Rhode Island Advance Directive Form

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A Rhode Island advance directive is a form used to record a person’s health care treatment preferences and select an agent to speak on their behalf if they cannot do so for themselves. The form is a combination of a medical power of attorney and a living will. To be valid, the form must be signed by the declarant and two (2) witnesses.

Advance Directive Includes

Table of Contents

Laws

StatuteChapter 23-4.11 (Rights of the Terminally Ill Act), Chapter 23-4.10 (Health Care Power of Attorney)

Signing Requirements (§ 23-4.11-3, § 23-4.10-2) – Two (2) witnesses.

State Definition (§ 23-4.11-2(1)) – “Advance directive protocol” means a standardized, state-wide method developed for emergency medical services personnel by the department of health and approved by the ambulance service advisory board, of providing palliative care to, and withholding life-sustaining procedures from, a qualified patient.

Versions (6)


AARP

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Catholic Church

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Dept. of Health

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Hope Health

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Providence Health Care

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Spanish (Español) Version

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Wallet Cards

Medical staff will commonly look in a patient’s personal belongings in the event of an emergency for a wallet card. This gives information on who is acting as the person’s medical agent and the location of their advance directive.

Complete, print, cut, and fold to place in your wallet.

How to Write

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Step 1 – Obtain The Rhode Island Advance Directive

The “Adobe PDF” link in this section of the page enables a direct download of the Rhode Island Advance Directive. Select this item (or the “PDF” button displayed with the preview) to initiate your download.

Step 2 – Review The Rhode Island Directive’s Introduction

The first page of this package will introduce you to the contents and purpose of the directives about to be completed. As the Rhode Island Principal formally documenting your medical preferences you should make sure that you fully comprehend your role and responsibilities before continuing. 

 

Step 3 – Identify The Rhode Island Principal Generating This Directive

The first article that requires attention is titled “(1) Designation Of Healthcare Agent” and expects three distinct entries on the first line. Utilize the area labeled “First Name,” “Middle Name,” and “Last Name” to report your full name as the Rhode Island Principal behind this appointment.  In addition to identifying yourself, proceed to the second line down. This area is also divided by a couple of labels. Satisfy the spaces labeled “Address” and “City/State/Zip” with your complete residential address.

 

Step 4 – Designate The Rhode Island Healthcare Agent

The paragraph titled “Do Hereby Designate And Appoint” includes the language needed to identify your choice for a qualified Rhode Island Health Care Agent who can be approached by Medical Staff for directions regarding your treatment when you are unable to communicate your treatment decisions because you are incapacitated or unable to communicate. A qualified Rhode Island Healthcare Agent cannot be your Healthcare Provider, a person who works for any of your Healthcare Provider, or anyone who is an operator of your community care facility (your Relatives being the exception). The first labeled lines following this designation paragraph seeks the full “Name” and (street) “Address” of your Rhode Island Healthcare Agent. This address must be composed of the building number, street, and unit number where your Healthcare Agent’s home can be found.  Below, two spaces have been provided so that you may disclose the Rhode Island Health Care Agent’s “Phone” number and complete his or her address using the (“City/State/Zip”) line.

 

Step 5 – Review The Authority You Are Delivering To Your Rhode Island Healthcare Agent

Read through Articles “(2) Creation Of Durable Power Of Attorney” through “(4) Statement Of Desires, Special Provisions, And Limitations.” If you have any questions, make sure to seek adequate advice from a qualified Rhode Island Medical or Legal Professional. The wording in these articles are set to be compliant with Rhode Island and Federal Statutes however, Article “(4) Statement Of Desires, Special Provisions” expects that you take advantage of an opportunity to put your directions to the Rhode Island Healthcare Agent and any attending Medical Staff reviewing this paperwork in writing. Locate the item labeled “(A) Statement Of Desires Concerning Life-Prolonging Care, Treatment, Services, And Procedures” then furnish the space below it with your concerns, any specific or general treatment directions and goals you may have in traumatic end-of-life medical scenarios, and any limitations or preferences regarding being put on a life support system. You may use an attachment if more room is required for your directives to be adequately presented but make sure to record the name of any such attachment in this space as well. All attachments to this document must be present at the time of signing and must also be signed and dated.  Naturally, you may be incapacitated for an extended period of time with some to a reasonable amount of hope for recovery. In such instances, you can also provide specific directions or information to your Rhode Island Healthcare Agent and any Rhode Island Medical Staff reviewing this paperwork. For instance, you may be strongly against the use of certain medications or wish to avoid certain types of (chemotherapy) altogether. Use the item labeled “(B) Additional Statement Of Desires, Special Provisions, And Limitations Regarding Health Care Decisions” to dispense such preferences. The final topic of “(4) Statement Of Desires, Special Provisions, And Limitations” is found in the space labeled “(C) Statement Of Desire Regarding Organ And Tissue Donation” where any intention you have of making anatomical gifts can be stated for the review of your Rhode Island Healthcare Agent and the attending Rhode Island Medical Staff. You may also specifically request that your “…Family/Next Of Kin” be the first choice for your anatomical gifts (if possible) by initialing the space to the left of “In the Event Of My Death).”

 

Step 6 – Review The Remainder Of Your Rhode Island Healthcare Agent Appointment

Read Articles “(5) Inspection And Disclosure Of Information Relating To My Physical Or Mental Health” and “(6) Signing Documents, Waivers, And Releases.” These further discuss your Agent’s power when representing you. You may place limitations on these items through the attachments developed in the previous section.  

 

Step 7 – Apply A Termination Date If Desired

Normally, this document’s appointment of your medical decision-making authority to your Rhode Island Healthcare Agent will remain in duration unless you revoke it. If you wish to place a time limit on this document so that it expires naturally, you can. To do so, locate Article “(7) Duration” then place the last date you wish your Rhode Island Healthcare Agent to be able to function with your authority on the blank line following the words “…Expires On” 

 

Step 8 – Appoint Two Rhode Island Healthcare Agent Successors

Article “(8) Designation Of Alternate Agents” enables you to take a highly recommended precaution. Here, the circumstance of being incapacitated while you Rhode Island Healthcare Agent is unable, unavailable, or unwilling to fill this role according to the expectations defined in this paperwork. When this happens, it would be useful to have a successor named. This party can be granted the same authority your Rhode Island Healthcare Agent no longer carries so that your expectations for representation with Rhode Island Medical Staff can be met. He or she will then have the ability to provide your attending Rhode Island Physician(s) with the guidance and consent needed to treat you according to your directives. Item (“A) First Alternate Agent” provides a space where this person’s full “Name, Address, And Telephone Number” should be reported.  If both the previous Agents cannot act as your Rhode Island Healthcare Agent, have refused to, or are not allowed to then the next item “(B) Second Alternate Agent” will give Rhode Island Physicians and Medical Staff an additional person to approach with this document. He or she can then be granted the authority needed to handle your medical decisions. Record the full name of the Second Alternate Agent along with his or her complete address and current phone number to the space provided in Item “(B).”    

 

Step 9 – Complete The Appointment Of Your Rhode Island Healthcare Agent

Directly below Article “(9) Prior Designations Revoked,” the area titled “Date And Signature Of Principal” will require your direct attention. The statement made here will need to be completed and signed before either two Witnesses or a Rhode Island Notary Public. Furthermore, all attachments that should be considered a part of this appointment should be physically present so that they can also be signed and dated before the Rhode Island Witnesses or Notary in attendance. When you are ready to execute this directive, locate the statement “I Sign My Name…” then produce the current date to the space labeled “(Enter Date).”  After identifying the signature date for this appointment, continue through this statement to the next three spaces where you must sign your name directly under the label “(You Sign Below),” then produce a record of the city and state where this signing occurred under the labels “(Enter City)” and “(Enter State)” 

 

Step 10 – Verify The Rhode Island Healthcare Agent’s Appointment As Authentic

The two Witnesses in attendance will be expected to sign their names to verify that they have observed your signing as a valid representation of your intentions and that neither has a conflict of interest by being any of the Agents you appointed or by being associated with your Health Care Provider or Community Care Facility as an Employee or Operator. The first Witness must locate the first “Signature” space then sign his or her name within it. Directly across from this space, the “Residence Address” of the Witness should be entered as well. The Signature Witness must proceed to then supply the “Print Name” space and the “Date” space with his or her own printed name and the current “Date.”  The Second Witness must read the above testimony then sign his or her name in the second space labeled “Signature” before reporting his or her home address in the “Residence Address” space.   After providing these items, the Second Witness must continue one row down to deliver his or her printed name and the signature “Date” to the spaces labeled “Print Name” and “Date” (respectively).   One of the Signature Witnesses must be unrelated to you by “…Blood, Marriage, Or Adoption” and not be entitled to any part of your estate after death or be unaware that he or she will be granted any of your belongings (tangible or intangible) after your death. This Qualified Witness must read the statement below the Notary Public’s section beginning with the words “I Further Declare…” then sign his or her name to the “Signature” space provided. Additionally, the Qualified Witness is expected to clarify his or her identity by supplying the printed version of his or her name to the “Print Name” line.  If you have decided to verify this appointment through the notarization process, then the attending Rhode Island Notary Public witnessing your actions will take control of this document when appropriate then complete “Option 2 – One Notary Public Signature” by subjecting this paperwork to the notarization process then providing his or her seal and credentials as required. Follow any directions the Rhode Island Notary Public puts forth to satisfy this process. 

 

Step 11 – Attend To The Rhode Island Living Will As Desired

If you have decided that you wish to include a deliberate request to be allowed a natural death by withholding or dying life-prolonging procedures such as being put on life support if (or when) you are incapacitated, there is no hope of recovery, and every treatment administered will only serve to prolong this condition. To begin this process, locate the page titled “Declaration” then furnish your name to the blank line in the first paragraph. This can be found preceding the term “Being Of Sound Mind willfully And Voluntarily…” 

 

Step 12 – Establish Your Artificial Feeding Preference

You will need to definitively consent to artificial feeds (i.e., being administered nutrient, water, and liquids through hand-feedings, intravenously, or through a tube) or formally refuse them to issue this declaration. When you are incapacitated for a significant period and cannot intake nutrients or liquids, death from starvation or hydration will be inevitable. If you wish this declaration to inform Rhode Island Physicians and Medical Personnel that you refuse to deliver consent to being fed artificially then mark the checkbox labeled “Includes The Withholding Or Withdrawal Of Artificial Feeding.”  If you wish this declaration to exclude the withholding or denial of artificial feedings, then mark the second checkbox labeled “Does Not Include.” This will mean that even when the above declaration goes into effect and all life support is removed, Rhode Island Medical Staff will still need to maintain your nutrition and hydration even through medical equipment such as a tube.

 

Step 13 – Issue The Date When You Make Your Rhode Island Living Will Declaration

The intent stated in this declaration as well as your signature must be accompanied by the date you formally sign this document. Supply this two-digit calendar day of the month, the name of the month, and two-digit calendar year to the three lines surrounding the phrase “…Day Of…” 

 

Step 14 – Formally Execute The Rhode Island Living Will

The “Signature” line must be signed by you on the date that has been reported above. This action must also take place before two Witnesses willing to sign the testimonial below your signature. Sign the blank line labeled “Signature.”  Once you have signed this, supply your home address on the next line down, then give this paperwork to one of the Witnesses in attendance. The first “Witness Signature” line expects the Witness to sign his or her name and enter the current date next to this then record the residential “Address” where he or she lives.  The next Rhode Island Witness has also been provided with a signature area beginning with a “Witness Signature” line that he or she must sign. This area also requires that the current “Date” be reported as the next Witness’s signature “Date” and the Signature Witness’s home “Address” disclosed below these items. 

 

Step 15 – Complete The Rhode Island MOLST With A Physician

If you have determined that formal orders from a Rhode Island Physician should be included in your medical records to support the above document, then you must coordinate with your Health Care Facility for an appointment. He or she will consult with you to fill out this form. The first part of this form should be filled out with your full name across the two lines labeled “Patient’s Last Name” and “Patient’s First Name.” This will be the Party this document concerns.  One of the “Gender” boxes (“M” or “F”) must be marked as a further means of identification then your birthday should be supplied to the spaces labeled “Patient’s Date Of Birth.” In addition to these items the header of this document must display the date and time that it was completed on the “Date/Time Form Prepared” 

 

Step 16 – Document The Rhode Island Medical Response To A Cardiopulmonary Failure

The first section is labeled as “A” in the left margin and titled “Cardiopulmonary Resuscitation (CPR)” presents two instructions corresponding to an individual checkbox. Only one of these checkboxes can be selected. If you wish Rhode Island Medical Responders to “Attempt Resuscitation/CPR” when your heart has stopped, or your lungs no longer function through whatever means available then select the first box. Otherwise, select the “Do Not Attempt Resuscitation/DNR” checkbox to be allowed a natural death. In the example below, the Rhode Island Declarant has elected to die a natural death when his or her heart or lungs cease functioning so the second checkbox in this area has been selected. This means that no attempt to restart the heart or aid in breathing will be made.  The next section, defined by the “B” in the margin, is titled “Medical Intervention.” Here three checkbox statements require a review. Each defines a level of treatment but only one may be selected as your formal request to Rhode Island Medical Personnel treating you when you are incapacitated but not in cardiac arrest or pulmonary failure. The first level defined here is “Comfort Measures Only.” This box must be selected if your intent is to request that Rhode Island Medical Personnel only ensure your comfort and manage your pain while refraining from administering any treatment to your condition. Only treatments geared toward keeping you comfortable will bear your consent when you select “Comfort Measures Only.”  If you have determined that “Limited Additional Interventions” may be administered, then select the second box. This will inform Rhode Island Medical Staff that you wish to be kept comfortable and will also authorize basic medical treatment or maintenance such as delivering antibiotics or IV Fluids. This also solidifies that you do not wish invasive measures used to treat your medical conditions and, if possible, a trip to the intensive care unit should be avoided.  You may also use this section to formally request the next level of care. Select the “Full Treatment” box of Section “B” to inform Rhode Island Physicians and Medical Staff that you authorize all treatment plans that can be used to prolong your life. 

 

Step 17 – Identify Your Desire To Be Transferred To A Rhode Island Hospital

The topic of being transferred to a Hospital for medical treatment or only for comfort care will be covered in this paperwork. Locate the letter “C” in the margin then review the choices given. If you do not want to be transferred to a hospital for any kind of medical treatment, then the first box (“Do Not Transfer To Hospital…”) must be selected however if you will allow a transfer to a hospital if that is the only way to maintain comfort then select the second checkbox should be selected to inform Rhode Island Responders and Medical Personnel that you authorize a “Transfer To Hospital If Comfort Measures Cannot Be Met In Current Location.” In the example below, the Rhode Island Declarant that he or she will not allow a transfer to a hospital for any reason, so the first checkbox has been selected.   

 

Step 18 – Discuss Your Artificial Nutrition Directives

There may be cases where you are incapacitated and require nutrients delivered to your system whether by hand or by tube. The area labeled “D” presents four checkbox options under the title “Artificial Nutrition” to gain your level of authorization should this need arise. The first two options allow you to deny artificial nutrition or only authorize it for a limited time period. Select the first checkbox (“No Artificial Nutrition”) if you do not authorize any medically administered nutrition when you are incapacitated or select the second checkbox (“Defined Trial Period Of Artificial Nutrition”) to indicate you authorize medically delivered nutrition for only a short time. If neither of these is appropriate continue to review the next two options. Notice below, the Rhode Island Patient has determined that he or she does not want to intake food artificially, so the second checkbox has been selected.  The next two options allow you to inform Rhode Island Medical Staff that you either approve of “Long-Term Artificial Nutrition, If Needed” or that you authorize “Artificial Nutrition Until…” it is no longer beneficial to your recovery or until it becomes a burden.

 

Step 19 – Define Your Authorization For Artificial Hydration

The area noted in the margin as “E” seeks your level of consent in receiving artificial hydration. That is, if you are dehydrated and incapacitated, Rhode Island Medical Personnel will wish to replenish your fluids even if intravenously. This can be especially important if you are incapacitated for an extended period of time. If you do not wish to be hydrated artificially then select the box labeled “No Artificial Hydration.” If you will allow a “Defined Trial Period Of Artificial Hydration” employed in your treatment, then select the second checkbox. If neither of these adequately define your wishes proceed to the next two choices. You can deliver Rhode Island Medical Staff the authorization needed to keep you fully hydrated (even artificially) by selecting the checkbox “Long-Term Artificial Hydration, If Needed” (see the example below) or you may inform Rhode Island Medical Staff that you will only authorize artificial hydration so long as it is beneficial and not a burden (see example below) by checking the final option. 

 

Step 20 – Account For All Rhode Island Health Directives

In the “Advance Directive” section (see “F” in the margin), a list of the documents that can be used to define your rights and medical decisions has been presented. This document is especially useful in that it can be used to immediately inform Rhode Island Medical Responders and Personnel of your acts as a Rhode Island Principal Declarant. Check the box next to “Durable Power Of Health Care,” “Health Care Proxy,” “Living Will,” and/or “Documentation Of Oral Advance Directive” to indicate which of these have been completed and issued. In the case below, the Rhode Island Declarant (or Patient) has issued a “Durable Power Of Health Care” and a “Living Will” therefore the first and third checkboxes have been selected. Your identity as the individual who has discussed this directive with the Rhode Island Physician must be defined as well. Here the attending Medical Professional would have checked the box labeled “Patient,” “Health Care Decision Maker,” “Parent/Guardian Of Minor,” “Court Appointed Guardian,” or “Other” to directly define your relationship to the Patient. Note that if the “Other” box is marked, your status or relationship must be entered on the blank line. In the example below, this document is discussed with the Patient it concerns.

Step 21 – Obtain The Rhode Island MOLST-Qualified Healthcare Provider And Patient Signature

The final area of review is noted by the letter “G” in the left margin. Two areas will require the participation of both the MOLST-Qualified Healthcare Provider and the Rhode Island Declarant or Patient. First, the section titled “Signature Of MOLST-Qualified Healthcare Provider” requires that the Rhode Island licensed Physician, Registered Nurse Practitioner, Registered Nurse, or Physician’s Assistant completing this form must sign the “Signature” line displayed then furnish the Office “Phone Number” and the “Date/Time” his or her signature was provided.  After documenting his or her formal approval for the Rhode Island Physician’s order above, the Signature MOLST Qualified Healthcare Provider must supply his or her printed name and “Rhode Island License #” (to practice medicine) to the next two lines of this section.  The “Signature Of Patient, Decision Maker, Parent/Guardian Of Minor, Or Guardian” issuing this form must be produced on the “Signature” line of the next section. Adjacent to this, the Signature Party must supply his or her “Phone Number” and define the “Relationship” held with the Patient this form concerns. If the Patient is the Signature Party, then the “Relationship” line should be populated with the word “Self.” Finally, the Signature Patient, Decision Maker, Parent/Guardian, or Guardian must present his or her name and address, in print, on the line labeled “Print Name And Address.” 

 

Step 22 – Follow Up On The RI MOLST As needed

Periodically, the Rhode Island MOLST Qualified Health Provider may wish to update this form or verify it stands as is. To this end, a table to record such conversations is available where each such follow-up should be reported by its “Date/Time.” Each row where a date and time of follow-up must be provided with the “Reviewer’s Name And Signature,” the “Location Of the Review” and an indication of the status of the above MOLST through a marking of the appropriate “Outcome Of Review” column where the checkbox labeled “No Change,” “Form Voided, New Form Completed,” or “Form Voided, No New Form” should be marked to indicate the MOLT’s status. 

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