Nebraska Advance Directive Form

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A Nebraska advance directive is a health planning document that lets a person choose someone else to handle medical decisions on their behalf (known as an “agent”). The document allows someone to outline their healthcare goals and let the agent, commonly a spouse or family member, make decisions in the event they cannot speak for themselves. The agent can ONLY make decisions in such an event where the patient is incapacitated.

Advance Directive Includes

Table of Contents

Laws

Statute§ 30-3408, § 20-404

Signing Requirements (§ 30-3404, § 20-404) – Two (2) witnesses or a notary public.

Versions (4)


AARP

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Avera Health

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Nebraska State Unit on Aging

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Spanish (Español) Version

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How to Write

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Step 1 – Save The Nebraska Advance Directive From this Page

The Nebraska Advance Directive on this page can be downloaded using the “Adobe PDF” link or the “PDF” button supplied on this display.

Step 2 – Supplement The Declaration With Your Name As The Principal

Once you access the Nebraska Advance Directive, review this document then when you are ready to appoint a Health Care Attorney-in-Fact to represent your interests and preferences to Nebraska Physicians charged to provide you care when you are incapacitated or when you are unconscious, locate the first empty line below the title “Power Of Attorney For Health Care.” This line must be populated with the full name of the Principal. If you are the Principal, then enter your name on this line. 
Step 3 – Formally Appoint Your Nebraska Health Care Attorney-in-Fact

This opening statement serves to officially name the person you elect to represent you as your Nebraska Health Care Attorney-in-Fact. It is worth mentioning this does not have to be an attorney practicing law however, it should be someone whom you (as the Nebraska Principal) trust. The empty line designated with the word “Name” should be used to present your Nebraska Health Care Agent.

 

Step 4 – Disclose The Contact Information For Your Health Care Attorney-in-Fact

The Nebraska Attorney-in-Fact being appointed will need some additional information presented with his or her appointment to satisfy this statement. Deliver his or her “Address” on the empty line directly underneath his or her “Name.” It is strongly recommended that this “Address” read exactly as it appears on his or her formal identification (i.e., Nebraska State ID or Driver’s License). Complete the presentation of your Nebraska Health Care Attorney-in-Fact by disclosing his or her contact “Phone Number” on the final blank line of this statement.

 

Step 5 – Set A Successor To Your Nebraska Attorney-in-Fact

Even though you have selected someone you trust such as Family Member or Friend to be your Nebraska Attorney-in-Fact over health care and medical decisions, there may be a time when this Party will be unavailable for a long period, unwilling to carry out one or more of your directives when needed, injured to a point of being unable to fill this role, has had his or her power revoked, or subject to any number of scenarios that leave you without a Nebraska Attorney-in-Fact to guide Physicians and Medical Staff through your treatment decisions. The next section seeks to handle this scenario by automatically granting a Successor to the Nebraska Health Care Attorney-in-Fact. The first blank line in this section is reserved for the Successor Attorney-in-Fact’s full “Name.” The second line, labeled as “Address,” seeks the Successor’s physical home address reported for display. Finally, furnish the “Phone Number” where the Successor to the Nebraska Attorney-in-Fact can be contacted on the last line of this set. 

 

Step 6 – Establish When Your Nebraska Attorney-in-Fact May Act

The next area, following the statement beginning with the phrase “By Initialing The Below…” provides several items that bear review. Each such item is a statement that may or may not require information. All the items making up this list will only be applicable to the scope of the Nebraska Attorney-in-Fact medical authority over your treatment if you initial the empty line that precedes it (in the left margin). Any item left without your initials will not be considered applicable to the Attorney-in-fact’s powers. Start this process with the first statement. If your intent to authorize your Nebraska Attorney-in-Fact to make your health care decisions (while you are unable to communicate) with the same authority, then you must initial the blank line in the left margin corresponding to the first statement. 

 

Step 7 – Set Your Instructions, Limitations, And Preferences In Writing

If you have any limitations to the granted authority you are bestowing on the Nebraska Attorney-in-Fact to use when representing you before Medical Personnel then they should be clearly stated in this document and authorized by you as a part of this document. Place all such conditions to the Nebraska Agent’s use of your principal powers in medical decisions made on your behalf on the blank lines below the phrase “…Comply With The Following Instructions Or Limitations” Once this report is submitted to the second item, make sure to initial the blank line in the left margin. Bear in mind that if you limit your Attorney-in-Fact ability to represent your wishes, then the instructions or medical preferences you write in this area will take precedence over his or her report on what your decision in that scenario would be. 

Step 8 – Furnish A Direct Report Regarding Life-Sustaining Treatments

In cases where you are unconscious for an extended period of time or when one or more of your organs fail, Nebraska Medical Staff may determine that life support is needed. This means that a machine or medical procedure will be used to maintain your vital functions. If you do not want life support or life-prolonging treatment administered under certain circumstances (i.e., there will be no hope of recovery) then such directives may be included. This is optional but recommended if you have such wishes. Use the blank lines in the third item to document your limitations or conditions on any life support or life-prolonging procedure, then initial the blank line preceding this statement. 

 

Step 9 – Discuss Artificially Administered Nutrition And Hydration

Your Attorney-in-Fact as well as Nebraska Medical Staff will need to adhere to your decisions in having your nutrition and water or fluid levels maintained when you cannot take in sustenance or liquids. Such aid can sometimes be provided by hand, may need to be done with a tube in the mouth, or can be carried out intravenously. If you wish to deny being artificially fed and hydrated in a circumstance where you are in a permanent coma or will remain in a severely debilitating condition, you may document this using the space provided following the words “…Artificially Administered Nutrition And Hydration.” Remember that if you have supplied information to this item, you must authorize it by initialing the blank line on the left. 

 

Step 10 – Prove Your Understanding For This Appointment

The document being developed need not be completed by the Principal. Every item that has been reported on must be initialed by the Principal but he or she can also have a Preparer or Agent (with the proper authority) furnish the information prior to such authorization. Regardless of the case, a separate statement, beginning with the term “I Have Read this Power Of Attorney For Health Care.” has been presented as the fifth item bearing review. The Principal issuing this document and appointing a Nebraska Health Care Attorney-in-Fact should read this item, then initial the available line on the left to show that he or she has reviewed the information above and approves it. 

 

Step 11 – Acknowledge The Consequences Of This Document

The warning provided in this document discussing the ramifications of granting your authority to your Nebraska Health Care Attorney-in-Fact must be read by the Principal. Verify this with the initials of the Principal produced on the blank line attached to the acknowledgment statement “I Have Read The Above Warning…” 

 

Step 12 – Sign This Paperwork To Appoint Your Nebraska Attorney-in-Fact

Now that the Nebraska Attorney-in-Fact and Successor Agent have been identified, the directives (if any) by the Principal documented, and the acknowledgments above verified by the Principal, this document can now be signed so that it can be effective. Locate the blank line labeled “Signature Of Person making Designation” then sign it. This signature can only be provided by the Nebraska Principal appointing the Attorney-in-Fact above or by his or her Attorney-in-Fact or similar Legal Representative with the Principal’s authority and approval. After this line is signed the Principal (or Signature Party) must record the current “Date” on the empty line on the right. These acts must take place before either two Nebraska Witnesses or a Notary Public licensed to operate as such in the State of Nebraska. 

 

Step 13 – Two Nebraska Witnesses Or A Notary Public Must Show Your Signature Is Authentic

If two Witnesses have watched the Principal sign this document the each one must read the “Declaration Of Witness” section. He or she will need to agree with this statement to continue.    Once the Witnesses have read the declaration, and agree with it, one must sign the first “Signature Of Witness/Date” line then enter the current date. This action also requires the Witness to print his or her name on the “Printed Name Of Witness” line.  The next Witness must sign the second “Signature Of Witness/Date” line and record the date of this signature then print his or her name on the next available line.
Should a Notary Public be used to authenticate the signing, he or she will fill out the Notary section with the basic facts (location of the signing, the date, and the Signer’s name) and present the proof of notarization and his or her credentials. 

 

Step 14 – Review The Introduction To The Nebraska Living Will

The next document of the Nebraska Advance Directives will begin with a declaration. As the Nebraska Declarant issuing this, it is strongly recommended that you read this passage to comprehension. Here, a statement requiring a response to being in persistent/permanent vegetative state or being permanently debilitated by a medical condition that results in death without Nebraska Medical Personnel’s long-term maintenance through life support machines or life-prolonging techniques/procedures will be issued. When in such a condition, this statement will engage the Rights To Terminally Ill Act which entitles the Nebraska Declarant to have life-sustaining treatment that does not affect his or her comfort or pain levels withdrawn or withheld so that the Nebraska Declarant may be allowed a natural death. 

 

Step 15 – Conclude The Living Will With Any Specific Instructions For Nebraska Medical Personnel

If there are any further conditions to the withholding or withdrawal of life-sustaining or life support treatment, they should be put in writing in the area labeled “Other Directions” and found below the living will’s declaration. 

 

Step 16 – Furnish Your Signature Date To This Declaration

This document will only be effective if the Nebraska Declarant issuing it supplies it with a dated signature to prove his or her intent to have these directives followed. The two lines following the phrase “Signe This” will seek first the two-digit calendar day when this signature takes place then, after the words “Day Of,” the month and year that completes the signature date.

 

Step 17 – Submit Your Signature As The Nebraska Declarant

The “Signature” line displayed immediately below the signature date you documented must be signed by you, the Nebraska Declarant, on that day before two Witnesses or before one Notary Public.  Due to the seriousness of this issue, your home address (as it appears on your medical paperwork and government ID) should be disclosed below your signed name on the lines labeled “Address.”    

 

Step 18 – Two Witnesses Or A Notary Public Must Testify To Your Signature

After you have satisfied the request for this document’s executing signature from the Nebraska Declarant, either two Witnesses or one Notary Public must take control of it. If two Witnesses are present to watch the Declarant’s act of signing, then each must read the statement that follows the Declarant’s signature area (“The Declarant Voluntarily Signed This Writing In My Presence” then show agreement by signing the “Witness” line and recording his or her “Address” below this. Once done, the first Witness must relinquish this paperwork to the second Witness. The second Witness should sign his or her name on the remaining “Witness” line then also dispense his or her residential address to the group of lines below the signature line being used labeled “Address.”   If a Notary Public is present for verification, then he or she must sign the “Notary Public” line and produce his or her seal or credentials as needed. 

 

Step 19 – Tend Your Identity To The DNR For The Medically Ill

The final document of the Nebraska Advanced Directives is the “Physician’s Do Not Resuscitate (DNR) Order For The Medically Ill” This document will discuss what Nebraska Responders and other Health Care Providers should do when they find you in a state of cardiopulmonary arrest while already suffering from a preexisting serious medical illness. In this condition, your lungs or your heart will have stopped functioning and death will (likely) be imminent without immediate intervention to maintain their functions. To begin this discussion, locate the blank line after the word “I” and before the phrase “Have Been Diagnosed As Having A Medical Illness” The statement you are making to Nebraska Medical Personnel and the permission to make this document available will make up the body of this declaration. Make sure to read this carefully. 

 

Step 20 – Produce Your Decision On Intubation

This DNR makes the distinction between intubation and cardiopulmonary resuscitation. In the event that your breathing cannot maintain the oxygen levels your body needs to survive, Nebraska Medical Responders and Health Care Providers will try to aid your body in this task immediately. This often requires the process of intubation where a tube is inserted into your airway. If you do not authorize this action when you are in this state, then mark the checkbox labeled “Do Not Intubate.” If you do not mark this checkbox then Nebraska Medical Staff will administer intubation when it is necessary to maintain your ability to breathe. 

 

Step 21 – Deliver A Record Of Your DNR Declaration

If your heart stops pumping an adequate amount of blood to keep you conscious or alive, if your lungs cease their function, or if both occur simultaneously then Nebraska Responders and Medical Personnel will attempt to resuscitate you by physically stimulating these organs until they function correctly or until you can be connected to devices that will do this for you, or until it is apparent that no treatment can be administered to keep them functioning. If you do not wish Nebraska Responders and Medical Personnel to engage in cardiopulmonary resuscitation to keep your heart and/or lungs functioning, then select the box labeled “Do Not Resuscitate (DNR)” 

 

Step 22 – Dispense The Executing Signature

The Nebraska Declarant seeking relief when in cardiopulmonary failure must sign his or her name on the line labeled “Patient, Or Next Of Kin Signature Or Guardian Of Person Or Durable Power Of Attorney For Health Care” line. Notice that if the Nebraska Patient cannot physically act as the Declarant, this paperwork is set to accept this declaration from a Party with the legal authority to issue it. Once the Declarant or Declarant’s Representative signs his or her name, the “Date” line must be populated with the present date. 

 

Step 23 – Document The Patient Address With A Witness Signature

The full home address of the Patient or that of the Medical Facility where he or she is located must be recorded on the “Patient Address” line while a person who has observed these past few items being placed by the Declarant or Representative must sign his or her name on the adjacent “Witness” line. 

 

Step 24 – Obtain Nebraska Physician Approval

This declaration cannot be made unless a Physician licensed in the State of Nebraska deems that it is appropriate for the Patient. The “I Certify That I Have Discussed His Or Her Medical Illness…” statement must be made applicable to the Patient and signed by the Physician. To this end, the name and birthday of the Patient must be produced (in print) on the lines labeled “Patient Name” and “Date Of Birth” respectively.  The “Printed Physician Name” line and “Physician Signature” line require the Nebraska Physician to print his or her name then sign his or her name. This signature must bear a date, therefore a formatted set of lines labeled “Date” have been provided for the Physician’s use.   

 

Step 25 – Complete The Requested Agency Information

In scenarios where the Nebraska Declarant’s Physician is not present to physically sign this form but has provided confirmation over the phone that the DNR is appropriate, the Agent responsible for this phone call must sign the “Agency Completing Form And Agency Representative” line then provide the “Date” of his or her signature on the adjacent set of formatted lines.

 

Step 26 – Indicate If This DNR Was A Phone Interview

If the Physician approval for the DNR was gained by phone, then mark the checkbox attached to the term “By Telephone Order…” 

Step 27 – Discuss This Paperwork’s Distribution

The last request of the Nebraska DNR is for a record of the Parties who have or will receive a copy of the completed form. Select the checkbox labeled “Patient File” since the original must be kept in the Nebraska Declarant’s medical files for future reference. If a “Home Health/Hospice Agency” does or will have a copy of this document, then select the adjacent checkbox. 

Mark the checkbox on the lower left if the “Attending Physician” will retain a copy of this DNR. Select the “Patient’s Home” checkbox only if the Patient is returning with a copy, a copy is already stored, or the Patient has requested a copy sent to his or her home address.  

 

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