New York Advance Directive Form

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A New York advance directive is a document that allows a person to pre-select their medical treatment options in the event they cannot speak for themselves. The form outlines how a person is to be treated with a spokesperson, an “agent”, to make the decisions on their behalf and in accordance with their wishes. It also includes post-death options such as making anatomical gifts in the form of organ and tissue donation.

Advance Directive Includes

Table of Contents

Laws

StatuteArticle 29-C – (2980 – 2994)

Signing Requirements (PBH § 2981) – Two (2) witnesses.

State Definition (10 CRR-NY 400.21) – An advance directive means a type of written or oral instruction relating to the provision of health care when an adult becomes incapacitated, including but not limited to a health care proxy, a consent to the issuance of an order not to resuscitate or other medical orders for life-sustaining treatment (MOLST) recorded in a patient’s/resident’s medical record, and a living will.

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How to Write

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Step 1 – Download The New York Attorney General – Advance Directive From This Page

The New York Advance Directive is available directly from this page by selecting the “Adobe PDF” link or “PDF” button displayed near their respective image.

Step 2 – Declare The New York Principal’s Identity

The first task set by the New York Advance Directive will be to formally name the New York Principal, who may be a Patient in the future, issuing this document. The first blank line, presented in Article 1, requires this Party’s first, middle, and last name presented. 

 

Step 3 – Formally Appoint the New York Attorney-in-Fact or Health Care Agent

The words “Hereby Appoint” serve to formally designate a person with the same medical decision-making powers over the Principal’s treatment that the Principal can exert with New York Medical Staff. Place the full name of the intended New York Agent or Health Care Attorney-in-Fact on the blank line that follows this phrase.

 

Step 4 – Dispense The New York Attorney-in-Fact Or Health Care Agent’s Address And Phone Number(s)

In addition to the Attorney-in-Fact’s full name, his or her residential address and telephone number should be displayed. Place these items directly below his or her name.

 

Step 5 – Name A Successor To The New York Attorney-in-Fact

The New York Health Care Agent that is receiving the Principal’s medical authority may not be able to fulfill this role in the future either for a lack of ability, will, or authority. The New York Principal can avoid losing the safety of representation by naming an individual who can immediately step in as his or her Health Care Representative or Medical Attorney-in-Fact on the first line of the second article (labeled “(2) Optional: Alternate Agent”). Be advised that this Party will not possess any authority to represent (medically) the Principal unless the Medical Attorney-in-Fact is no longer fulfilling this role or has had his or her authority to do so revoked. 

 

Step 6 – Register The Address And Contact Information For The Successor

It should be considered crucial that the Successor to the New York Medical Attorney-in-Fact can be contacted at will by a New York Health Care Provider reviewing this paperwork. Therefore, two additional lines have been produced in this area to receive the Successor’s home address and contact phone number. 

 

Step 7 – Set A Condition Or Date Of Termination For This Designation

Naturally, there may be a set of conditions, life events, medical events, or even a date that defines the automatic termination of this document (thus canceling the applicability of its contents). The New York Principal can use the blank lines in the third article to present this termination’s conditions. 

 

Step 8 – Optionally Limit The Decision-Making Power Of The New York Health Care Agent

Article (4) of this paperwork seeks a record of the New York Principal’s preferences in medical treatments and responses. This is an optional area where the Principal can set as many instructions as possible relating to medical events, how they should be handled, who should be connected, and any other topic found relevant by the New York Principal. 

 

Step 9 – Furnish The Formal Execution Of This Paperwork

The New York Principal must finalize his or her designation of the Medical Attorney-in-Fact as well as his or her directives. This requires written proof of the New York Principal’s intent. Thus, Article “(5) Your Identification” requires the full name of the New York Principal reported on the “My Name” line.  To officially execute this form, the New York Principal must sign the “Your Signature” line as well as furnish the “Date” when this action is completed.   After completing the signing, the New York Principal should continue to the next line down to supply his or her home address on the “Your Address” line.  

 

Step 10 – Discuss the Organ Donation Status Of The New York Principal

The next area of this appointment is optional but has been provided so that the New York Principal can document his or her feelings regarding anatomical gifts. Article “(6) Optional: Organ And/or Tissue Donation” contains three statements of which one must be selected. If the Principal intends to donate “Any Needed Organs And/or Tissues” then he or she should place a checkmark next to the words “Any Needed Organs And/or Tissues”  If the Principal only intends to allow certain body parts donated upon death, then place a checkmark next to the word “The Following Organs And/or Tissues.” Utilize the blank lines after this phrase to discuss the anatomical donations approved by the New York Principal. Any “Limitations” the Principal wishes to place on anatomical donations can be documented on the final line of this section. 

 

Step 11 – Obtain The New York Principal’s Acknowledgment Signature To The Organ Donation Statement

The New York Principal must verify his or her anatomical gifts preferences by signing the “Your Signature” line and declaring the “Date” line. The verifying signature of the Principal must be proven as authentic through the testimonial of two Witnesses. Once the New York Principal has completed the execution of the above directive. 

 

Step 12 – Produce Witness Statements To Prove the Signature

Once the New York Principal has completed the execution of the above directive, the Witnesses serving this purpose must review Article “(7) Statement By Witnesses” since the signature each provides will serve as proof of each Signature Witness’s acknowledgment and agreement with this statement.  This process must begin with the “Date” of the Witness signing reported on the first line below the declaration in their respective columns. Once the Signature Witness(es) has identified the calendar “Date” of signature, each must print his or her name directly below it. The “Signature” line presented in each column requires that the Witness named within it sign his or her name on it. Finally, the home “Address” of each Witness must be documented below his or her name. 

 

Step 13 – The New York Living Will Can Be Included By The Declarant

The New York Living Will constitutes the next section of this paperwork. This document will state the New York Declarant’s preferences or instructions when he or she is enduring an end-of-life event, cannot maintain his or her body independent of medical aid, or is permanently unconscious or incognizant. Since the New York Declarant will be making decisions that will have permanent repercussions this document will act of proof of his or her intentions. Review the introduction at the onset of this declaration. 

 

Step 14 – Name The Living Will’s Declarant Or Future New York Patient 

The first empty line of this declaration must be supplied with the full name of the New York Declarant. The Party named on this line will be considered the New York Declarant making the statements that follow.

 

Step 15 – Present The New York Declarant’s Life-Sustaining Directives

The Declarant behind this document should make use of the “Life-Sustaining Treatments” section to indicate how he or she wishes New York Medical Personnel to behave when faced with an “Irreversible Mental Or Physical Condition With No Reasonable Expectation Of Recovery” then he or she can decide not to receive cardiac resuscitation, mechanical respiration, medically or artificially administered nutrition and hydration, and antibiotics. To present this refusal, the New York Declarant must initial “(A) Choice Not To Prolong Life.”If the New York Declarant prefers to receive treatment to prolong his or her life when faced with a fatal or terminal condition, then he or she must initial the space preceding “(B) Choice To Prolong Life.” This statement will mean that New York Medical Personnel will be authorized by the Principal to use any means necessary and legally available to maintain the Principal’s body. 

 

Step 16 – Deliver The New York Declarant’s Instructions On Pain Management

The “Relief From Pain” portion of this document allows the New York Principal to directly report his or her instructions on pain management. It should be understood that by default, this section will determine that all efforts to relieve the Patient of pain and/or discomfort will take priority, even if the process of death will be accelerated as a result. 

 

Step 17 – Place Conditions, Additions, Or Restrictions To The Contents Of This Declaration

If there are “Other Wishes” that should be placed in this document, then record them on the blank lines in the next section. This will allow the New York Principal to dictate exactly what the conditions causing this living will to go in effect and to what extent. For instance, the New York Principal may approve of all methods used for life-prolonging procedures except for artificial nutrition or the administration of CPR. 

 

Step 18 – Gather The New York Declarant’s Organ Donation Authorization

The topic of anatomical gifts can be addressed through this document. The section titled “Optional Organ Donation” seeks the New York Principal’s status regarding this subject. If the New York Principal does not wish or want to make any anatomical gifts and does not give any Attorney-in-Fact named for representation to authorize any organ, tissue, or body part donation.  If the New York Principal authorizes the donation of any “Needed Organs, Tissues, Or Parts” upon his or her death, then Statement B should be initialed by the New York Principal. Statement C in the “Optional Organ Donation” section should be initialed if the New York Declarant intends to give only certain organs, tissues, or (body) parts. The blank lines presented should be used to list all authorized organ donations.  The statement beginning with the words “My Gift, If I Have Made One…” enables the New York Declarant to define the purpose of an authorized organ donation made by the Principal. The four items presented each list a purpose for the act of anatomical gifting. Any purpose the New York Principal does not wish to satisfy with an organ donation should be initialed by the Principal. For instance, if the New York Declarant will not donate his or her organs to satisfy a “Transplant” then the first item on this list should be initialed.  If the New York Declarant does not want his or her anatomical gifts to be made for “Therapy” then the second item must be initialed. The New York Principal should initial the third item if he or she does not wish to donate organs, body parts, or tissues for “Research” purposes.  The fourth item, “Education,” should be initialed by the New York Principal if he or she intends will not authorize an anatomical gift made for this reason. 

 

Step 19 – The New York Declarant’s Signature Is Mandatory For Execution

In order for this document to be completed with the proven authorization of the New York Principal, he or she must sign it before two Witnesses. The New York Principal must locate the first line in “Part III. Execution” then sign his or her name to it. This will set his or her intent to paper but there must be a formal “Date” attached, therefore, the next blank line to the right must be presented with the current “Date.”  The line labeled with the words “Print Name” requires that the New York Declarant presents his or her name is standard print or type face as its content. 

In addition to his or her signature, date of execution, and printed name, the New York Principal’s “Address” should be presented.

 

Step 20 – Witnesses To the Declarant’s Signature Must Prove The Signature

After the signing, the New York Declarant must relinquish this paperwork to the Witnesses in attendance. The blank lines below the declaration statement ending with the term “…This Document In My Presence” must be completed by the Witnesses in attendance. The “Witness 1” section of this area is reserved for the first Witness who has read this document. He or she must sign the blank line labeled “Signed” then produce the current “Date” on the line to the right of this.  After this signature, Witness 1 must print his or her name to the blank line underneath the submitted signature.  Witness 1 must complete this with the residential “Address” of his or her home.  The next Witness must tend to the area labeled “Witness 2.” The blank line labeled “Signed” and “Date” must be presented with Witness 2’s signature and signature date, respectively. The “Print Name” line requests that Witness 2 prints his or her name. Finally, the “Address” line must be supplied with the home address of the second Witness. 

 

Step 21 – The New York Declarant Must Work With A Physician To Include The MOLST

The New York Medical Orders For Life-Sustaining Treatment is developed to allow a New York Physician to present specific treatment orders in a Patient’s files that have been developed with the Patient and authorized by the concerned New York Physician. The first requirement to be fulfilled will be to display the full name of the New York Declarant or New York Patient whose care is being discussed. Present this Party’s full name on the blank line labeled “Last Name/First Name/Middle Initial Of Patient.” 

 

Step 22 – Proceed With Additional Descriptions Of The New York Declarant

The residential address of the New York Declarant or Patient is expected on the next two blank lines. The line labeled “Address” expects only the first line (building/street/apt) of the New York Declarant’s home “Address.” The “City/State/Zip” line that follows is set to receive the remainder of the New York Declarant’s residential “Address.”  The last items requested to identify the New York Declarant is his or her Date of Birth, his or her sex, if needed The EMolst Number (if one is assigned). The line labeled “Date of Birth” calls for the New York Declarant’s birthday as a two-digit month, two-digit day, and four-digit year. After this, if the New York Declarant is a “Male” then place a mark in the first checkbox but if the checkbox is a “Female” then he or she must initial the second box. 

 

Step 23 – Review The MOLST Conditions Applying

Section A of this paperwork will open the discussion on the New York Principal’s directives to define the “Resuscitation Instructions When The Patient Has No Pulse And/or Is Not Breathing” If he or she wishes to issue a “CPR: Attempt Cardio-Pulmonary Resuscitation” order then the first checkbox in “Section A” must be marked.  If the New York Declarant intends to use this document to issue a “DNR Order: Do Not Attempt Resuscitation (Allow Natural Death)” then the second checkbox should be marked. 

 

Step 24 – Prove The New York Declarant’s CPR Or DNR Request

The New York Declarant will need to provide an authorization to the determined “CPR…” or “DNR…” order that has been issued. The “Signature” line at the beginning of “Section B Consent For Resuscitation Instructions” must be signed by the “Signature” line. If the Declarant cannot sign this document (i.e., he or she does not have enough motor control) then check the box labeled “Check If Verbal Consent.” Finally, the date and time when the “Signature” or “Verbal Consent” was presented should be distributed to the line attached to the “Date/Time” label. The full name of the New York Declarant or the Agent issuing this document with the attending New York Physician on the line labeled “Print Name Of Decision-Maker”Finally, two Witnesses must print their names on the blank lines labeled “Print First Witness Name” and “Print Second Witness Name” The final question of Section B, “Who Made This Decision” presents five checkboxes “Patient,” “Health Care Agent,” “Public Health Law Surrogate,” “Minor’s Parent/Guardian” or “§1750­b Surrogate.” Place a checkmark in the box that best defines the Party acting as the Signature Declarant.   

 

Step 25 – The New York Physician Must Approve The MOLST Directive

“Section C Physician Signature For Sections A And B” requires that the New York Physician discussing this document with the Declarant sign his or her name, print it, then report the current date and time on the blank lines labeled “Physician Signature,” “Print Physician Name,” and “Date/Time”  Next, the “Physician License Number” allowing the New York Professional to operate as well as his or her telephone or pager number must be displayed on the “Physician License Number” and “Physician Phone/Pager Number” line (respectively). 

 

Step 26 – Define Any Attached Directives To The NY MOLST

In “Section D Advance Directives” this declaration will seek a list of any other documents containing the New York Declarant’s health care directives. In this area, you can select as many checkboxes as necessary to indicate which declarations have been issued by the New York Patient issuing the MOLST. Check the “Health Care Proxy,” “Living Will,” “Organ Donation,” and/or “Documentation Of Oral Advance Directive” 

 

Step 27 – Attach The New York Declarant To The Next Page Of The MOLST Form

The second page of this form begins with an area to identify the New York Declarant. Delver his or her Last Name, First Name, and Middle Name of the New York Declarant and his or her birthday on the blank lines labeled “Last Name/First Name/Middle Initial Of Patient” and “Date Of Birth”   

 

Step 28 – Present The New York Declarant’s Treatment Guidelines

The next area of the MOLST seeks the New York Declarant’s “Orders For Other Life-Sustaining Treatment And Future Hospitalization When The Patient Has A Pulse And The Patient Is Breathing” and has been set to receive the New York Declarant’s “Treatment Guidelines.” If the Declarant requests that New York Medical Responders engage “Comfort Measures Only” then the first checkbox in Section E’s “Treatment Guidelines must be selected. This statement indicates the New York Declarant does not wish invasive measures used to treat his or her medical condition unless it is to manage his or her pain and maintain comfort.  The second statement in the “Treatment Guidelines” requests that “Limited Medical Interventions” be administered according to the Patient’s MOLST directives when New York Medical Staff attend to the Patient’s symptoms.  If there should be “No Limitations On Medical Interventions” when tending to the New York Declarant’s medical needs, then the third checkbox must be selected from the “Treatment Guidelines” section.

 

Step 29 – Include A Report On The New York Declarant’s Assisted Ventilation Instructions

There may be times when New York Medical Staff must assess the Patient’s breathing. If it is obstructed, the default response will be to ensure the New York Declarant’s ability to breathe even with invasive measures such as intubation. If the New York Declarant does not approve of intubation, then select “Do Not Intubate” from the section titled “Instructions For Intubation And Mechanical Ventilation.”  If the New York Declarant will accept “A Trial Period” for the use of intubation or medically assisted breathing, then select the second checkbox. This will bear further definition.  The New York Declarant must define what methods of assisted breathing he or she will tolerate for a limited amount of time. If he or she will approve of a trial administration of “Intubation And Mechanical Ventilation” then select the first checkbox in “Trial Period.”    If the New York Declarant will approve the use of “Noninvasive Ventilation” then the second checkbox in “A Trial Period” should be selected.  The New York Declarant may be open to long term assisted breathing through whatever means are medically appropriate. If so, then select the final option of this section by marking the checkbox corresponding to the label “Intubation And Long-Term Mechanical Ventilation, If Needed.” 

 

Step 30 – Convey The New York Declarant’s Preferences For Hospitalization

If the New York Declarant is found unresponsive he or she may need to be hospitalized however, the Patient may not authorize admittance to a hospital or transfer to one therefore, the “Future Hospitalization/Transfer section must be attended. If the only reason the New York Declarant will accept hospitalization will be for the goals of maintaining comfort or managing the level of physical pain he or she is in, then mark the first checkbox in this section “Do Not Send To The Hospital Unless Pain Or Sever Symptoms…”  If the New York Declarant has defined in previous sections whether he or she will accept hospitalization for treatment of his or her medical condition then, select the second checkbox in this section.   

 

Step 31 – Document Artificially Administered Nutrition Requirements Of The New York Declarant

The “Artificially Administered Fluids And Nutrition” section will present several levels of authorization on the topic of nutrients and liquids being medically administered when the Patient is not able to effectively take in food and water. If the Patient or New York Declarant does not wish a feeding tube to be used or to receive IV Fluids, then the first and the second check boxes in this section must be selected.  If the New York Declarant will authorize “A Trial Period OF Feeding Tube” administered and/or  “A Trial Period Of IV Fluids” used to deliver his or her food and water, then select the second and/or third checkboxes.  The final checkbox, “Long-term Feeding Tube, If Needed” should be selected if the New York Declarant has no such objections.  The “Antibiotics” Section has been included to receive the New York Declarant’s directives when an infection must be treated. If the New York Directive only approves of antibiotics used to keep him or her comfortable and pain-free, then select the “Do Not Use Antibiotics” checkbox.  If the New York Declarant will “Determine Use Or Limitation Of Antibiotics When Infection Occurs” then select the second checkbox in “Antibiotics.” 

The New York Declarant can approve New York Medical Provider’s administration of antibiotics as needed and as determined to treat the New York Declarant’s condition by marking the third checkbox “Use Antibiotics”

 

Step 32 – Produce Additional Instructions From The New York Declarant

The “Other Instructions” section has been included to accept additional directions, preferences, authorizations, and, if appropriate, time limits or conditions to treatment. If no “Other Instructions” are required, then this are may be left blank. 

 

Step 33 – Gain The New York Declarant’s Signature

The section labeled “Consent For Life-Sustaining Treatment Orders” will require the consent of the New York Declarant. If he or she can sign this document, then the “Signature” line must be supplied with this item. If this is not possible and verbal consent was given, then the “Check If Verbal Consent” box must be selected. Additionally, the date and the time of consent must be documented on the “Date/Time” line.  Next, the Decision-Maker’s printed name must be displayed on the next line down.  Finally, both Witnesses must supply their names to the “Print First Witness Name” line and “Print Second Witness Name” line.  The statement below this signature area “Who Made This Decision” seeks clarification as to the Originator of this form. Several descriptions that may answer this question are defined with the check box labels “Patient,” “Health Care Agent,” “Based On Clear And Convincing Evidence,” “Public Health Law Surrogate,” “Minor’s Guardian,” or “§1750­b Surrogate.” Since our example has been filled out with the New York Declarant and Physician working together, the checkbox labeled “Patient” has been selected.

 

Step 34 – The New York Physician’s Approval Signature Must Be Obtained For Presentation

The “Physician Signature For Section E” section will require the direct approval for these directives on this MOLST by signing the “Physician Signature” line, printing his or her name on the second line of this section, then dispense the signature date on the “Date/Time” line. 

Step 35 – Follow Up Evaluations Of The NY MOLST Are Encouraged

The second page of the NY MOLST must be clearly identified as concerning the New York Declarant we have just discussed. To this end, supply his or her full name on the line labeled “Last Name/First/Middle Initial Of The Patient” then his or her “Date Of Birth” to the right.  Both these items should be supplied where requested at the top of the page.  An ample table has been provided on the second page where the New York Physician and Declarant can work together to evaluate the NY MOLST, Each row will represent a different evaluation “Date/Time” that should be documented in the first column. The second and third columns require the reviewing New York  Medical Professional’s printed name and signature (“Reviewer’s Name And Signature”) and the “Location Of The Review” provided (respectively). The results of the follow-up review will be expected in the final column with a checkbox report. In this way, the current NY MOLST can be evaluated to have “No Change,” as being a “Form Voided, New Form Completed,” or listed as a “Form Voided, No New Form.” There will be enough rows to perform this review multiple times until the current NY MOLST of the Patient is formally voided during one of these reviews. 

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