her home or residence. This act of providing a signature must be performed as two Witnesses watch.

Witnesses

(17) Witness Declaration. Indiana requires that two Witnesses observe the signing of the Declarant or Patient issuing this form regarding life-prolonging care. Each should read the Witness Statement displayed below the Indiana Patient’s signature then sign his or her name as an affirmation that the Indiana Declarant has executed this document under observance.

(18) Witness Declaration Date. The calendar date that each Witness documents as his or her signature date should be supplied. It is important that this information is provided at the time of signing as the current date.

Living Will Declaration

(19) Living Will Date Of Declaration. The Indiana Declarant behind this directive packet can choose to decline or refuse life-prolonging procedures should he or she develop an untreatable medical condition that will result in death shortly. That is, life-support or life-prolonging measures administered by Indiana Physicians will only serve to extend the dying process. This declaration should begin with a formal calendar date to give Reviewers a point of reference as to how recent the statement being made is.

(20) Declarant’s Full Name. The name of the Indiana Declarant using the living will to decline the use of life-prolonging measures when he or she has a fatal condition must be recorded.

(21) Nutrition Requirements Of The Declarant. A statement regarding whether the Indiana Declarant will accept artificially supplied nourishment (including water) will need to be selected. He or she may use the act of initialing to declare that artificially delivered nutrition may be provided to sustain his or her life even when it is uncomfortable or painful, that he or she does not wish to be supplied with nourishment (including water) artificially, or that this decision will be made by the Declarant’s Health Care Representative when needed.

(22) Signature And Location Of Declarant. A witnessed signature from the Indiana Declarant is the only method that can place this directive in effect. The signature of the Indiana Declarant should be produced on the available signature line then his or her residential city, county, and state should document below it.

Witnesses

(23) Witness Signature Confirmation. Two Witnesses must watch the Indiana Declarant sign his or her living will then review the statement titled “Witnesses.” Upon agreement, each one should produce a signature of agreement to the “Witnesses” statement on a unique line.

(24) Date Of Witness Signature.

Indiana Physician Orders For Scope Of Treatment

(25) Name Of Indiana Patient. The Indiana Patient issuing medical treatment declarations with this packet also has the option of working with a licensed Physician, APR Nurse, or Physician’s Assistant with credentials recognized by Indiana to attach specific directives coupled with a Physician’s treatment orders to his or her medical file. To do so the full name of the Indiana Patient must be attached to the POLST.

(26) Indiana Patient Information. The birth date and, if available, the medical record number of the Indiana Patient should be reported.

(27) Date Prepared. The calendar date when this document is prepared is required.

Part A Cardiopulmonary Resuscitation

(28) Indiana Patient CPR Instructions. If the Indiana Patient is found with a non-beating heart or lungs that no longer function, then CPR or Cardiopulmonary Resuscitation will usually be administered as a response by Indiana Doctors. The Patient behind this POLST can deliver immediate consent to this method of reviving him or her when in this condition by selecting the first checkbox in Part A or can deny being revived through the administration of CPR by selecting the second checkbox. It should be mentioned that while CPR can be invasive, when the heart and lungs cease to function death can typically be expected within a matter of minutes without this type of intervention.

Part B Indiana Medical Interventions

Select Item 29 Or Select Item 30 Or Select Item 31

(29) Comfort Measures (Allow Natural Death). Since the purpose of this document is to inform Indiana Doctors of the Patient’s medically approved treatment goals on first glance, the level of care that should be supplied will need to be displayed clearly. To inform Indiana Medical Professionals that the Patient wishes for a natural death when his or her medical condition is untreatable and life can only be extended without recovery, select the first treatment option from Part B. This selection will also inform Indiana Physicians that the Patient wishes treatment to prioritize his or her comfort over his or her longevity.

(30) Limited Additional Interventions. If the Patient requests that a balance between treatment to sustain life and his or her comfort is reached by denying only invasive treatments and non-comfort-oriented hospitalization, then the second checkbox should be selected from this area.

(31) Full Intervention. The Indiana Patient can request and consent to all life-prolonging procedures and treatments administered with the goal of extending his or her life for as long as possible by choosing the final statement of this section.

Part C Antibiotics Directive Of Indiana Patient.

(32) Patient Preferences On Antibiotics. The Indiana Patient can also address when antibiotics should be used. That is, the Indiana Declarant can consent to antibiotics given when this is the only measure available to reduce the pain of an infection or can declare that antibiotics may be used to remain consistent with all approved treatment goals by selecting either the first statement or the second statement (respectively).

Part D Artificially Administered Nutrition

Select Item 33 Or Item 34 Or Item 35

(33) No Artificial Nutrition. When a Patient is incapacitated the chances of him or her being unable to physically eat or drink can cause starvation or dehydration. Since at times even a hand-assisted feeding may be ineffective or dangerous, the subject of artificially administered nutrition and water (i.e., a tube or intravenously) will be addressed by attending Indiana Physicians. The Declarant can inform all Indiana Health Care Providers that he or she will deny any artificial delivery of nutrition or water through this form by selecting the first statement in this section.

(34) Defined Trial Period. If the Indiana Patient will consent to the artificial delivery of his or her nutrients and water, but only for a limited time period, this can be documented by filling in the appropriate checkbox then defining the length of time the trial should be implemented for. Additionally, the goal of this trial period should be defined so that Indiana Physicians can respond appropriately. For instance, the Patient may wish to receive artificial nutrition and hydration for the first few weeks of falling into a coma with a goal such as hoping for recovery or to give his or her Health Care Representative the time to prepare loved ones.

(35) Long-Term Artificial Nutrition. The Indiana Declarant or Patient can give consent to receiving nutrition and water through any means necessary even if intravenously by choosing the final declaration statement.

Optional Additional Orders

(36) Additional Indiana Patient Directives. An area has been set aside to receive additional instructions from the Indiana Patient that have been left unaddressed. The Indiana Patient can use this area to handle specific medications, procedures, or experimental programs that he or she would consent to or wish to avoid.

Attaching The Second Page

(37) Indiana Patient Identification. The name and birth date of the Indiana Patient must be attached to the top of the next page to ensure the two POLST pages are always kept together in the Patient’s medical files.

Part E Signature Of Patient Or Legally Appointed Representative

(38) Signature Of Effect. The POLST being completed can only be considered a valid representation of the Indiana Patient’s wishes if he or she signs it. If the Indiana Patient cannot perform this action, his or her Legally Appointed Representative may do so on the Patient’s behalf. The Indiana Declarant must sign his or her name in Part E then continue and proceed to supply some supporting signature information.

(39) Printed Name Of Signature Declarant.

(40) Date Of Indiana Declarant Signature.

Part F. Contact Information For Legally Appointed Representative In Section E (If Applicable)

(41) Representative Relationship. Even though the Indiana Declarant signature has been provided, the Party delivering it will need to be defined if not the Patient. Thus, the relationship the Signature Party holds with the Patient must be dispensed (i.e., Medical Attorney-in-Fact, Legal Proxy, etc.).

(42) Signature Representative Address. If this document has been issued by the Indiana Patient’s Health Care Agent, it will be imperative that his or her contact information be supplied beginning with the mailing address where he or she can be reached.

(43) Signature Representative Phone Number.

Part G. Documentation Of Discussion

(44) Issuing Party. The identity of the issuing Party will need to be established as the individual who the Indiana Physician consulted to define the Patient’s directives. If this is the Patient, then the first checkbox can be selected to indicate otherwise the Party the Indiana Physician discussed this form with may be classified as the Patient’s Parent, Health Care Representative, Health Care Attorney-in-Fact, or Legal Guardian by selecting the proper checkbox.

Part H. Signature Of Treating Physician

(45) Signature Of Treating Physician. The Indiana Physician, Advanced Practice Registered Nurse or Physician Assistant working with the Declarant to issue this form should sign his or her name as confirmation that its contents are appropriate for the Patient’s medical condition.

(46) Printed Name Of Physician/APR/PA.

(47) Signature Date. The date that the Indiana Physician, APR Nurse, or PA has signed this document must be submitted.

(48) Physician Office Number.

(49) Physician/APRN/PA License Number. The medical license number that enables the Indiana Medical Professional signing this document to practice medicine must be presented.

(50) Health Care Professional Preparing Form. If the information on this form was produced by someone other than the Licensed Indiana Medical Professional, then this Preparer’s name must be documented where requested.

Health Care Representative Appointment

(51) Name Of Indiana Patient/Appointor. A Health Care Agent that can represent the Indiana Patient’s wishes can be appointed using this document. To do so, make sure it is attached to the Indiana Patient by recording that Patient’s full name.

(52) Identifying Information. Both the Patient’s birthday and medical record, I.D., or filing number should be supplied to this document where requested.

(53) Health Care Facility Or Provider. While an optional report, if the Patient’s primary source for health care and treatment is known, then the name of his or her Primary Health Care Facility should be presented.

Health Care Agent Terms And Conditions

(54) Indiana Patient Declaration. The appointment of an Indiana Health Care Agent through this form will grant the Agent the full power of representation allowed by Indiana State. This is not mandatory and the Indiana Health Care Agent’s use of principal power to decide upon the Patient’s care, access his or her medical records, approve/refuse treatments on his or her behalf, and decide upon admissions and discharges from Health Care Facilities can be limited by the Patient. To place any kind of term, condition, or limitation to the principal powers being delivered, use the area provided. For instance, the Patient may prefer to leave the subject of pain management to the attending Physicians or his or her directive.

(55) Name Of Representative Appointed. The full name of the Patient’s chosen Indiana Health Care Representative must be submitted to make this appointment.

(56) Address Of Representative.

(57) Telephone Number Of Representative.

Indiana Patient Signature Execution Of Directives

(58) Signature Of Patient/Appointor Or Designee. The Indiana Patient or legally designated Health Care Agent can complete this appointment by signing his or her name.

(59) Printed Name Of Patient/Appointor Or Designee.

(60) Date Of Appointment.

Witness Testimony.

(61) Signature Of Witness. The individual who can verify that he or she watched this document being signed by either the Indiana Patient or the Patient’s Designated Agent. The Witness verification required must be provided by the Witness’s act of signing.

(62) Printed Name Of Witness

(63) Date Of Witness Signature.

 

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