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Kentucky Advance Directive Form

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A Kentucky advance directive is a form that gives guidelines to a hospital on how a patient would like to be treated and if they have a health care agent to represent their needs. An advance directive combines a medical power of attorney and a living will to create a form that fulfills the end-of-life treatment options for an individual. The document needs to be signed in accordance with State law, with either two (2) witnesses or notary public, and the form must be kept in an easily accessible place for future use.

Table of Contents

Laws

StatuteKentucky Living Will Directive Act (§ 311.621 to § 311.647)

Signing Requirements (§ 311.625(2)) – Two (2) witnesses or a notary public.

State Definition (§ 311.621(2)) – “Advance directive” means a living will directive made in accordance with KRS 311.621 to 311.643, a living will or designation of health care surrogate executed prior to July 15, 1994, and any other document that provides directions relative to health care to be provided to the person executing the document.

Versions


Attorney General

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Catholic Conference of Kentucky

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ENT and Allergy Specialists

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National Alliance on Mental Illness (NAMI)

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Norton Healthcare

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Spanish (Español) Version

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How to Write

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Step 1 – Acquire Your Kentucky Living Will Directive And Health Care Surrogate Designation Form

Locate then select the “PDF” button paired with the sample image of the Kentucky Living Will Directive And Health Care Surrogate Designation Form. Once done, engage the browser dialogue to save this template.

Step 2 – Identify The Kentucky Principal In The Title

Open the downloaded form, then read through the introduction. It will be important to be abreast of Kentucky’s form requirements and some useful information is presented here. You, as the Grantor Or Principal, can solidify some of your preferences regarding medical events or scenarios where you cannot reasonably communicate your wishes to the attending Physicians or Medical Staff. To do so, you must identify this directive as yours by entering your “Printed Name” as the Kentucky Principal or Grantor Or Principal Power on the first blank line in the title.  The second blank line in the document title calls for the “Date Of Birth” of the Grantor or Principal. Dispense this in a standard date format.

 

Step 3 – Present Principal Verification Of This Appointment

As mentioned in this packet’s introduction, the Kentucky Principal behind this document does not necessarily need to name a Health Care Surrogate if he or she intends to document his or her wishes on paper. Thus, to verify that the “Health Care Surrogate Designation” section at the beginning of this directive is being completed in a conscientious manner, the Principal must mark the first checkbox and dispense his or her initials to the box and line attached to the instructional statement “Check Box And Initial Line, If You Desire To Name A Surrogate” before such an appointment can be made. 

 

Step 4 – Document The Kentucky Health Care Surrocate’s Identity

The language set beneath the Grantor’s authorizing initials will allow him or her to name a specific individual as his or her Health Care Surrogate. This Surrogate will be able to make medical treatment and health care decisions on behalf of the Grantor during events where the Grantor cannot represent his or her own wishes to attending Medical Staff. Record the full name of the Health Care Surrogate being granted these representational powers on the blank line after the word “Designate” and preceding the term “As My Health Care Surrogate(s)…” 

 

Step 5 – Appoint An Alternate Surrogate To Represent The Grantor’s Health Care Wishes

If this Health Care Surrogate named above cannot or will not fulfill his or her role as a Kentucky Health Care Surrogate then the Grantor can be left without representation when he or she cannot communicate. To offset this concern, a Reserve or Alternate Health Care Surrogate can be designated with the right to assume principal power if (and only if) the First Health Care Surrogate is unable or unwilling to represent the Grantor. Before continuing to this appointment, re-enter the Health Care Surrogate’s name on the blank line just before the words “Refuses Or Is Not Able To Act For Me…” Identify the individual that should have the right to assume the principal power to make medical decisions for you if the original Health Care Surrogate cannot or will not live up to this role by recording his or her name to the last available line of this paragraph statement.

 

Step 6 – Discuss The Principal’s Directive Governing Life Prolonging Treatment

The Grantor behind this document can directly address how Medical Personnel should handle certain treatments when he or she cannot voice such decisions. The section titled “Living Will Directive will address two topics. The first is “Life Prolonging Treatments.” In this area a discussion of how Medical Staff should behave when the decision to administer a medical treatment strictly to keep the Grantor or Principal alive even when death is inevitable and he or she is unconscious or incoherent. If the Kentucky Grantor wishes his or her “Life Prolonging Treatment” to be withheld or withdrawn altogether during such a scenario then the first box under “Life Prolonging Treatment” should be marked and the corresponding blank line initialed by the Grantor.  If the Grantor wishes to have “Life Prolonging Treatment” given or continued even when faced with the above scenario, then he or she should select the second checkbox in the “Life-Prolonging Treatment” area and initial the blank line attached to it. 

 

Step 7 – Produce The Principal’s Preferences Regarding Artificial Nourishment And Fluids

The second area of the “Living Will Directive” section is titled “Nourishment And/Or Fluids.” If the Grantor is suffering a medical event that will result in death while unable to inform Medical Staff as to his or her decision on whether artificial nutrition and/or fluids can be administered (to prevent starvation or dehydration) then such preferences can be documented in this section. For instance, if the Grantor wishes that nutrition and fluids being delivered artificial be withdrawn or not administered when death is inevitable, then the Grantor must select the first box under “Nourishment And/Or Fluids.” If the Grantor does not “Authorize The Withholding OR Withdrawal” of food and water being delivered artificially when death is imminent then the second check box in the “Nourishment And/Or Fluids” area should be marked and the blank line next to it initialed by the Grantor. 

 

Step 8 – Optionally, The Principal May Relinquish Control Over Some Decisions To The Surrogate

If the Principal wishes the Health Care Surrogate to make the decision as to whether or not “Life Prolonging Treatment” and “Nourishment And/Or Fluids” should be administered when the Grantor faces inevitable death and cannot participate in such a conversation due to unconsciousness or incoherence then the previous areas should be left unmarked. Additionally, the Grantor must mark the checkbox in the “Surrogate Determination OF Best Interest” option and initial the corresponding empty line. This decision will mean the Health Care Surrogate will decide when it is appropriate and inappropriate to allow Medical Staff to provide “Life Prolonging Treatment” or “Nourishment And/Or Fluids.” 

 

Step 9 – Review The Organ Donation Options For Approval

The Grantor can also use this form to verify that he or she is a qualified Organ Donor and wishes to make such an anatomical gift upon death. A checkbox list that enables the Grantor to discuss this gift has been presented in the next area. Thus, if the Grantor wishes to donate “Any Needed Organs, Tissues, And Eye/Cornea” upon death with no real consideration or limitation then the first checkbox in the section titled “Organ/Tissue/Eye Donation” should be marked. Notice the blank line beside it will also seek the Grantor’s initials for authorization. If the Grantor wishes to name only certain parts but not others, then the checklist below the statement beginning with the words “The Following Organs or Tissues Only” bears his or her attention. Instead of selecting the general statement above the Grantor can check then initial specific as many of the list items on display below the bold word “Or” that apply. For instance, if the Grantor is willing to donate “All Needed Organs” only (i.e. this excludes body parts such as the skeleton) then he or she should select the first checkbox of the list and initial the line attached to the phrase “All Needed Organs.”  The second option allows for “All Needed Tissues” to be donated after death. The Grantor should initial select the checkbox and initial this option.  The third donation option is “Corneas.” If the Grantor is willing to donate his or her corneas after death then he or she must check or mark the third box and initial the blank line attached to it.  If the Grantor will donate his or her eyes as a post-death anatomical gift then he or she must check the box for “Eyes” and initial the accompanying blank line.  If the Grantor wishes to donate body parts not listed above, then he or she can select the “Other” box and initial where requested. Be advised, that if this box is selected then it will be assumed the appointed Health Care Surrogate will be up-to-date on what body parts the Grantor wishes to donate.  For cases where a very specific list of body parts, organs, and/or tissues are to be considered anatomical gifts the final option must be enabled. To achieve this then, locate the statement “Only The Specified Organs/Tissues As Listed.” The Grantor should mark the provided checkbox and initial the attached blank line. Once these tasks have been completed, the blank lines below this statement should be populated with the tissues, organs, skeletal parts, and any other parts he or she wishes considered an approved anatomical donation. 

 

Step 10 – Execute The Kentucky Directive On A Specific Date

It is vital that a Reviewer of this paperwork have confidence that it represents the current directives of the Kentucky Grantor or Principal. The words “Signed This” introduce three empty lines in the phrase needed to solidify exactly when the Kentucky Grantor is signing this template. Use these lines to present the calendar date marking when the Grantor formally presents this completed form as his or her treatment directives and Health Care Surrogate appointment. 

 

Step 11 – Deliver The Kentucky Grantor Or Principal Authorization

The Grantor issuing this paperwork to appoint a Health Care Surrogate and establish medical preferences must sign his or her name on the “Signature And Address Of The Grantor” line. Immediately after providing this signature the Kentucky Grantor of medical power must document his or her address on the same line.  

 

Step 12 – Authenticate The Execution By Witness If Desired

The issuing of this directive will only be considered authentic if the Grantor’s act of signing is observed either by a qualifying Witness or a Notary Public. If two Witnesses have observed the Kentucky Grantor’s signing then control of this document must be given to them upon its execution. The First Witness must attest to the statement declaring the Grantor’s competency by signing the “Signature And Address Of Witness” line presented directly below the declaration.  The Second Witness must also be willing to agree to the above declaration by signing the second line below it (labeled “Signature And Address Of Witness”).  

 

Step 13 – Verify The Kentucky Designation With A Notary As Needed

If the Kentucky Grantor opted to have his or her signing notarized then, he or she must follow the Notary Public’s instructions. Once the signing and notarization process is completed the Grantor should review the notary section at the end of this document to verify the accuracy of the reported county and date of signing as well as confirm the presence of the Kentucky Notary Public’s credentials.     

 

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