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Kentucky Advance Directive | Medical POA & Living Will

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Kentucky Advance Directive (Medical POA & Living Will) is used for the appointment of a “surrogate” who will be the issuing party’s representative for healthcare decisions in the unfortunate event that individual has a condition that makes it impossible to communicate successfully. In addition, naming the health care surrogate, this form allows the individual to specify the end of life treatment preferences. This template is often referred to as a medical power of attorney or living will as it contains both forms in the package.

Laws – § 311.623

Durable Power of Attorney – The Principal is given the ability to appoint a financial representative to make decisions on their behalf.

How to Write

1 – The Kentucky Directive Is Available On This Page

The Kentucky form required for an individual to grant a Health Care Surrogate the Authority to make Health Care Decisions on his or her behalf may be opened and used through the buttons under the preview image.

2 – The Designation Of A Kentucky Health Care Surrogate

The first order of business to attend to will be to officially declare the Identity of the Health Care Surrogate who will receive the Grantor’s Approval of this Authority. Enter the Name of this person on the first two blank lines (each labeled “Name of Surrogate”). The Health Care Surrogate is the individual who the Grantor wishes to appoint the Power to make Health Care decisions when necessary. The third blank line, labeled “Name of Alternate Surrogate,” should have the name of an Alternate Health Care Surrogate, or Agent in Reserve, willing to accept the Grantor’s Power of Authority should the one named on the first line be unable or no longer willing or allowed to act in such a capacity. That is, this individual will not be allowed to make any Health Care Decisions on behalf of the Grantor unless the first Health Care Surrogate cannot or will not.

3 – The List Of Health Care Surrogate Decisions Must Be Reviewed

There will be several issues that should be addressed directly in such paperwork. In the item labeled “Living Will Directive,” the Grantor will have to personally review and approve the list of Decision Making Powers scenarios presented. In order to indicate the Grantor’s wishes, he or she will need to initial and check the blank space preceding the applicable statement

If the Principal approves of the Agent deciding if or when Treatment should be withdrawn so the Grantor may die naturally, the first statement (Beginning with the words “Direct that treatment be withheld.”) should be initialed then checked by the Grantor. If the Agent is not authorized to withhold Life-Prolonging Treatment for the Grantor, the second statement must be initialed and checked. If the Grantor authorizes the Health Care Surrogate to decide when or if artificially provided food and water be administered, then he or she should initial and check the third statement The Grantor should initial and check the fourth statement, if the Health Care Surrogate will not have the Power to withhold food, water, and nourishment when it is administered. If the Grantor wishes the Health Care Surrogate to have the Authority to withdraw any treatment and/or nourishment not previously discussed, believing it will benefit the Grantor’s wishes, the fifth statement will need to be initialed and checked by the Grantor.


4 – The Grantor Should Indicate His Or Her Stance On Anatomical Gifts

The next section, “Anatomical Gift,” will cover the subject of Organ, Tissue, and Body Part Donation. The Grantor of this Authority must initial and check each applicable statement in this section.

The first statement will authorize the Health Care Surrogate to make a gift of any part of the Grantor’s body upon the Grantor’s death at the discretion of the Health Care Surrogate. If the Grantor approves of this statement and its results, then he or she should initial and check the blank space corresponding to it. If the Grantor does not wish to allow the Health Care Surrogate the broad decision-making power of making any Anatomical Gift of the Grantor’s body, the second statement will need to be initialed and checked.

5 – Special Instructions Form the Grantor

If the Grantor wishes to specify his or her expectations and/or instructions concerning the Decisions Making Process of the Attorney-in-Fact, he or she may provide such instructions in the space below the words “Other Directions.”

6 – The Grantor Approval Of Delivered Decision Making Power

The last page of this form will deliver an area so the Grantor may approve the Decision-Making Power defined here. The first step will be for the Grantor to enter the Calendar Day he or she is executing this document on the blank space between the terms “Signed this” and “day of.” Then on the next two blank spaces after “day of,” the Grantor must report the Month and Year he or she is signing this form. Next, the Grantor must sign his or her Name on the space labeled “Signature of the Grantor.” This must be done on the same Date he or she has reported as the Date of Signature. The blank lines following the words “Address of the Grantor,” will require the official Residential Address of the Grantor to be reported. There are two ways the Grantor Signature may be substantiated. The first will be in the section labeled “Witnessing Procedure.” This choice has been provided so the two Witnesses observing the Principal signing this Directive may testify to the Signature’s Validity by Signing their Names and providing their Residential Addresses. If two Witnesses are unavailable, the Grantor Signature may be substantiated by Notarization. That is, the Grantor must sign this document in the presence of a Notary Public at the direction of that entity. The Notary Public will then fill out this section as required.