Rhode Island Advance Directive Form

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A Rhode Island advance directive is a form used to record a person’s medical 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. A notary may also be used instead of witnesses (see Step 22 in our How to Write section).

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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Article 1. Designation Of Healthcare Agent

(1) First, Middle, And Last Name. The first portion of this directive enables the Rhode Island Principal to appoint an Agent to act as his or her Representative before Physicians and Health Care Providers in this state. Identify yourself as the Rhode Island Principal making this appointment.

(2) Address And City/State/Zip. The street address, city, state, and zip code where you live should be documented with your name.

(3) Rhode Island Healthcare Agent. The first, middle, and last name of your Rhode Island Healthcare Agent is the next requirement. As your Agent, this Party will be responsible for informing Rhode Island Physicians and Medical Personnel of your treatment authorizations.

(4) Phone Number Of Contact.

(5) Address And City/State/Zip.

Article 4 Statement Of Desires, Special Provisions, And Limitations

(6) Life-Prolonging Care, Treatment, Services, And Procedures. The sweeping powers given to the Rhode Island Healthcare Agent over your medical treatment when suffering an incurable or fatal condition or in a permanent coma can have a meaningful impact on your quality of life and lifelong medical condition. You may either impose limitations on your Rhode Island Healthcare Agent’s power to decide for you by documenting them or by issuing specific instructions to him or her in Area (A). Any such power restriction or instruction regarding life-prolonging care given and available treatments in the State of Rhode Island should be presented in this document. If you need more room for this task, then compose an attachment containing this information.

(7) Additional Statement Of Desires, Special Provisions, And Limitations. Use Area (B) to discuss additional medical concerns, instructions, or Agent limitations regarding topics such as a secondary nonfatal but complicated medical condition, a strong belief system regarding treatments, or desired experimental treatments or trial periods.

(8) Tissue Donations. Area (C) is included so that, if desired, you may deliver instructions on anatomical gifts you wish made. As a Rhode Island Organ Donor, you can determine which tissues, organs, or other parts of the body can be donated after death and for what purpose. To do so, document your wishes where requested. Notice an additional statement that will request and authorize your Rhode Island Healthcare Agent to inform your family and/or your next of kin of your decision to become a Rhode Island Organ Donor should they remain unaware of your intention at the time of your death.

Article 7 Duration

(9) Rhode Island Principal’s Declared Termination Date. In most cases, a Rhode Island Principal will wish to keep documents defining his or her treatment preferences active until they are revoked (i.e., such to update one’s health care authorizations). If preferred, you may set an expiration date to this appointment. If you wish for this appointment of power and any treatment directive to automatically terminate and cease being effective as of a certain day, then the calendar date of this predetermined revocation or voiding of this document should be established with a report. Present the intended revocation (i.e., expiration, termination) date where requested otherwise, to keep this document active until you revoke it, leave this area blank.

Article 8 Designation Of Alternate Agent

(10) First Alternate Agent. If the Rhode Island Healthcare Agent, you have appointed with the principal powers above does not fill this role when he or she is called upon to do so then Rhode Island Physicians will refer to this paperwork for any Rhode Island Agents that you hold in reserve. The First Rhode Island Alternate Agent you name will have the authority to act as your Healthcare Agent only if (and when) your original appointment is not available, cannot be found or reached, or has been removed by a previous revocation. For this Alternate Agent to be able to receive the Healthcare Agent’s principal powers, his or her identity must be fully verifiable through this document. Thus produce the same address that is found on his or her State ID as well as the phone number(s) where your First Alternate Agent can be reached.

(11) Second Alternate Agent. Naturally, there is a chance that your First Rhode Island Alternate Agent cannot be reached or is not able to accept the Healthcare Agent role. If this happens, it is at a time when your original appointment has also failed. This document allows an additional precaution to be taken so such a scenario does not leave you without representation. Attach the name and contact information of the next person you wish approached for your health directives to this document as your Second Alternate Rhode Island Agent.

Date And Signature Of Principal

(12) Signature Date. The calendar date when you sign your name as the Rhode Island Principal should be established by recording it where requested.

(13) City And State.

(14) Signature. The State of Rhode Island requires a signature from the Principal behind this appointment that is verifiable. This is accomplished through the testimony of an impartial Party observing this act. Therefore, sign this paperwork before two Adult Witnesses.

Statement Of Witnesses

(15) Witness 1 Signature And Printed Name. The Witnesses in attendance will each need to provide a signature testimony in a predetermined area. Witness 1 must sign and print his or her name after watching you sign this document as the Rhode Island Principal.

(16) Residential Address.

(17) Witness 1 Signature Date. The calendar date when the first Rhode Island Witness signed his or her name is also needed after providing his or her signature and address.

(18) Witness 2 Signature And Printed Name. The next Witness must also present his or her signature and printed name as proof that he or she has watched you sign this document.

(19) Residential Address. Witness 2’s address should be documented after signing this form.

(20) Witness 2 Signature Date.

Option 2 – Notary Public Signature (Note: Read Below)

(21) Notary Verification. Rhode Island law allows for a notary acknowledgment in lieu of witness attestation when executing durable healthcare power of attorneys. However, it is recommended the principal opt for the witness method of execution when including a declaration relating to life-sustaining treatment, most of which are contained within an advance directive. (§ 23-4.11-3.) Therefore, the principal is recommended to select Option 1 when enacting an advance directive or living will. Still, a notary public acknowledgment shall be sufficient to legally bind the terms of an advance directive. 

(22) Additional Witness Declaration. At least one Witness must be completely impartial in that he or she cannot be considered a relation (i.e. by blood, by marriage, by adoption) of the Rhode Island Principal behind this document. This Non-Relative Witness must sign and print his or her name to self-identify to Reviewers.

Rhode Island Living Will Declaration

(23) Rhode Island Declarant. The State of Rhode Island gives you the option of denying any treatment that only prolongs your life after you have lost your capacity of communication and have been formally pronounced as being in a permanent coma or suffering a fatal and untreatable medical injury or condition. This statement is done by the virtue of issuing your Rhode Island Living Will. To begin, attach this form to your directive by recording your full name in the statement it makes.

(24) Artificial Feeding Declaration. Consider the circumstance of a lifelong coma or being in the end-stage of a fatal medical injury or disease. Your body will be unable to take in food and water independently at a certain point. This will cause additional complications from malnutrition and dehydration therefore if you wish to accept nutrition and water through the use of a machine/tube then you must display your authorization for artificial feedings. Similarly, if you do not wish nourishment to be delivered artificially, then you must display the authorization Rhode Island Doctors will need to deny artificial feedings or withdraw any machinery currently in use for this purpose when you become unconscious or unable to convey your wishes any longer.

(25) Signature Date. Rhode Island Medical Professionals will wish to confirm this is the latest document you have issued regarding your treatment requests when pronounced with an incurable or untreatable coma, fatal injury, or disease. Report the current date to display this information to Rhode Island Reviewers.

(26) Rhode Island Declarant Signature. Sign your name as two Witnesses (both adults) watch.

(27) Rhode Island Declarant Address.

Rhode Island Witness Statement

(28) Witness 1 Signature Requirement. The signature, signature date, and address of Witness 1 are mandatory for the Witness requirements of this signing. 

(29) Witness 2 Signature Requirement. Witness 2 will complete the signature requirement for this living will by also presenting his or her signed name, current date, and address of residence.

Medical Orders For Life-Sustaining Treatment (MOLST)

(30) Name Of Rhode Island Patient.

(31) Gender And Birth Date Of Rhode Island Patient.

(32) Document Date And Time.

Part A Cardiopulmonary Resuscitation (CPR)

(33) Attempt Resuscitation/CPR. The Rhode Island Patient’s decision on cardiopulmonary resuscitation is the first topic of discussion with the Medical Personnel consulting on this document. If the Rhode Island Patient has decided that CPR or the resuscitation of the hearts and lungs may be engaged when either or both organs fail, then select the appropriate statement in Part A.

(34) Do Not Attempt Resuscitation/DNR. The option to prematurely deny or withdraw authorization for cardiopulmonary resuscitation methods to be administered when the Rhode Island Patient’s heart/lungs stop is also available. To enact this directive the alternate checkbox statement provided in Part A should be selected.

Part B Medical Intervention

(35) Comfort Measures Only Order. The Rhode Island Patient’s desired level of medical intervention when he or she suffers a life-threatening medical event should be assessed and reported in this document. Three options are available for this definition beginning with the directive that only medical treatment geared to promoting and maintaining the Rhode Island Patient’s comfort is administered while denying all life-prolonging techniques (especially invasive ones). Select the first checkbox directive of Part B to set this directive to the Rhode Island Patient’s instructions.

(36) Instruction For Limited Additional Interventions. If the Rhode Island Patient authorizes the goal of life-sustaining treatments but only so long as they are not invasive (i.e., surgeries, physically uncomfortable or painful attachments to machines), then present this as the Rhode Island Patient’s Physician-approved directive for medical interventions.

(37) Full Treatment In Rhode Island. The Rhode Island Patient can immediately authorize all life-sustaining treatments to preserve his or her life by selecting the “Full Treatment” directive.

Part C Transfer To Hospital

(38) Refusing Rhode Island Hospitalization. The Rhode Island Patient’s willingness to be hospitalized to receive life-saving or life-sustaining treatment should be included with the medical orders presented here. If he or she refuses hospitalization to receive any treatment required to prolong life, then select the first statement.

(39) Authorizing Admittance To Rhode Island Hospitals. If the Rhode Island Patient has expressed that he or she will only authorize hospitalization for the purpose of comfort care (not for life-sustaining treatment), select the second statement. 

Part D Artificial Nutrition

(40) No Artificial Nutrition Authorization. The Rhode Island Patient may have decided that it would be best to deny the use of machines, tubes, and other invasive methods of delivering nutrition to his or her system when unable to eat naturally. The first statement in Part D will allow this direction to be made.

(41) Long-Term Artificial Nutrition Request. The Rhode Island Patient’s authorization or request to have his or her nutrition administered (even artificially) when needed, can be shown by marking the second statement.

(42) Trial Period For Artificial Nutrition In Rhode Island. Select the third option should the Rhode Island Patient wish to approve of machine-provided nutrition but only for a limited period of time.

(43) Conditional Authorization Of Artificial Nutrition. Sometimes, a medical condition can debilitate the body enough so that medically delivered nutrition would be considered very painful or even overly burdensome. This can outweigh the benefits to the Patient therefore he or she can indicate that using machines to deliver nutrition so long as it does not cause pain or be considered non-beneficial. If this is the case, then locate and fill in the final checkbox statement.

Part E. Artificial Hydration

(44) No Artificial Hydration Instruction. A Rhode Island Patient is at severe risk of dehydration when he or she is in a permanently unconscious state or in the advanced stages of a fatal illness. If the Rhode Island Patient indicates that water or hydration should not be provided through invasive methods or machines, then this desire should be coupled with the Physician authorization this form provides by marking the first checkbox.

(45) Request Long-Term Artificial Hydration In Rhode Island. The directive to authorize long-term hydration delivered using medical technology for the Patient (at his or her request) can be documented through the second statement in Part D.

(46) Trial Period For Artificial Hydration Directive. A trial period when artificial hydration will be approved can be set by selecting the third option. This means that artificial hydration measures will be ceased or removed if there is no improvement to the Rhode Island Patient’s condition. If the Rhode Island Patient wishes to adopt this directive the third checkbox statement must be used.

(47) Placing Conditions On Artificial Hydration. The Rhode Island Patient may indicate he or she wishes to authorize artificial hydration so long as it does not create an unmanageable strain on his or her health or is painful. If so, then select the final statement for this directive. 

Part F. Advance Directive

(48) All Current Rhode Island Patient Directives. If the Rhode Island Patient has shown that he or she has issued a “Durable Power Of Health Care,” “Health Care Proxy,” “Living Will,” or “Documentation Of Oral Advance Directive” then mark the checkbox corresponding to each directive that has been executed.

(49) Source Of Rhode Island Patient’s MOLST. If this MOLST has been completed by the Rhode Island Patient, then present him or her as the source of the information above. If not, then categorize the source of the information above as coming from the Rhode Island Patient’s “Health Care Decision Maker,” “Parent/Guardian Of Minor,” “Court-Appointed Guardian,” or as an Entity type that is defined by recording.

Part G Signature Of MOLST-Qualified Health Care Provider

(50) Signature Requirement For Rhode Island Medical Professional. The Rhode Island Medical Professional facilitating these medical orders should sign his or her approval. This will need to be a Licensed Physician, Registered Nurse Practitioner (RNP or APRN), or a Physician’s Assistant This Party must sign his or her name, dispense the number needed to reach him or her by phone, and supply the date and the time this authorizing signature was produced.

(51) Medical Authorization By Signature. The Physician, Registered Nurse, or Physician’s Assistant approving these orders must do so by signature. He or she must sign this document then furnish the Rhode Island License Number that qualifies him or her to practice medicine in this state.

Signature Of Patient, Decision Maker, Parent/Guardian Of Minor Or Guardian 

(52) Signature Of Rhode Island Declarant. The Rhode Island Declarant, either dispensing his or her medical orders or those of the Patient being represented, must sign his or her name then continue to document his or her telephone number and relationship to the Patient. Keep in mind this relationship must be defined even if the Rhode Island Patient is the Declarant (in which case, record the word “Self” as the relationship).

(53) Printed Name And Address.

Future Rhode Island Patient MOLST Evaluations

(54) Keep The Rhode Island MOLST Up-To-Date. The Rhode Island Patient should be encouraged to keep this paperwork current even if no change in his or her directions is needed. Such a review will require that is conducted by a Rhode Island Medical Professional. Notice the final table of this document. Here, the date and time when this document is reviewed, the name and signature of the Reviewer, the location of this review, and the results of the interview must be documented in this table. 

 

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