North Carolina Advance Directive Form

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A North Carolina advance directive lets a person choose their lift-ending treatment options and the option to select an “agent” to carry out the instructions. The form only is for use when a person is no longer able to make decisions for themselves due to Alzheimer’s disease, dementia, or any type of incapacitation. The agent is commonly a spouse or family member and makes decisions based on the intentions in the directive.

Advance Directive Includes

Table of Contents

Laws

Statute§ 90-320 to § 90-323, § 32A-25.1

Signing Requirements (§ 90-321) – Two (2) witnesses and a notary public.

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Registry

Download and complete the Registration Form and attach a $10 check made payable to the ‘Secretary of State’. Attach a copy of the advance directive and send to:

North Carolina Secretary of State
Advance Health Care Directive Registry
P. O. Box 29622 Raleigh, NC
27626-0622

How to Write

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Step 1 – Save The North Carolina Advance Directive To Your Computer

The “Adobe PDF” link in this area of the page along with the “PDF” button near the sample image of the North Carolina Advance Directive.

Step 2 – Record The County Where This Document Is Issued

The first piece of information required by the “Advance Directive For A Natural Death (“Living Will”)” is the name of the country where this paperwork is issued. Produce this information on the blank line after the words “County Of”   

 

Step 3 – Review The North Carolina Living Will General Instructions

The “General Instructions” section that introduces this paperwork will discuss the requirements its Declarant must satisfy to execute this directive properly as well as the content presented.

 

Step 4 – Identify The North Carolina Declarant

This declaration shall convey to North Carolina that its Issuer or Declarant prefers that a natural death be allowed when his or her body cannot maintain its vital functions. The first blank line that is presented following the title “My Desire For A Natural Death” expects the full name of this paperwork’s Issuer or North Carolina Declarant presented to its content.

 

Step 5 – Define When North Carolina Medical Providers Must Refer To This Directive

The first article, “1. When My Directives Apply,” informs North Carolina Physicians of the Declarant’s desire to cease or withhold any life-prolonging procedures upon a diagnosis of being unable to “…Make Or Communicate” Health Care Decisions when suffering through a specific set of medical circumstances. Review the of Article “1. When My Directives Apply.” The table that continues the first statement made by Article “1. When My Directives Apply” with several distinct medical scenarios the North Carolina Declarant may be vulnerable to. In order to apply one of these statements to the instruction made by this section’s statement, the North Carolina Declarant must initial the corresponding blank line on the left of the concerned medical condition. For instance, if the North Carolina Declarant wishes to deny any life-prolonging treatment when diagnosed as being uncommunicative and suffering an “…Incurable Or Irreversible Condition” that shall cause his or her death (soon) then the first box must be initialed. If the North Carolina wishes to refuse life-prolonging treatment when he or she is unable to communicate and has been pronounced permanently unconscious (i.e., a coma, brain death), then the second row must be initialed.  Should the North Carolina Declarant be unable to represent his or her medical wishes and suffers from an “…Advanced Dementia Or Any Other Condition Which Results In The Substantial Loss” of his or her cognitive ability then the third blank line in “1. When My Directives Apply” section must be initialed by the North Carolina Declarant.

 

Step 6 – Furnish The North Carolina Life-Prolonging Directives

The North Carolina Declarant can place specific instructions on the extent of his or her Health Care Agent’s ability to deny or withdraw life-prolonging techniques on behalf of the North Carolina Patient or Declarant issuing this instruction. If The North Carolina Health Care Agent has the ability to decide on this issue by balancing the North Carolina Declarant’s wishes with his other Health Provider’s recommendations, then initial the blank line corresponding to the statement “May Withhold Or Withdraw Life-Prolonging Measures”    If the North Carolina Declarant wishes that life-prolonging procedures be denied or withdrawn once the criteria in the first article is met, then the statement “Shall Withhold Or Withdraw Life-Prolonging Measures” should be initialed. This will mean that regardless of the treatment determination made by North Carolina Declarant’s Health Care Agent, life-prolonging techniques will be denied.  

 

Step 7 – Define The North Carolina Declarant’s Artificial Nutrition Or Hydration Preferences

The third article, titled as “3. Exception – “Artificial Nutrition Or Hydration,” will allow the North Carolina Declarant to make additional statements regarding the cessation of life-prolonging directive made in the first article. Even though life-prolonging procedures can be withdrawn or denied, the North Carolina Declarant can determine a separate set of instructions regarding nutrients and hydration. If the North Carolina Declarant wishes to receive the medical administration of nutrients and water/liquids when he or she cannot take in these substances, then the first statement should be initialed. 

If the North Carolina Declarant (You) intents only to deny artificial nutrition and approve the delivery of fluids to his or her body (even through a tube) then initial the second statement.

The North Carolina Declarant can choose to deny only liquids from being artificially delivered and allow only nutrition to be medically administered by Medical Personnel if he or she initials the third statement.

 

Step 8 – Discuss This Paperwork’s Interaction With A North Carolina Health Care Agent

The sixth article of this declaration shall address the topic of the North Carolina Declarant’s Health Care Agent. If this Party disagrees with the directives of this paperwork, then North Carolina Medical Personnel will do well to have some definition of how the Health Care Agent and the Declarant’s living will may interact. If the North Carolina Declarant has determined that the living will should be followed even if his or her Health Care Agent disagrees with its directive, then initial the first row presented in this section (labeled “Follow Advance Directive”). If the North Carolina Declarant believes his or her Health Care Agent’s determination should take precedence over this document, then he or she must initial the row containing the statement labeled “Follow Health Care Agent.” 

 

Step 9 – Attach The Applicable Execution Date Of This Document

The North Carolina Declarant must issue this paperwork with a formal date of execution. That is, a date when North Carolina Medical Providers can use as the time when you have authorized the removal (or denial) of life-prolonging machines when certain criteria are met. The final article (“9. I Have The Right To Revoke This Advance Directive”) presents three blank lines where the calendar day, month name, and four-digit calendar year of the North Carolina Declarant’s signature must be supplied.

 

Step 10 – The North Carolina Declarant Must Sign The Living Will

The North Carolina Declarant will be required to sign the blank line labeled “Signature Of Declarant” below the defined signature date and on the right. This action is required to take place before two North Carolina qualifying Witnesses and Notary Public. The printed name of the North Carolina Declarant is requested by the blank line labeled “Type/Print Name”

Step 11 – Complete Witness Declaration Statement

As established by the “General Instructions” section, this document’s execution requires the verification that only a Witness’s signature can provide. Begin this process by making sure the printed name of the North Carolina Declarant completes the language of the “I Hereby State…” with a presentation on the blank line that follows it.

 

Step 12 – Each North Carolina Witness Must Confirm The Testimonial

After reading the statement declaration of the Witnesses, each one must supply the date he or she has read these words and will sign this document in agreement. The first “Date” line requires this report while the first “Witness” line should be signed by the Witness agreeing to the testimonial statement.  The next area also displays a line labeled “Date” and “Witness.” The remaining Witness must report his or her signature “Date” and sign the “Witness” line.

 

Step 13 – Obtain Verification From The North Carolina Notary Public In Attendance

The final area of the North Carolina Living Will is reserved strictly for the use of the Notary Public verifying the fact that the Declarant signed this document. This area requires his or her “Official Seal” and signature along with some facts surrounding the North Carolina Declarant’s act of signing.  If the Notary Public was required to make an Emergency Video to verify this signing then he or she will also fill out the second part of the Notarization section being tended to with a record of the North Carolina Declarant’s name and location as well as the location and date of the signing.

 

Step 14 – Attend To The North Carolina Medical Order For Scope Of Treatment Forms

The North Carolina Medical Order For Scope Of Treatment or the NC MOST can only be filled out by a licensed Physician, Physician Assistant, or Nurse Practitioner actively discussing this paperwork with the North Carolina Declarant responsible for issuing it. Before beginning, tend the concerned North Carolina “Patient’s Last Name” and the official “Effective Date Of Form” to the first two boxes requiring information. These can be found in the upper right-hand corner of the first page of the NC MOST.

 

Step 15 – Further Define The North Carolina MOST Form

The “Patient’s First Name, Middle Initial,” and the “Patient’s Date Of Birth” should be furnished to the next two boxes. Both are appropriately labeled to request this information and can also be found in the upper right-hand area of the page.

 

Step 16 – Record The North Carolina Declarant’s Resuscitation Directives

For our purpose, the North Carolina Declarant behind the MOST being discussed and the Patient who is issuing this directive will be the same Party. The first topic of discussion that must take place between the North Carolina Physician is a scenario where the Patient or North Carolina Declarant is found with no pulse and not breathing. The response to this scenario (in the majority of cases) will be to attempt to restart either or both of these organs or maintain their functioning until treatment and (if needed and authorized) life support can be administered. The North Carolina Declarant pre-authorize this response by marking the checkbox labeled “Attempt Resuscitation (CPR)” in “Section A Cardiopulmonary Resuscitation (CPR).” The North Carolina Patient (or Declarant) reserves the right to deny the administration of “Cardiopulmonary Resuscitation.” If so, indicate this by marking the checkbox labeled “Do Not Attempt Resuscitation (DNR/No CPR)”

 

Step 17 – Document The Approved Interventions Allowed To North Carolina Medical Professionals

The second topic the concerned North Carolina Declarant should cover is the extent of treatment response when he or she is found needing medical attention but is breathing and displays a pulse. If he or she is unconscious, then North Carolina Health Care Providers will refer to “Section B Medical Interventions.” If the North Carolina Patient indicates that he or she approves or authorizes the “Full Scope Of Treatment” options available to Medical Personnel, then the first checkbox in Section B should be selected.  Should the North Carolina Patient wish a limited scope of treatment, that is considered less invasive and forbids the use of techniques such as intubation, then the second checkbox (labeled with the term “Limited Additional Interventions” should be selected. In a case where the North Carolina Declarant (or Patient) has put forth that only “Comfort Measures” should be employed “…To Relieve Pain And Suffering” then the final checkbox should be selected. This statement will specifically request that the Patient not be moved to a Hospital unless pain and comfort management in the current location are insufficient to meet this goal. The “Other Instructions” line will enable additional comments on the subject of “Medical Interventions,” including any trial period discussions that must be presented. If no additional discussion is required in this section, then you may enter the word “None.”

 

Step 18 – Address The Use Of Antibiotics

When North Carolina Medical Staff determines that the Patient requires “Antibiotics,” the question of whether he or she authorizes this will (naturally) come up. This can be settled in “Section C Antibiotics.” If the North Carolina Declarant approves the use of antibiotics as needed, then select the first statement “Antibiotics If Indicated”  If the North Carolina Declarant only wishes antibiotics administered when an infection occurs and only in a limited manner, then select the “Determine Use Or Limitation Of Antibiotics When Infection Occurs” box. The North Carolina Declarant can forbid the administration of antibiotics by marking the “No Antibiotics (Use Other Measures To Relieve Symptoms)” checkbox.  The line labeled “Other Instructions” at the end of this section allows a more specific order regarding the use of antibiotics to be delivered. If no additional dialogue is needed, then you may record the term “Not Applicable,” “None,” or leave it blank.   

Step 19 – Solidify The North Carolina Declarant’s Nutrition And Hydration Instructions

The North Carolina Declarant may become susceptible to malnutrition or dehydration while receiving medical care, however, he or she should indicate how the topic of “Medically Administered Fluids And Nutrition” must be handled in Section D. If the North Carolina Declarant will approve of the administration of IV Fluids, then select the “IV Fluids If Indicated” checkbox. Similarly, if he or she will authorize the free use of a feeding tube, even if this will be a long-term maintenance plan for nutrition/fluids, then select the box labeled “Feeding Tube Long-Term If Indicated.”  If the North Carolina Declarant will only approve of “IV Fluids For A Defined Trial Period” then select the second checkbox of the first column in “Section D Medically Administered Fluids And Nutrition.” This approval can also be delivered for the administration of tube feedings by selecting the “Feeding Tube For A Define Trial Period” checkbox. The North Carolina Declarant can deny the use of intravenously receiving fluids (unless to provide comfort) by selecting the “No IV Fluids” checkbox and, if desired, deny the delivery of Nutrients through a tube by selecting the “No Feeding Tube” box. If any “Other Instructions” regarding “Medically Administered Fluids And Nutrition” have been indicated for (and by) the Patient, then record them on the blank line in this section.

 

Step 20 – Present The Type Of Entity Issuing This Paperwork

As discussed earlier we have thus far assumed the North Carolina Declarant and Patient issuing this statement are one and the same. If this is the case the “Patient” box in “Section E Discussed With And Agreed To By” should be marked.  If this is not the case and the North Carolina Physician’s Office is discussing this paperwork with the “Majority Of Patient’s Reasonably Available Parents And Adult Children” then the first checkbox in the second column should be selected. If the Declarant is the Patient’s “Parent Or Guardian If Patient Is A Minor” then select the second checkbox in the first column.In a case where the Patient’s “Health Care Agent” is delivering this declaration then select the third checkbox in the first column. If the Patient does not have a Health Care Agent and the Parents are not available to speak with or inappropriate, then the North Carolina Physician’s Office may need to discuss this matter with other entities. Thus, If the Parents are not available and this document has been discussed with the “Majority Of Patient’s Reasonably Available Adult Siblings” then the second checkbox of the second column in Section E must be selected. If the “Legal Guardian Of The Patient” is issuing this document on behalf of the Patient then, select the fourth box of the first column.  The Patient may have formally instructed an “Attorney-in-Fact With Power To Make Health Care Decisions” to discuss this form with the North Carolina Physician’s Office. If so, then select the second to last checkbox of the first column.  If the North Carolina Declarant representing the Patient is “An Individual With An Established Relationship With The Patient Who Is Acting In Good Faith And Can Reliably Covey The Wishes of the Patient” then select the final checkbox of the second column. If the North Carolina Declarant is the Patient’s “Spouse” then select the first checkbox of the first column to establish this Party as the Patient’s Declarant.

 

Step 21 – Present The North Carolina Medical Professional’s Signature Approval

The North Carolina Physician, Physician’s Assistant or Nurse Practitioner completing this document with the Declarant should print his or her name in the box labeled “MD/DO, PA, Or NP Name” then sign his or her name in the box adjacent to this. Note that the “MD/DO, PA OR NP Signature And Date” requires the current calendar date. This should be the same as the “Effective Date” referred to earlier but may also be an earlier date. Lastly, the North Carolina Physician, Physician’s Assistant, or Nurse Practitioner completing this form should disclose the “Phone #” where this Office can be reached. 

 

Step 22 – Gain The North Carolina Declarant’s Execution Signature

The North Carolina Declarant must issue this form by signature. This can be the Patient being discussed or one of the Agents mentioned in the previous section. The North Carolina Declarant must print his or her name in the box labeled “Patient Or Representative Name (Print)” box then sign the box labeled “Patient Or Representative Signature.” If the Patient and the Declarant are one and the same then the final box in this area should be supplied with the word “Self” if not, and it is a separate Party, then his or her “Relationship” with the Patient must be dispensed (i.e., Attorney-in-Fact, Spouse, Brother, etc.) 

 

Step 23 – Disclose the Identity Of the North Carolina Declarant’s Attorney-in-Fact

If the North Carolina Patient has a representative, then the “Contact Information” section must be filled out with this Party’s information. The “Patient Representative” name should be produced in the first box available while his or her “Relationship” with the Patient should be disclosed in the second box. The final box of the first row in this section requires the Representative’s “Phone #” and “Cell Phone #” If the Patient Representative does not have a “Cell Phone #” then his or her work number may be supplied. The “Health Care Professional Preparing…” this document must self-identify in the next box. Once you have supplied your name to this area, continue to the right where your job title should be documented in the “Preparer Title” box. Finally, record your “Preferred Phone #” for contact regarding this paperwork then supply the current date of its completion in the “Date Prepared” box. 

 

Step 24 – Follow Up On The North Carolina MOLST

In addition to the declaration just completed, an area where the North Carolina Declarant and Physician can document future visits by date, location, signature, and a status update on this paperwork has been supplied for the future use of the North Carolina Medical Professional. He or she will use these follow-ups and the final area to keep the Patient’s medical files up-t0-date. 

 

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