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.

Table of Contents

Laws

Statute§ 30-3408, § 20-404

Signing Requirements (§ 30-3404(5), § 20-404(1)) – 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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Nebraska Power Of Attorney

(1) Nebraska Principal. The full name of the Nebraska Principal issuing this appointment should be presented. This is the Patient who wishes to appoint an Attorney-in-Fact for Health Care in the State of Nebraska with the principal power to direct attending Physicians with treatment instructions on the Patient’s behalf.

(2) Nebraska Attorney-in-Fact For Health Care. The Nebraska Attorney-in-Fact for Health Care should be a Private Party that the Principal trusts to reliably act in this role. This is often a trusted Family Member or long-time friend and does not have to be an attorney.

(3) Attorney-in-Fact For Health Care Address. The mailing address where the Nebraska Attorney-in-Fact can be contacted is required for this appointment.

(4) Nebraska Attorney-in-Fact For Health Care Telephone. The Nebraska Attorney-in-Fact’s telephone numbers should also be provided. It is recommended to provide a home number, a work number, and a cell phone number so that Medical Professionals in the State of Nebraska seeking to contact the Attorney-in-Fact through this document can do so quickly.

Successor To Power Of Attorney For Health Care

(5) Nebraska Successor Attorney-in-Fact Name. A precaution allowed by this document will address the possibility of the Party appointed as a Nebraska Attorney-in-Fact for Health Care does not wish to represent the Principal when called upon to, is unreachable, or has been revoked before another is appointed. In any of these cases, the Nebraska Principal can be left without representation regarding his or her medical care unless a Successor is set up through this appointment to take over the Nebraska Attorney-in-Fact for Health Care role should this be necessary. Report the name of the Party who may act as the Successor Nebraska Attorney-in-Fact for Health Care so this Party will be approached for this role should it be vacant.

(6) Successor Attorney-in-Fact Address.

(7) Phone Number Of Nebraska Successor Attorney-in-Fact. It is especially important to deliver the direct contact information of the Successor Attorney-in-Fact since he or she will be called upon when the original Representative is proven unreachable or ineffective while Nebraska Doctors seek direction on the Principal’s directives.

Granted Powers Of Nebraska Attorney-in-Fact For Health Care

(8) Authorize The Nebraska Attorney-in-Fact. The Nebraska Principal must provide direct proof that he or she authorizes the Attorney-in-Fact for Health Care to be the instrument used by Medical Professionals in this state to obtain the Principal’s treatment instructions. This proof should be provided by initialing the first declaration statement provided.

(9) Preferences For Nebraska Health Care. Naturally, there will be a wide scope of decisions that can be made regarding the medical care Nebraska Physicians can administer as well as where this care may be given. If the Principal wishes to place any limits on the medical decision-making powers given the Nebraska Attorney-in-Fact may make on his or her behalf, they should be detailed using the space available in the second statement. This area can also be used to issue direct instructions to the Attorney-in-Fact. If such limitations or instructions will be included, then this statement must be initialed to show the Nebraska Principal’s approval.

(10) Directions For Life-Sustaining Treatment. If the Nebraska Principal requires life-sustaining treatment but cannot communicate any decisions because he or she is unconscious, severely incoherent, or incognizant then he or she can communicate medical decisions through the appointed Attorney-in-Fact and this directive by initialing the third declaration and providing any needed instructions to the Attorney-in-Fact or detail any limitations or restrictions that apply to the Attorney-in-Fact’s scope of principal powers when the Nebraska Principal requires life-sustaining treatment.

(11) Instructions On Artificial Nutrition And Hydration. Many medical scenarios where a Nebraska Patient is unable to communicate or incapacitated while persistently unconscious and afflicted with a terminal (fatal) condition can result in severe to fatal malnutrition and/or dehydration. If desired the Principal can give direct instructions regarding the administration of medically delivered food and water (for instance through a tube or an I.V.) through the fourth declaration. This statement must be initialed to apply.

(12) Acknowledge Your Powers As The Nebraska Principal. The Principal must read through the information presented in the second to last item since this will inform him or her on topics such as the right to revoke (or cancel) this document and how to do so. The Nebraska Principal must understand and initial this statement before proceeding.

(13) Acknowledge Consequences Of Executing This Document. The final item should be initialed by the Nebraska Principal as a demonstration of his or her understanding of this document and the effect it will have on their health care once he or she signs it. The Nebraska Principal’s initials are required to show his or her comprehension of this fact.

Nebraska Principal Signature

(14) Signature Of Person Making Designation. This document will use the signature of the Nebraska Principal or the Signature Proxy designated by him or her to become effective. Sign your name to this paperwork upon its completion and successful review.

(15) Signature Date.

Declaration Of Witnesses

(16) Witness Signature And Date. One of two methods to verify the signature produced was done so to observe and testify to the executing signature of this appointment. If a Witness will serve this purpose, then he or she must testify that the signature provided was done so with a healthy understanding of this document’s content while in a clear state of mind. Each Witness must review this statement then sign a unique signature line immediately below it.

(17) Printed Name Of Witness.

Notary

(18) Notary Public. A Notary Public can be used instead of or along with the Witness signatures to show that the circumstances present at the time of this document’s execution are appropriate for the State of Nebraska. The Notary Public will notarize this document as part of his or her testimony to the signing.

Nebraska Living Will Declaration

(19) Other Directions. The Nebraska Patient can issue a declarative statement as an instruction to withhold life-sustaining treatment administered while he or she is in a persistent vegetative state or unable to communicate and diagnosed with a medical condition that is terminal or fatal regardless of any effort for recovery. If life-sustaining treatment has not yet been administered when the Nebraska Principal has been evaluated with these conditions, then this directive will instruct Medical Professionals not to administer any life-prolonging treatment after such a diagnosis. If any additional directives should be made in addition to the above declaration or to further define it, then use the space provided to present it.

(20) Signature Date.

(21) Signature. The Nebraska Declarant behind this document should sign this document after recording the current date to place it in effect.

(22) Declarant Address. The current address of the Nebraska Principal should accompany the signature he or she provided.

Nebraska Declarant Signature Verification

(23) Witness Signature And Mailing Address. Two options are provided to support the authenticity of the Nebraska Declarant’s signature. The first is to have two Witnesses present and viewing the act of signing when it is performed by the Principal. After this, both Witnesses must use signature areas following the verification statement to present his or her signature and address.

(24) Notary Public. The second option presented to prove that signature requirements have been met is the area dedicated to the notarization of this paperwork’s execution. Here, the Notary Public shall engage the notarization process then document proof of its completion.

Physicians Do Not Resuscitate (DNR) Order For The Medically Ill

(25) Nebraska Principal. The final portion of this directive serves to inform Nebraska Physicians of the Principal’s current diagnosis of a fatal illness and his or her directive to withhold lifesaving procedures in response to traumatic events that prevent you from breathing or your cardiopulmonary system to fail. To issue this document the full name of the Nebraska Principal must be dispensed as the Party declaring his or her treatment preferences.

(26) Do Not Intubate Directive. If the Nebraska Principal is unable to take in oxygen, then Doctors and Medical Staff in this state will seek appropriate treatment so that the Patient can breathe. This can sometimes involve the practice of intubation where a tube is inserted directly down the throat then connected to a machine. If the Nebraska Principal does not wish to be revived with the delivery of oxygen in this manner, then the first special directive statement must be selected.

(27) Do Not Resuscitate (DNR) Order. If the Nebraska Principal’s heart, lungs, or both cease to function correctly, then death could be expected shortly. First Responders, Physicians, and Medical Staff in this state will be trained to immediately use cardiopulmonary resuscitation techniques to restart these organs. If the second special directive is selected, it will inform Nebraska Medical Professionals not to administer CPR to revive the Nebraska Principal.

(28) Signature Execution. This medical order must be signed to be issued. If the Nebraska Principal does not possess the ability to provide a physical signature, he or she can direct a Proxy to do so. Sign this line as the Nebraska Principal or the Proxy effecting this signature on his or her behalf.

(29) Signature Date. The calendar date when the Nebraska Principal (or Proxy) signs this paperwork should be presented.

(30) Patient Address. The address where the Nebraska Principal can be found should be recorded. If the Principal is currently in a Health Care Facility, then, this address (and his or her room and bed number) should be recorded.

(31) Witness To Signature Party. The Witness observing the Nebraska Principal (or Proxy) sign this document must sign his or her name to demonstrate that he or she watched the Principal execute this form. 

Physician Order

(32) Patient Name. The State of Nebraska requires that a licensed Physician sign this document as proof that the Physician orders it issues are justified and should be followed. Thus, a separate signature area for the Nebraska Physician will need to be completed beginning with the name of the Nebraska Patient being discussed.

(33) Patient Date Of Birth. The Patient’s date of birth should be used to further identify him or her.

(34) Printed Physician Name. The Nebraska Physician completing this area must present his or her printed name.

(35) Physician Signature. The signature of the Nebraska Physician must be supplied by him or her so that these orders may be appropriately issued.

(36) Signature Date. The date of the Nebraska Physician’s signature is also needed for this area.

(37) Agency Completing Form And Signature Of Agency Representative. If this directive will be issued through a Medical agency, then a signature line for a Representative of this Agency has been supplied. This Representative must sign his or her name. This signature line is only mandatory if the Physician is unavailable to sign this form but informs the Medical Facility where he or she works that he approves its execution. This will enable the concerned Medical Facility to verify the Physician’s order by phone.

(38) Agency Signature Date.

(39) Telephone Verification From Physician. If this document received its Physician’s approval by phone, then the statement on display must be selected to establish this delivery of authorization of the Nebraska Physician.

Copy Distribution

(40) Copy Holder Recipients. It is strongly recommended that once this document is completed, it is stored in one or more places. To this end, mark every checkbox statement that defines where a copy of this document is stored. In this way, storage of this document in the “Patient File,” “Attending Physician,” “Home Health/Hospice Agency,” and/or the “Patient’s Home.” Select every applicable checkbox.

 

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