Missouri Advance Directive Form

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A Missouri advance directive is a document that outlines the preferred medical treatment options for an individual and an agent to speak on their behalf. An advance directive only comes into use when a person can no longer speak for themselves. In such an event, the agent will be the sole decision-maker of all health care decisions. If the patient is determined to be permanently incapacitated, medical staff are required to follow the life-sustaining treatment options located in the directive.

Advance Directive Includes

Table of Contents

Laws

StatuteChapter 404, Chapter 459

Signing Requirements – Two (2) witnesses and a notary public.

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Missouri Attorney General

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Missouri State BAR

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How to Write

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Part I. Durable Power Of Attorney For Health Care

Introduction

(1) Missouri Health Care Principal. The full name of the Missouri Principal is required at the start of this document. This will identify the Issuer of the directive. It is assumed that you will be filling out this form as the Potential Missouri Patient appointing a Medical Attorney-in-Fact, declare your treatment decisions when incapacitated, or both, therefore, record your name and contact information to the space provided.

(2) Principal Home Address.

(3) Missouri Principal Telephone Number.

(4) Social Security Number.

(5) Medicare Number.

Article 1. Selection Of Agent

(6) Option To Designate A Health Care Attorney-in-Fact. The first part of this form is optional (as long as you complete the second part). If you do not wish to appoint someone as your Missouri Health Care Agent or Attorney-in-Fact, provide proof of this decision by initialing the appropriate declaration statement.

(7) Missouri Health Care Attorney-in-Fact. If you are determined to designate a Private Party as your Missouri Health Care Agent or Attorney-in-Fact, then his or her name must be presented as such. Document the name of your intended Missouri Health Care Attorney-in-Fact (or Agent).

(8) Missouri Health Care Agent Address.

(9) Telephone Number Of Missouri Attorney-in-Fact.

Article 2 Alternate Agents

(10) First Alternate Agent Name, Address, And Telephone. If Missouri Doctors cannot contact your Health Care Agent or Attorney-in-Fact or your Agent refuses to act in the Health Care Attorney-in-Fact role, then an Alternate Agent that you name can be approached for the Health Care Attorney-in-Fact role. This Alternate to the Health Care Attorney-in-Fact will only be able to act in your name if he or she occupies this role. Document the full name, address, and phone number of your Missouri Alternate Agent where requested.

(11) Second Alternate Agent Name, Address, And Telephone. Many consider the appointment of a Second Alternate Agent a wise precaution to aid in making sure that you have your medical directives conveyed to Missouri Doctors even if both your Primary Health Care Agent or Attorney-in-Fact and First Alternate Agent are unable or unavailable to represent you. To make appoint a Second Alternate Agent, record his or her complete name and contact information.

Article 3. Effective Date And Durability

(12) Determined Number Of Diagnosing Physician(s). In most cases, two licensed Physicians will be used to formally diagnose your incapacitation. If you believe time may be a factor, especially where pre-existing conditions are considered, then you may inform Reviewers that you consent to only one Physician required for this diagnosis. Initial the box provided to consent to only one Diagnosing Physician or leave it blank to have your diagnosis made by two licensed Physicians.

Article 4 Agent’s Powers

Initial Item 13 Or Item 14

(13) Agent’s Power To Decide Artificial Nutrition. In order for your Missouri Health Care Agent to provide your consent to or refusal of nutrients and water administered artificially (i.e., using a tube or an I.V.) then initial the appropriate directive statement in the fourth article.

(14) Restricting The Agent’s Power On Artificial Nutrition. To explicitly deny the ability on deciding upon the medical (artificial) delivery of nutrients and water on your behalf then initial the second statement.

Part II. Health Care Directive

Missouri Health Care Directive Status

(15) Missouri Health Care Directive Option. If you have appointed a Party to act as your Missouri Health Care Agent, then the second part of this document can be considered optional. If you have determined that your appointed Missouri Health Care Agent will be able to represent your medical preferences and that “Part II Health Care Directive” will be left intentionally blank, then place your initials in the first box to indicate this decision to Reviewers. If you do intend to issue a directive on your health care preferences (recommended) by completing the second part of this form, then leave this box blank. Be advised, that unless you indicate otherwise, the instructions you provide directly will overrule the opinion or directives of your Missouri Health Care Agent.

Missouri Principal’s Health Care Preferences And Instructions

Choose The Directives You Wish Applied

(16) Artificial Nutrition And Hydration. You can directly inform Missouri Doctors that if you are suffering a medical condition that has no treatment or cure and will result in death and/or you are in a long-term or permanent coma with little to no chance of waking up then all medically (artificially) sullied nutrients and liquids (i.e., water) be withdrawn, withheld, and considered denied by you (the Patient or Declarant). Initial the first directive provided to make this statement.

(17) Surgery Or Other Invasive Procedures. To deny the use of surgery and invasive procedures meant to prolong life (i.e., the insertion of probes, tubes, or wires) then use the second directive in this list to inform Missouri Doctors of your refusal of this treatment.

(18) Heart-Lung Resuscitation (CPR). If you suffer cardiopulmonary failure in the State of Missouri (i.e., a heart attack or cessation of lung function) then First Responders and Medical Staff will immediately administer CPR (in most cases). To deny CPR used to resuscitate your heart or lungs initial the third directive provided.

(19) Antibiotic. By initialing the fourth directive, you will inform Missouri Doctors that you refuse the use of antibiotics administered for medical treatment.

(20) Dialysis. Some medical conditions may cause renal failure (or kidney failure) while other long-term conditions may prevent your kidneys from functioning. In such cases, Missouri Physicians will seek to administer dialysis treatment to take over for your kidneys. If you wish to deny dialysis treatments as a measure to extend your life while you are permanently unconscious or suffering a terminal condition, then initial the fifth directive.

(21) Mechanic Ventilator (Respirator). Outside of cardiopulmonary events, some conditions may make it impossible for you to breathe on your own (i.e., neurological damage, paralysis, etc.). Missouri Physicians will seek to extend life by attaching you to a respirator when needed. If you intend to deny this treatment when it is administered merely to keep you alive without any hope of recovery, then initial the sixth directive.

(22) Chemotherapy. Some medical conditions may require that chemotherapy be applied (i.e., cancer). Similarly, Patients who have been incapacitated or unconscious for a significant period of time may also exhibit cancer as a separate condition altogether. If you wish to deny the use of chemotherapy, deliver your initials to the seventh directive.

(23) Radiation Therapy. In addition to chemotherapy, Missouri Doctors will also consider radiation therapy to treat some diseases (such as cancer). Initial the eighth directive to refuse the administration of radiation therapy.

(24) All Other Life-Prolonging Medical Or Surgical Procedures. Missouri Medical Personnel will have a host of other life-prolonging procedures and equipment at their disposal, especially with advances made on a daily basis in some fields. You can refuse all such life-support maneuvers if the only treatment goal will be to extend or prolong life when you are terminally ill and/or have been diagnosed as unconscious or in a coma for the duration of your life by initialing the final directive.

Part III. General Provisions Included In The Directive And Durable Power Of Attorney

Signature

(25) Signature Date. You must issue your appointment and/or directive by signature in a formal fashion for this document to be effective. This means your signature must be made while you are of clear mind as two Witnesses watch you. If you have appointed a Missouri Health Care Agent, then your signature must be notarized as well. Gather the necessary Parties on the day of your signing, then report the current date.

(26) Signature. Sign your name immediately after providing the current date.

(27) Printed Name And Address.

(28) Witness Signatures. Each Missouri Witness must sign the confirmation statement.

(29) Printed Names And Addresses Of Witnesses.

Notary Public Requirement

(30) Notarization. It will be mandatory that you have your signature notarized if you are appointing a Missouri Health Care Agent. Otherwise, if only issuing a Health Care Directive, this is still recommended as it will lend credence to the authenticity of your signature to future reviewers. The Notary Public will control this document during the notarization process, supply information and his or her credentials, then return it when this process is complete. In general, this will only take a few minutes.

 

 

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