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Nevada Living Will Form

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A Nevada living will, or “living will declaration”, is a brief form clearly stating the choices that the Declarant/Principal would like to occur in and end-of-life situations. It references that the patient would not wish to seek artificial treatment options if they should check the appropriate box and sign. This form should be filed with their physician and/or family including close friends.

Definition NRS 449.560

LawsNRS 449.610

Medical Power of Attorney – Allows a surrogate to be elected by a patient to make decisions on their behalf if they should become incapable to do so on their own.

How to Write

Download: Adobe PDF

1 – Acquire This Form To Designate A Durable Power Of Attorney For Health Care

When you are ready to designate an Attorney-in-Fact to make health care decisions on your behalf (if necessary), locate the “PDF” button underneath the preview then select it. Download this file then open it with the software you use to edit pdfs. If necessary, you can also print this page. Once you have opened this document, set some time aside to read the first few pages which are aimed directly at the individual appointing an Attorney-in-Fact.   

 

2 – Identify The Nevada Resident Granting This Power

After reading the first three pages, search for the first request for information this appointment makes at the top of the fourth page under the title “Designation Of Health Care Agent.” Place your full name on the blank line attached to the parentheses label “(Insert Your Name).” This act will solidify that you are the individual who wishes to designate another person with the power to make health care decisions on your behalf when you are suffering a medical event or condition preventing you from communicating or remaining conscious.     Notice the words “…Do Hereby Designate And Appoint.” Record the entire name of the individual you are appointing as your Health Care Agent or Health Care Attorney-in-Fact on the line labeled “Name.” This is especially important because this person may need to show paper I.D. to reach you during a medical emergency.  Naturally, it will be imperative that anyone reading this is able to contact your Attorney-in-Fact immediately if required thus, document your Attorney-in-Fact’s residential “Address,” “Phone” number and “Work” phone number (including any extensions) to the blank lines bearing these labels.   Read the remainder of this page, then initial the blank line in the lower left-hand corner (attached to the word “Principal”). Keep in mind that, as the Principal, You are the only one allowed to designate the Attorney-in-Fact here and must initial this line to prove that you have read and agree with the contents of this page. Every page in this document will require such verification on your part.

 

3 – Establish Some Basic Facts Regarding This Appointment

The fourth article, “4. Special Provisions And Limitations,” includes the wording necessary to place conditions, limitations, or restrictions on your Attorney-in-Fact’s decision-making power. The blank lines in this section, below the phrase “…Following Special Provisions And Limitations,” expect you to populate them with your own words. You may type directly into the pdf on these lines. If you need more room to fully report your directives, you may cite an attachment with your instructions or insert additional space.  Normally it will be understood the Attorney-in-Fact you named above can represent you as your Health Care Agent for the remainder of your life unless you change or revoke this power of attorney. If you prefer another option, then locate area titled “5 Duration.” the formatted lines underneath the words “If Applicable” will accept a specific calendar date that you choose for the official termination of this document meaning that your Attorney-in-Fact will no longer be approved to represent you as of that date. To set this termination date, enter the month and calendar day on the first blank line after “…Health Care End On” then follow through with the appropriate two-digit year. 

 

4 – You May Include Statements Of Desires At Your Discretion

The sixth article is set to aid you in quickly solidifying your preferences on some basic issues regarding traumatic medical events. You have the option of skipping this section since it will be understood that your Health Care Agent is fully up-to-date on your feelings regarding life support and artificial feedings, however, some consider it a wise precaution to put such feelings down on paper as well. If this is the case, then read through the list provided under the bold heading “If the Statement Reflects Your Desires…” Every statement that displays your initials in the corresponding box to its left will be considered a declaration on your part. You may initial as many that apply but keep in mind that the first one will countermand some of the others.  If you wish to prolong your life by any means necessary regardless of the chance for recovery, quality of life, or cost then initial the box to the left of the statement beginning with “(1) I Desire That My Life Be Prolonged To The Greatest Extent Possible.”  The second statement presents a scenario where you are in an irreversible coma. If you do not wish life-sustaining treatments used to prolong your life, then initial the box corresponding to “(2) If I Am In A Coma Which My Doctors have Reasonably Concluded…”  You can also disapprove the use of life-sustaining equipment when you have a terminal or incurable disease/condition by initialing the third checkbox of this list. If you do not wish your death to be a result of starvation or dehydration and wish to receive artificial nutrition and hydration then initial “(4) Withholding Or Withdrawal Of Artificial Nutrition ANd Hydration May Result In Death…”  The fifth statement will enable you to document that you wish the quality of your life and expected benefits of any treatment that could extend your life or contribute to your recovery is balanced against certain circumstances. That is, if the burden of recovery will be too great (i.e. treatment that is financially unattainable and carries a side effect of long-term intense pain) and you wish to instruct your Attorney-in-Fact to strongly consider this balance, then initial the box corresponding to “(5) I Do Not Desire Treatment…”  Continue to the next area, titled “My Memorial Service,” where several blank lines have been placed to accept the preferences or desires you wish fulfilled at your memorial service. A good example is wishing that a specific song is played at the beginning.  If you have any other instructions regarding your post-death wishes, record them on the blank lines under the words “Add Other Wishes Here.”  The next few items in the sixth article are declarations that you may either leave in (thereby agreeing with them) or cross out. Once you strike through or cross out one of these statements, it will be understood that it does not accurately represent your intentions. Item “B) It Is My Intention…,” will declare this appointment as automatically delivering the powers contained to the Attorney-in-Fact when he or she needs to access them. Item “C) I Desire That My Wishes…” should be left alone if you intend for the Attorney-in-Fact to carry out the directives here or those he or she believes to be yours even when his or her representation or decisions are opposed by your family members and friends. The next item (“D”) declares that you have confidence your Attorney-in-Fact would exercise the same judgment you would even if others interpret this document differently. The next item, beginning with “E) If My Attorney-in-Fact Or My Alternate Attorney(s)-in-Fact…,” solidifies that you wish this document to be used as a direct representation of your decisions even when none of your Representatives are available.    

 

5 – A Precautionary Appointment Of Power Can Be Included

This directive will make an allowance for circumstances or conditions that may prevent the Attorney-in-Fact you appointed above from living up to the role you clearly expect. For instance, he or she may not be available at a time of crisis when a decision must be made, you may have verbally revoked his or her principal power, or they may be unable to act. This can be devastating if you require representation for a medical decision with long-term consequences. To avoid such a dangerous situation, you may name an Alternate Attorney-in-Fact. This entity will only be able to represent you when your original appointment cannot make medical decisions for you or will not. By keeping the Alternate Attorney-in-Fact’s appointment in suspension, the original one you named can represent you unimpeded. You can appoint an Alternate Attorney-in-Fact using article “7. Designation Of Alternate Attorney-in-Fact.” To do this, input the full “Name,” “Address,” “Phone,” and “Work” telephone number to the appropriately labeled lines in “A. First Alternative Attorney-in-Fact.”  Consider the scenario where both your original appointment and your alternate are both unable to represent you. To set up a “Second Alternative Attorney-in-Fact” who will only assume the principal power in this directive if both the original Attorney-in-Fact and Alternate Attorney-in-Fact can not/will not represent you, fill in his or her “Name,” “Address,” and telephone numbers to the blank lines in item “B. Second Alternative Attorney-in-Fact.” 

 

6 – Execute This Nevada Directive By Signature

The final area where you must produce material immediately follows the statement “I Sign My Name…” and is located after the ninth article. Locate the blank spaces (labeled “Date”) that immediately follow this statement, then present the calendar date at the time you sign this directive.  Additionally, supply the “City And State” where this document is being signed on the next blank space.   Now, this document will only be placed in effect as of the above date when you sign your name to the blank space labeled “Signature” before either two Witnesses or one Notary Public. Sign your name on this line before one of these entity types.

Document your “Name,” current “Address,” and telephone numbers to the next three areas.

Lastly, record your “Social Security Number” on the next blank line. 

 

7 – Verify The Signing Using A Notary Public Or Two Witnesses

Article “10. Certificate Of Acknowledgment Of Notary Public” or “11. Statement Of Witnesses” will need to be attended to by the appropriate party. If you have signed this document before a Notary Public, then you must give it to him or her after you’ve signed it. The Notary will reproduce the location, signature date, and signature party identity along with his or her credentials to article 10.  If you’ve decided to verify your signature act by performing it before two Witnesses then, you must give this document to them after signing it. Each must read the statement in “11. Statement Of Witnesses” then sign his or her name on a unique “Signature” line.  In addition to this action, each Witness must produce his or her printed name, address of residence, and signature date on the blank lines labeled “Print Name,” “Residence Address,” and “Date” respectively. There will be two distinct areas so that each Witness can clearly provide these items. This statement will specifically verify the Witness’ status as a Witness along with a verification that the Principal has signed this document before them.

The next article, “12. Declaration Of Witness,” will seek some further confirmation as to the Witnesses’ eligibility. Both of the Signature Witnesses must produce their signature, print their names, report their “Residential Address,” and supply the signature “Date” on the blank lines underneath the statement in this article.   

 

8 – Produce Material To Set Up Your Living Will

The “Declaration/Living Will” portion of this directive will open with a declarative statement that instructs attending physicians to act in compliance with NRS 449.535 To 449.690 by removing, ceasing, or withholding life-sustaining treatment when you are experiencing an end-of-life event. This statement will also mean that you will not be given any artificial nutrition or hydration when needed (if it prolongs your life) and that you will not be put on a significant pain management program if you are in pain. However, if you would like to receive artificial nutrition and hydration, you can indicate this by initialing the checkbox next to the paragraph beginning with the term “Withholding Or withdrawal Of Artificial Nutrition And Hydration May Result…”  The living will we are working on is considered a separate document from the power of attorney you’ve just executed therefore you must prove your intention to set the living will in motion. Begin this process by recording the calendar date of the living will’s execution. This is the same date that you sign this document. Locate the three spaces that follow the phrase “Signed This…” then input the two-digit calendar day, month, and year of your signature. For our purpose, we shall assume the signature date is the current date this document is being worked on.    Immediately after recording the signature date, sign the “Signature” line below it and provide your address. This act must be performed before two Witnesses so, when you have finished signing this document release it to the Witnesses in attendance.  Two distinct areas, each one with a blank line labeled “Witness” and one labeled “Address,” have placed below the statement “The Declarant Voluntarily Signed…” Both Witnesses must sign their names then produce their residential address.   

 

9 – Develop A Letter To Your Loved Ones Using The Presented Statements

If you wish to solidify some personal statement to comfort your family, friends, and those you care about then, seek the page titled “A Letter To My Loved Ones.” This letter assumes that you are either having an end-of-life experience or are about to have one and cannot communicate for yourself. It will be composed of a list of lettered statements, each defining a request that can be made of your loved ones from this list. In order to let the person reading your letter know which of these you wish made, you must initial the box to the right of your chosen statements. For instance, in the example below the Principal has initialed A, D, and F indicating that he or she will wishes medical treatment to include considerations made for comfort and the alleviation of pain, that he or she wishes to “…Kept Fresh And Clean At All Times,” and that personal grooming or care (i.e. clipping nails, brushing teeth, etc.) be maintained if it does not cause pain.    While the above list will handle some basic physical needs, you have the option of delivering more personal messages using this list. Look for the cursive statement “I Hope My Family And Friends Would Consider That…” The list below this will operate similarly as the one above. Notice that letters A, B, F, and H have been initialed in the example below. This will indicate that the Principal wishes his or her friends and family to know that he or she enjoys their company and wishes them to stay with the Principal when at his or her time of dying, that the Principal wishes his or friends and family to talk to them about daily events, that pictures of the Principal’s loved ones should be placed about the room and near him or her, and that the Principal wishes to die in his or her home.

The next statement “I Want You To Know…” will allow you to directly address your loved ones. Eight statements with personal messages are included in this area. Each one that you wish to be delivered to your loved ones should be initialed while the other left blank. For instance, the Principal below wishes his or her loved ones to know that he or she loves them, would like to be forgiven for anything he or she has done to hurt them, and forgives offending loved ones because the Principal has initialed the boxes corresponding to items “(1),” “(2),” and “(3).”     

 

10 – Discuss Some Post-Life Preferences

The statement starting with the wording “If Friends Want To Know…” will contain a few blank lines for your use. Use this item to let your friends and family know how you would like to be remembered    If a specific person has the funeral plans you prefer, then record his or her name after the words “The Following Person(s) Know My Funeral Plans).    You may make specific memorial service requests using the next set of blank spaces (placed just after the statement ending with “…Other Plans For Such A Service.”  You may include additional last requests using the blank lines under the words “I Also Have The Following Requests.” 

 

11 – Sign The Living Will Into Effect

When you have read this letter to verify it represents your requests and wishes properly you must sign it into execution. First, report the calendar date of signature on the blank space after the words “Date This…”  Sign and print your name on the two lines underneath the signature date labeled “Signature” and “Print Name” respectively. 

 

12 – Complete And Detach the Directive On File Notice

As both a convenience and a precautionary measure a wallet insert has been included which you may fill out then keep on your person. This insert will alert any emergency medical personnel that you have a Health Directive in place. First, record your full name on the blank line “Emergency Medical Notice: Avance Directive On File” on the blank line that follows “I (Name)”    The second wallet insert should be kept with the first and will require some additional information. You must produce your Health Care Agent’s full name on the first blank line, his or her contact telephone numbers directly below this, then do the same for both of the Alternate Health Care Agents you will keep in reserve.  Two cards have been supplied which will allow for the added security of keeping one in your car or office as well.


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