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.

Table of Contents

Laws

StatuteArticle 29-C – (2980 – 2994)

Signing Requirements (PBH § 2981) – Two (2) adult witnesses. The person appointed as agent shall not act as witness to execution of the health care proxy.

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, 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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Article 1

(1) Name Of New York Principal. As the Party issuing this paperwork, you will be able to appoint a Representative to speak to New York Medical Professionals when you are unable to and, if preferred, document your specific medical instructions. Begin by claiming the New York Principal role by documenting your full name in Article 1.

(2) Identity Of Determined Health Care Agent. The name of your chosen New York Health Care Agent should be furnished. Make sure this is a capable and reliable individual that you maintain a current level of communication with. This is the Agent who New York Doctors shall consult to obtain your approval for medical treatments and present their knowledge of your medical preferences. It is recommended that you document your Health Care Agent’s name as it appears on his or her formal identification (i.e., New York State Driver’s License).

(3) New York Health Care Agent Information. Present the residential address and telephone number(s) where the New York Health Care Agent being appointed can be reached by Medical Professionals seeking to contact him or her.

Article 2 Optional: Alternate Agent

(4) Alternate New York Health Care Agent. It would be considered wise to anticipate a situation where your New York Health Care Agent cannot act on your behalf when called upon. This can be for any number of reasons ranging from travel to being revoked. In any case, to aid in the prevention of being incapacitated without a Health Care Agent to communicate on your behalf, this appointment can include the designation of a pre-authorized Alternate Agent to represent your medical wishes to New York Medical Professionals. The Alternate New York Agent will not have access to the principal powers being granted unless the Health Care Agent proves ineffective, and the role becomes unoccupied. List the full name of your Alternate New York Agent for Health Care to provide the authorization to represent you if this becomes necessary.

(5) Contact Information For Alternate New York Agent. The Alternate New York Agent will be contacted when it has become known that the currently appointed Health Care Agent will not be representing you. It is therefore imperative that the details needed to contact this Party is accurate and current.

Article 3 Date Of Expiration

(6) Termination Date Option. As a default, this document remains in effect permanently once it is properly executed unless you revoke it. The opportunity to set a natural expiration date is provided and left to your discretion. If you wish this document and its contents to become void and considered canceled or terminated as of a certain date, then record the intended expiration date to the contents of the third article.

Article 4 Formal Limitations And Instructions

(7) New York Principal Directive. The New York Health Care Agent will be able to make a host of decisions regarding your medical care, treatment, hospitalization, and medications when you are in a permanent vegetative state or incapacitated with an incurable medical condition. Some of these decisions may be extremely difficult to make under the best of circumstances. Therefore, you can deliver instructions that will override any decisions your New York Health Care Agent may make, impose limits on his or her ability to decide for you, require that he or she consult with specific Parties, and document other preferences using the space in Article 4.

Article 5 Your Identification

(8) Your Name. To execute this form, you must complete the signature area while two Witnesses watch. Review your completed medical power appointment then, if satisfied, print your full name at the introduction of the signature area.

(9) Your Signature And Signature Date. As two adult Witnesses (who are not named as either Agent) watch, sign your name.

(10) Your Address.

Article 6 Optional: Organ And/or Tissue Donation

(11) Organ And Tissue Donation. If you have decided to donate any organs or tissues needed at the time of your death to eligible Recipients, place a checkmark next to the first statement of the sixth article. If you only wish to donate only your organs or only your tissues, then circle the appropriate term. Otherwise, proceed to the next area to provide a list of the organs and tissues that you wish to donate as anatomical gifts.

(12) List Of Authorized Anatomical Gifts.

(13) Anatomical Gift Limitations. If there are any restrictions (i.e., you do not wish to donate your body to science or for research) then make sure to document them in the space provided.

(14) Your Signature. Sign your name to demonstrate that your anatomical gift donation is an authorized directive.

(15) Date. Furnish the current date after you sign your name then give the signed appointment form to the attending Witnesses.

Article 7 Statement By Witnesses

(16) Signature Date Of Witness 1. Witness 1 must begin completing his or her confirmation that you signed your name to this form while aware of your actions by also supplying the current date.

(17) Witness 1 Signing. Witness 1 must print then sign his or her name and document the address where he or she can be reached.

(18) Signature Date Of Witness 2. The next Witness is expected to record the date of his or her signature.

(19) Witness 2 Signing. Witness 2 must make the same testimony as the first Witness by printing and signing his or her name then presenting his or her residential address. 

New York Living Will

(20) New York Declarant Identity. This package continues to a second form that will focus on your treatment instructions to New York Medical Professionals administering care when you are diagnosed with an incurable medical condition (mental or physical) such as being in a permanent vegetative state, experiencing the advanced stages of neurodegenerative disease, or rendered with a condition that will result in death. Claim this living will as part of your directives by furnishing your full name to the first declaration statement. If you are a Preparer, make sure the Patient’s full name is produced as it appears in his or her medical records and I.D.’s (i.e., Passport, New York State ID). Note, it is assumed the New York Patient and Preparer will be the same person for our purpose. 

Life-Sustaining Treatments

Select Item 21 Or Item 23

(21) Choice Not To Prolong Life. If you are diagnosed with a severely debilitating or fatal medical condition, the chances that you will require life-sustaining medical procedures will (generally) increase. If you do not wish New York Doctors to extend your life through life-support technology (i.e., dialysis, chemotherapy) then, initial Choice A.

(22) Specific Requests To Withhold. If you have indicated that you do not wish to receive life-sustaining treatment (with the goal of extending life) then take a moment to review the list of treatments being denied. If you wish any of the treatments listed administered when needed, then you must cross out the statement denying it. For instance, if you wish to receive artificial nutrition and hydration, you must cross out the third statement.

(23) Choice To Prolong Life. If you wish your life prolonged for as long as possible using the medical treatments available, then provide New York Physicians with this declaration by initialing Choice B.

Relief From Pain

(24) Pain Management In New York. Some medical conditions can inflict a significant or even debilitating amount of pain to the New York Patient. While pain management provides many options, some may conflict with the Patient’s beliefs or have been known to produce unpleasant side-effects the Patient believes are best avoided. Thus, a space has been set aside so that you may provide any instructions regarding pain management techniques you wish New York Doctors to administer or refrain from employing.

Other Wishes

(25) New York Declarant Directives. If you have requests or instructions to present to New York Physicians and Medical Staff that have not yet been addressed, then make use of the space provided to document them. This report should be an accurate representation of your treatment preferences and concerns therefore you may continue on an attachment if more room is required for this task.

Optional Organ Donation

Choose Item 26, Item 27, Or Item 28

(26) To Refuse Making Donation. The option to include directions regarding anatomical gifts is included with this document. To inform Reviewers of this paperwork that you do not authorize any donation of anatomical gifts, initial Choice A of this area.

(27) To Approve All Anatomical Donation. You can use this document to give general consent to making an anatomical donation of any body part or organs by initialing Choice B.

(28) Specify Approved Donations. If neither of the above declarations suits your wishes then you may also list specific organs and tissues that you authorize for donation, any not listed in Choice C will not be donated. To select this option, you must initial Choice C and list the anatomical gifts you authorize for donation.

(29) Discussion For Purpose. Generally, anatomical gifts are made for the purpose of Transplant, Therapy, Research, and or Education. If you wish to restrict the purpose of your donation then initial the purpose that you do not wish to contribute to. For instance, if you do not wish to make an anatomical gift to any Research or Therapy Recipients then initial these two items. 

Part III Execution

(30) Signed. You must sign this form to execute it as a genuine representation of your treatment instructions when diagnosed with a debilitating or fatal medical condition. This act of signing must be supported by the signatures of two Witnesses. (31) Date. Place the current date next to your name.

(32) Print Name And Address.

Witness 1

(33) Signed. The first Witness to take control of this document, or Witness 1, will need to sign his or her name to confirm the statement verifying your signature as authentic and informed.

(34) Date.

(35) Print name And Address.

Witness 2

(36) Signed. Witness 2 has been given a unique signature area where his or her signed name must be produced. This act will inform Reviewers that he or she has also observed you signing represents informed consent.

(37) Date.

(38) Print Name And Address.

Medical Orders For Life-Sustaining Treatment (MOLST)

(39) Patient Name. The third form in this package is commonly referred to as the MOLST and also issues treatment instructions to New York Medical Personnel. This form however must be authorized by a licensed Physician and will be stored in your medical files for attending First Responders and Medical Staff in this state. As the New York Patient, you must document your name and address at the top of the page. Be advised that your name must be presented in a requested format (last name, first name, and middle initial).

(40) New York Patient Address.

(41) Identifying Patient Information. Your birth date and sex should be produced. This is not a formal eMOLST form however if one has been issued, make sure the necessary digits are displayed.

Section A Resuscitation Instructions When The Patient Has No Pulse And/Or Is Not Breathing

Select Item 42 Or Item 43

(42) CPR Order. If your heart stops or lungs cease to function, cardiopulmonary resuscitation will be immediately administered by attending Health Care Professionals in this state. To preauthorize the use of CPR (cardiopulmonary resuscitation), select the first checkbox of Section A.

(43) DNR Order. If you do not want Physicians and other Health Care Professionals to administer CPR when you experience cardiopulmonary failure and do not wish to be resuscitated so that a natural death may occur, select the second checkbox directive.Section B Consent For Resuscitation Instructions

(44) Signature. Your signature will be required to confirm your decision to issue the CPR or DNR order you selected above. Sign your name to Section B under the observance of two Witnesses. If you lack motor coordination, a Proxy may sign on your behalf but must mark the checkbox statement provided to indicate he or she performed this action and is not the Patient.

(45) Date.

(46) Print Name Of Decision Maker. The full name of the Party who has decided upon the New York Patient’s treatment choice above must print his or her name. Since it is assumed that you are the Patient, print your name after you have signed this document and delivered the date and time you furnished your signature.

(47) Printed Witness Names. Each Witness in attendance must supply his or her name for future reference. These individuals will be able to testify that you have signed your name without being pressured to do so and while aware of the implications behind the treatment orders above. 

(48) Decision Maker Status. The Party issuing the Patient’s decision(s) above should be categorized as the New York Patient, his or her Health Care Agent, an authorized Public Health Law Surrogate, the Parent or Guardian of the Patient, or an Agent operating under New York State §1750-b Surrogate.

Section C Physician Signature For Section A And B

(49) Physician Signature. At this time, the Physician consulting with the Patient on the New York MOLST must sign his or her name to authorize this document as standing medical orders for this Patient.

(50) Print Physician Name. The licensed Physician must print his or her name to clarify his or her identity.

(51) Date/Time. The exact time and date when the Physician signed this document must be provided.

(52) Physician License Number.

(53) Physician Phone/Pager Number.

Section D Advance Directive

(54) Completed Directive. If you, as the New York Patient, have formally executed other directives then inform Reviewers of this MOLST by selecting the checkbox next to each directive that has completed and executed.

Identifying Page 2

(55) New York Patient Identity. All pages of this form must be kept together in your medical records. Make sure your full name and date of birth are supplied to the top of the next page.

Section E Orders For Other Life-Sustaining Treatment And Future Hospitalization Treatment Guidelines

Select Item 56 Or Item 57 Or Item 58

(56) Comfort Measures Only. There are a multitude of fatal or incurable medical conditions (including being in a permanent coma or suffering from severe dementia) that do not cause your heart and lungs to stop but will cause other organs and bodily systems to fail. When your internal organs start to shut down and cease functioning, death is often near. You can address such a condition by issuing treatment guidelines for New York Doctors to follow. For instance, if you do not want life-prolonging treatment when in such a condition and unable to speak or communicate then select the “Comfort Measures Only” directive by marking the checkbox to its left. This will inform New York Doctors that if you suffer a traumatic medical event while carrying a severely debilitating or fatal condition that is incurable that any treatment that focuses on extending life without significantly improving the quality of life or effecting a cure should not be administered.

(57) Limited Medical Interventions. If you wish New York Doctors to intervene when you suffer a life-threatening medical event during your incapacitation, then select the second checkbox statement as your directive. This will inform New York Medical Professionals that while you wish to continue receiving non-invasive treatment (i.e., taking a pill) when needed to continue life but prefer a natural death over invasive treatments (i.e., being physically connected to a machine in order to life).

(58) No Limitations On Medical Interventions. The final choice that can be used to define your medical directives when enduring a fatal or untreatable medical condition authorizes all available life-prolonging treatments to be used to extend life when a medical event may result in death relatively quickly.

Instructions For Intubations And Mechanical Ventilation

Choose Item 59 Or Item 60 Or Item 61

(59) Do Not Intubate (DNR). There is a procedure used by New York Doctors called intubation that is often used as a reliable response when Patient’s in this state cannot physically breathe (for instance, when the Patient’s abdominal muscles become paralyzed for a significant period of time). This involves the insertion of a tube down the throat and can be considered unpleasant or increasingly invasive by some. You can declare that you do not authorize intubation used when you cannot breathe even though your lungs can still absorb oxygen.

(60) A Trial Period. If you have determined that a trial period of intubation can be tolerated in the hopes that you will be able to breathe (recover) at its end, then select the second directive choice in this section. This act will authorize the use of intubation to aid in your continued breathing but only for a limited amount of time.

(61) Intubation And Long-Term Mechanical Ventilation. If desired, you can use this section to inform New York Physicians that you authorize the use of intubation and the aid of long-term mechanical ventilation by selecting the final option presented.

Future Hospitalization/Transfer

(62) Hospitalization Directive. There may be a time when your only hope of extending life is to be hospitalized. If you do not wish to be admitted to a New York Hospital (or transferred to a different one) unless it is purely to treat pain or manage your comfort, select the first checkbox statement presented on this topic otherwise, to inform New York Doctors that you approve of hospitalizations or transfers under the conditions for treatment you require through this document, select the second statement provided.

Artificially Administered Fluids And Nutrition

Select Only One Definition From Item 63 And Only One Definition From Item 64

(63) Tube Feeding Directive. As time progresses, your fatal or untreatable medical condition may prevent your body from eating, even when assisted. Since a host of other problems can be caused by malnutrition or starvation, Physicians in the State of New York will wish to administer your nutrition directly by inserting a tube into your gastrointestinal tract. To prevent this, select the “No Tube Feeding” directive’s checkbox. If you do intend to approve of tube feedings, you may do so for a trial period of tube feeding or to receive long-term tube feeding whenever these procedures are needed by selecting the appropriate directive in this area.

(64) I.V. Fluid Directive. New York Doctors may need to keep you hydrated through an I.V. if you cannot swallow or have a medical condition that prevents you from drinking water. I.V.’s can also be used to deliver nutrients when your G.I. tract is compromised to a point where it can no longer absorb nutrients. You can state that you do not wish to receive any IV Fluids or will approve an IV delivery system for a limited time (a trial period) by selecting one of the checkbox directives discussing this topic. Do not select both since these options clearly contradict one another.

Antibiotics

(65) Instructions For Antibiotics Use. If you develop an infection while you are incapacitated and enduring a serious medical condition, then Physicians and Medical Staff in New York will (usually) attempt to treat it with antibiotics. This is an effort to avoid additional complications for your medical condition and, at times, maintain your comfort. This document allows you to declare that you do not approve of the use of antibiotics, to request that an antibiotics treatment be used with the limitation that they are administered only when an infection occurs, or that you fully approve the use of antibiotics whenever needed by selecting one of the three checkbox statements presented on this topic.

Other Instructions

(66) Additional Patient Directives. Additional Patient instructions approved by a licensed Physician can be included with this MOLST by producing them directly to the area available in “Other Instructions” if needed you may use an attachment so that a complete report can be included with this paperwork. Examples of such directives include how long a trial period for indicated treatments should be as well as medical treatment instructions dictating what should be done when certain conditions occur.

Consent For Life-Sustaining Treatment Orders (Section E)

(67) Signature. If you, as the New York Patient, are satisfied with the contents of this form, then you may execute it by signing it whenever you are ready. Two Witnesses will watch you sign your name and produce the current time and date. If you are a Proxy signing this document for the New York Patient, make sure to check the status box that verbal consent from the Patient has been issued for this form’s execution.

(68) Date/Time.

(69) Print Name Of Decision Maker. The printed name of the person who has decided what should be done in the treatment scenarios above should be produced. If the Patient (you) filled out and signed this form, then print your own name.

(70) Print Witness Names. Both Witnesses must record their names for future proof that you signed your name with the knowledge of this paperwork’s effect.

(71) Decision-Maker Identity. A series of checkboxes will allow you to quickly define who the Decision Maker behind this form is. The options provided are Patient, Public Health Law Surrogate, Health Care Agent, the Patient Minor’s Parent or Guardian, or if the directions above are based on the Patient’s wishes and that these wishes are obvious and convincing, or a surrogate under New York Statute §1750­b. Select the applicable checkbox to define who made and delivered the decisions on the treatment above.

Physician Signature For Section E

(72) Physician Signature. The consulting Physician must sign his or her name to verify that the instructions above constitute formal medical orders issued by a licensed Physician and determined by the New York Patient (you).

(73) Print Physician Name.

(74) Date/Time of Physician Signature.

Identify Page 3

(75) New York Patient. A third and fourth page where the status of the NY MOLST can be updated has been included. This page must bear the full name and birth date of the New York Patient it concerns. Place this information at the top of each page where it will be clearly visible.

Section F Review And Renewal Of MOLST Orders On This MOLST

(76) MOLST Update. A table where a status update can be documented has been provided. When the Patient is interviewed regarding this MOLST, the date and time of the interview, the Interviewer’s printed name and signature, location of the review, and the outcome of the review must all be presented. There will be an ample number of rows to keep this MOLST active and updated for a significant period of time has been provided. Notice that the status of this MOLST must be documented by selecting the appropriate checkbox from the final column (“No Change,” “Form Voided, New Form Completed,” or “Form Voided, No New Form”). 

 

 

 

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