Utah Advance Directive Form

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A Utah advance directive lets a person select an agent to make health care decisions on their behalf in case the person cannot speak for themselves. This is usually due to incapacitation and allows, in the advance directive, to outline a person’s treatment choices in the last stages of their life. After an advance directive is signed, a copy should be kept with the agent, family members, and the primary care physician.

Advance Directive Includes

  • Part I: Health Care Power of Attorney
  • Part II: Living Will

Table of Contents

Laws

Statute – Title 75, Chapter 2a (Advance Health Care Directive Act)

Signing Requirements (§ 75-2a-107(c)) – One (1) disinterested witness.

State Definition (§ 75-2a-103(2)) – “Advance health care directive”  includes: a designation of an agent to make health care decisions for an adult when the adult cannot make or communicate health care decisions; or an expression of preferences about health care decisions; may take one of the following forms: a written document, voluntarily executed by an adult in accordance with the requirements of this chapter; or a witnessed oral statement, made in accordance with the requirements of this chapter; and does not include a life with dignity order.

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Utah.edu Version

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Spanish (Español) Version

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How to Write

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(1) Utah Patient Identity. Before you engage in the documentation of your appointment of a Utah Health Care Representative or Agent to carry out your treatment decisions and/or setting your medical instructions to paper, you must identify yourself as the Utah Patient performing these actions through this document. Present your full name.

(2) Residential Address Of Utah Patient. Your complete residential address must be furnished. This should be kept up-to-date since it will aid in verifying your identity.

(3) Utah Patient Contact Phone Numbers

(4) Date Of Birth. A final measure to aid in proving your identity in this document is to produce your date of birth with your name and contact information.

Part I: My Agent

A. No Agent

(5) Agent Appointment Waiver. If you have decided that you will only use this instrument to set your medical instructions to paper and do not wish to appoint a Utah Health Care Representative or Agent, then place your initials in the statement confirming this fact.

B. My Agent

(6) Utah Health Care Agent. To appoint a Representative or Health Care Agent in the State of Utah, you must attach his or her name to this role by recording it to the declaration section of this appointment.

(7) Residential Address.

(8) Telephone Numbers.

C. My Alternate Agent

(9) Alternate Agent’s Name. An Alternate Utah Agent can be held in reserve and ready to receive the principal powers of this document should the Utah Health Care Agent not be able or is unwilling to act in this role. If you name an Alternate Agent, then the authorization this document presents will be transferred to the Alternate Agent. Many consider this a wise precaution.

(10) Complete Address.

(11) Telephone Number(s).

E. Other Authority

(12) Obtaining Your Medical Records. Many would consider it wise to make sure your Utah Health Care Agent is prepared to take on the responsibilities being placed upon him or her. This may involve being able to review your medical files before you are incapacitated while you are still able to communicate. Such access however requires your approval. If your Utah Health Care Agent should be able to access your medical files immediately upon the signing of this document regardless of your medical condition, then initial the first “Yes” line otherwise, provide your initials to the “No” line to restrict your Utah Health Care Agent from accessing your medical files while you are able to communicate with Physicians in this state.

(13) Medical Health Care Facility Placement. You may also delegate the principal authority to admit or discharge you from a Health Care Facility such as a hospital or Assisted Living Facility even while you are conscious and able to communicate your needs to Utah Medical Personnel. Appoint this authority to your Utah Health Care Agent or restrict him or her from having such power unless you are incapacitated/uncommunicative or permanently unconscious by initialing “Yes” or initialing “No.”

F. Limits/Expansion Of Authority

(14) Directions On Health Care And Agent’s Authority. Your Utah Health Care Representative or Agent will receive only a basic explanation of his or her duties and the default powers granted to him or her as a result of this document. Limitations to his or her power to make medical decisions for you as well as the instructions you wish him or her to comply with when representing you before Utah Medical Staff must be directly reported to the content of Section F. You may also use this area to give specific authorization to engage in additional decisions or actions in your name so long as your instructions remain lawful and compliant with Utah State Law.

G. Nomination Of Guardian

(15) Utah Agent As Guardian. At times, it may be declared by the State of Utah that a Court-Appointed Guardian should be assigned to your benefit. If so, you may inform Utah State Courts on whether you would wish your Health Care Representative or Agent to be considered for this role by initialing your approval to the “Yes” line or by declaring that you would not wish Utah Courts to appoint your Health Care Representative as your Guardian by initialing the “No” line.

H. Consent to Participate In Medical Research

(16) Utah Health Care Agent Decision Power. One of the decisions over your treatment that would require additional authorization is to decide whether you should participate in a treatment or procedure still considered in the experimental stage. To grant your Utah Health Care Agent the right to make this decision on your behalf, initial “Yes.” To deny your Utah Health Care Representative the right to make this decision on your behalf, initial the line labeled “No.”

I. Organ DonationAnatomical Gift Directive

(17) Utah Principal Identity. If there are no records as to whether you wish to be a Utah Organ Donor, you may grant your Health Care Representative the ability to decide for you by initialing the line corresponding to the word “Yes.” Otherwise, to restrict this power of decision from your Utah Health Care Agent’s abilities of representation, initial the “No” line.

(18) Confirming Page 2 As Your Directive. Produce your full name to the bottom of the second page.

Part II: My Health Care Wishes (Living Will)

(19) Option 1 Let Agent Decide. Initial Option 1 if you would like your Utah Health Care Agent (according to this living will) to consult with Utah Doctors regarding your treatment for a terminal condition or while in a permanent coma as well as decide upon that treatment. Additional concerns or instructions may accompany your approval using the space provided to document them.

(20) Option 2 Life-Prolonging Directive. If you have already determined that, regardless of your medical condition, you wish your life prolonged using whatever medical techniques or technology available, then authorize Option 2 by initialing it. This will inform Utah Physicians of your treatment decision to receive life-sustaining health care. Any concerns, circumstances, or instructions that should accompany this approval should be documented in the “Additional Comments” area.

(21) Option 3 Comfort Care Decision. If you prefer to engage in only treatments that will let you experience a natural (but as comfortable as possible) death when diagnosed as permanently unconscious or with a fatal medical condition, then initial Option 3 to convey this desire to Utah Physicians along with any additional directions that you provide. This means that you will not receive any treatment to extend life when enduring a medical condition that is debilitating and terminal or fatal. Option 3 will require that you either indicate that you do not wish any limits placed on your Utah Health Care Provider’s denial or withdrawal of life-sustaining treatment by initialing Choice A. If you do have some limitations, then initial Choice B. Note that if you initial Choice B, then you must give further definition using the statements it contains.

(22) Applying Circumstances To The Comfort Care Decision. If you have opted for comfort care but wish to limit when it becomes a priority then locate the list provided for Choice B. Initial at least one of the statements displayed to indicate to your Utah Health Care Providers when comfort care should be employed or when life-sustaining procedures should be discounted from your treatment goals.

(23) Option 4 Bypassing Health Care Instructions. You may have decided to rely completely on your Utah Health Care Agents to make treatment decisions for you when you are uncommunicative in a lifelong coma, with a permanent and debilitating medical condition, or with a fatal condition. If so and you do not wish to provide any instructions in this area of the directive, then initial Option 4.

(24) Confirm Utah Declarant Identity. Confirm your identity as the Utah Patient once you are ready to proceed.

(25) Additional Instructions About Health Care. The statements this portion of your directive enables you to make are standardized and may require additional definitions, provisions, conditions, concerns, or instruction to be a valid report of how you wish Utah Health Care Professionals to proceed when you are unable to communicate because you are in a lifelong state of unconsciousness, will be dependent on medical technology to live, or have a fatal disease or injury. Use the area provided to document all such medical directives and concerns.

Part IV Making My Directive Legal

(26) Signature Date Of Utah Patient.

(27) Utah Patient Signature. Sign your name as the Utah Patient issuing the directives above as one Adult Witness observes.

(28) Location Of Residential Address.

(29) Signature Of Witness. The Witness verifying your signature must be completely impartial meaning he or she may not be a relative of any sort, directly or indirectly involved with your care as a Health Care Professional, and ineligible to inherit or claim any part of your estate. He or she must read the qualifications required to be a Utah Witness then agree to his or her status as an impartial witness to your signature by signing his or her name.

(30) Printed Name Of Witness

(32) Residential Address Of Witness

(33) Witness Confirmation Of Oral Directive. If you were unable to complete this form (i.e., you cannot move your fingers or hands) then it may have been prepared for you. If so, then the Witness in attendance must report how this document was executed and why you were not able to complete or sign it personally.

(34) Utah Patient Name. Complete this final page with the full name of the Utah Declarant who has completed this directive.

 

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