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Indiana Living Will Form

In Indiana, this form allows for the establishment of a resident’s living will. A living will may include the following details: (1) the identity of the person assigned to oversee the incapacitated individual’s health care conditions; (2) the schedule of the administration of the treatments; and (3) the condition for the cessation of the end-of-life treatments.Download

Extracted Text for Proper Search

6 	
INDIANA ADVANCE DIRECTIVE  – PAGE 1 OF  8 
 
PART ONE:   APPOINTMENT OF HEALTH -CARE REPRESENTATIVE 
AND POWER OF ATTORNEY  
 
I, ________________________________ ________________________ 
(name)  
 
of __________________________________________________________  
(address)  
 
hereby appoint _______________________________________________  
(name of  health-care representative) 
 
_____________________________________________________________  
(address)  
 
_____________________________________________________________  
(home telephone number)        (work telephone number)  
 
as my  health- care representative —  and attorney -in- fact , if I have had this 
document notarized on page 7  — (“health- care representative”)  to make 
health- care decisions on my behalf whenever I am incapable of making my 
own health- care decisions.  
 
In the event the person I appoint above is unable, unwilling or unavailable 
to act as my  health-care representative, I hereby appoint:  
 
_____________________________________________________________    
(name of successor  health-care representative) 
 
of _____________________________ _____________________________ 
(address)  	
 	
_____________________________________________________________  
 
_____________________________________________________________ 
(home telephone number)      (work telephone number)  
 
as my successor health-care representative. 	
 
INSTRUCTIONS  
 
 
 
 
 
PRINT YOUR NAME 
AND ADDRESS  
 
 
 
 
 
PRINT THE NAME,  
ADDRESS AND  
TELEPHONE 
NUMBERS OF YOUR 
HEALTH -CARE 
REPRESENTATIVE  
 
 
 
 
 
 
 
 
 
PRINT THE NAME,  
ADDRESS AND  
TELEPHONE 
NUMBERS OF YOUR 
SUCCESSOR 
HEALTH -CARE 
REP RESENTATIVE  
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization. 
2012 Revised.

7 	
INDIANA ADVANCE DIRECTIV E – PAGE 2 OF  8 
 
PART ONE:  APPOINTMENT OF HEALTH -CARE REPRESENTATIVE 
AN D POWER OF ATTORNEY (Continued)  
 
Powers Granted to my Health -Care Representative 
 
I grant my  health-care representative  all powers  available under Indiana 
Code, Title 16, Article 36, Chapter  1 to make health- care decisions for me 
in the event I am unable to make such decisions myself.   These powers 
include, but are not limited:   
  (1) to consent to or refuse health care for me;  
(2 ) to admit or release me from a hospital or health -care facility;  and  
(3 ) to have access to my records, including medical records , 
concerning my condition.  
 
I understand health care to include any medical care, treatment, service, or 
procedure to maintain, diagnose, treat, or provide for my physical or 
mental well -being. Health care also includes the providing of nutrition and 
hydrat ion through intravenous,  gastrostomy, or nasogastric tubes.  	
 
I authorize my health- care representative to make decisions in my best 
interest concerning withdrawal or withholding of health care. If at any time 
based on my previously expressed preferences an d the diagnosis and 
prognosis , my health- care representative is satisfied that certain health care 
is not or would not be beneficial or that such health care is or would be 
excessively burdensome, then my health- care representative may express 
my will that  such health care be withheld or withdrawn and may consent on 
my behalf that any or all health care be discontinued or not instituted, even 
if death may result.  
 
My health- care representative must try to discuss this decision with me. 
However, if I am unable to communicate, my health- care representative 
may make such a decision for me, after consultation with my physician or 
physicians and other relevant health- care givers. To the extent appropriate, 
my health- care representative may also discuss this decision with my family 
and others to the extent they are available.  
 
 
 	
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
THESE POWERS  
CAN BE GRANTED  
TO YOUR  HEALTH-
CARE  
REPRESENTATIVE 
WITHOUT HAVING 
A NOTARY PUBLIC 
WITNESS YOUR 
SIGNATURE  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
© 20 05 National 
Hospice and 
Palliative Care 
Organization. 
2012 Revised.

8 	
INDIANA ADVANCE DIRECTIVE  - PAGE 3 OF 8  
 
PART ONE:  APPOINTMENT OF HEALTH -CARE REPRESENTATIVE 
AND POWER OF ATTORNEY (Continued)  
 
Additional Powers Granted  to my Health -Care Representativ e as 
my Attorney -in -Fact  (Notary Required)  
 
If my signature of this document is witnessed by a notary public, I further 
grant my health- care representative all powers available as  my attorney -in-
fact under Indiana Code §§ 30 -5-5-16 and 30 -5-5-17 to make health -care 
decisions for me in the event I am unable to make such decisions myself, 
including , but not limited to : 
 
(1) to employ or contract with servants, companions, or health care 
providers involved in my health care;  
(1 ) to make anatomical gifts on my  behalf; 
(3 ) to request an autopsy; and  
(4 ) to make plans for the disposition of my body.  
 
 
Revocation  of Health-Care Representative’s Power and 
A ppointment  
 
I may revoke the authority of my health- care representative, including any 
powers granted to my hea lth-care representative as my attorney -in- fact , 
and all of the powers granted in this document,  whenever I am  capable of 
consenting to health care by notifying my health- care provider or my 
health- care representative  orally or in writing.    
 
I may revoke the appointment of my health- care representative, and all of 
the powers granted in this document,  whenever I am capable of consenting 
to health care by notifying my health- care representative orally or in 
writing . 
 
 	 
 
 
 
 
 
 
 
 
 
 
 
IN ORDER TO 
GRANT YOUR 
HEALTH -CARE 
REPRESENTATIVE 
THESE ADDITIONAL 
POWERS  TO SERVE 
AS YOUR 
ATTORNEY -IN-FACT , 
YOU MUST HAVE 
YOUR SIGNATURE 
WITNESSED BY A 
NOTARY PUBLIC ON 
PAGE  7 OF THIS 
FORM  
 
 
 
 
REVOCATION 
OPTIONS  
 
YOU MAY REVOKE 
ALL POWERS 
GRANTED TO YOUR 
HEALTH -CARE 
REPRESENTATIVE 
IN THIS FORM, 
INCLUDING THOSE 
AS YOUR 
ATTORNEY -IN-FACT, 
AS DESCRIBED 
HERE  
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization. 
2012 Revised.

9 	
INDIANA ADVANCE DIRECTIVE  - PAGE 4  OF  8 
 
PART ONE:  APPOINTMENT OF HEALTH -CARE REPRESENTATIVE 
AND POWER OF ATTORNEY (Continued)  
 
Guidance for my Health -Care Representative 
When making  health-care decision s for me, my  health-care representative 
should think about what action would be consistent  with past conversations 
we have had, my treatment preferences as expressed in P art Two  (if I have 
filled out P art Two ), my religious and other beliefs and values, and how I 
have handled medical and other important issues in the past. If what I 
would decide is still unclear, then my  health-care representative  should 
make decisions for me that my  health-care representative  believes are in 
my best interest, considering the benefits, burdens, and risks of my current 
circumstances and treatment options.    
 
In a ddition, my health- care representative  should consider the following 
instructions in making health- care decisions on my behalf: (attach 
additional pages if needed.)  
 	
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       	
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ADD OTHER 
INSTRUCTIONS, IF 
ANY, REGARDING 
YOUR ADVANCE 
CARE PLANS  
 
THESE 
INSTRUCTIONS CAN 
FURTHER ADDRESS 
YOUR HEALTH CARE 
PLANS, SUCH AS 
YOUR WISHES 
REGARDING 
HOSPICE 
TREATMENT, BUT 
CAN ALSO ADDRESS 
OTHER ADVANCE 
PLANNING ISSUES , 
SUCH AS YOUR 
BURIAL WISHES  
 
ATTACH 
ADDITIONAL PAGES 
IF NEEDED  
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization. 
2012 Revised.

10	 	
INDIANA ADVANCE DIRECTI 0VE  – PAGE  5 OF  8 
 
PART TWO: DECLARATION   
 
Declaration made this _________ day of  ___________________________. 
                                        (day)      (month, year) 
I, ___________________________________________________________,  (name) 
being at least eighteen (18) years old and of sound mind, willfully and 
volunt arily exercise my right to determine the course of my health ca re and 
to provide clear and convincing proof of my treatment decisions .  If at any 
time I have an incurable injury, disease, or illness determined to be a 
terminal condition  and am unable to make decisions , I declare that:  
 	
    (Life-Prolonging Procedures De claration) I want  the use of life -
prolonging procedures that would extend my life  under all circumstances .  
This includes appropriate nutrition and hydration, the administration of 
medication, and the performance of all other medical procedures necessary 
t o extend my life, to provide comfort care, or to alleviate pain.  
 
   (Living Will Declaration)  I request that my dying shall not be 
artificially prolonged .  If my death will occur within a short time and  the 
use of life prolonging procedures would serve only to artificially prolong the 
dying process, I direct that such procedures be withheld or withdrawn, and 
that I be permitted to die naturally with only the performance or provision 
of any medical procedure or medication necessary to provide me with 
comfort  care or to alleviate pain, and, if I have so indicated below, the 
provision of artificially supplied nutrition and hydration. (Indicate your 
choice by initialing or making your mark before signing this declaration):  
 
 ____ I wish to receive artificially supplied nutrition and 
  hydration, even if the effort to sustain life is futile or 
  excessively burdensome to me.  
 
  _____ I do not wish to receive artificially supplied nutrition   and 
hydration, if the effort to sustain life is futile or excessively burdensome to 
me. 
 
  _____ I intentionally make no decision concerning artificially 
  supplied nutrition and hydration, leaving the decision to my   health-
care representative appointed under Indiana Code 16-  36-1-7 or my 
attorney -in- fact with health- care powers under  Indiana Code 30 -5-5. 
 
 
 
 	
 
 
 
 
 
 
PRINT THE DATE  
 
PRINT YOUR NAME  
 
 
 
INITIAL ONLY ONE 
OF THE FOLLOWING 
TWO CHOICES  
 
 
INITIAL HERE IF 
YOU WANT L IFE-
PROLONGING 
PROCEDURES 
UNDER ALL 
CIRCUMSTANCES  
 
 
INITIAL HERE IF 
YOU WANT LIFE -
PROLONGING 
PROCEDURES 
WITHHELD OR 
WITHDRAWN 
UNDER THE 
CONDITIONS 
LISTED  
 
 
IF YOU INITIALED 
THE LIVING WILL 
DECLARATION 
ABOVE, INITIAL THE 
STATEMENT  
THAT REFLECTS  
YOUR WISHES 
ABOUT ARTIFICIAL  
NUTRITION 
( FEEDING ) AND 
HYDRATION 
(FLUIDS)  
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization. 
2012 Revised.

11	 	
INDIANA ADVANCE DIRECTIVE  – PAGE  6 OF  8 
 
PART TWO: DECLARATION (Continued)  
 
 
I further declare that:   (add additional instructions, if any, adding 
additional pages, if needed.) 	
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
 
In the absence of my ability to give directions regarding the use of life -
prolonging procedures, it is my intention that this declaration be honored 
by my family and physician as the final expression of my legal right to 
refuse medical or surgical treatment and accept the consequences of the 
refusal.   My  health- care representative, under Indiana Code 16 -36-1- 7 or 
my attorney -in- fact, under Indiana Code 30 -5-5, if I have appointed one, is 
responsible for interpreting this declaration if there is a disagreement as to 
its applicability.  	
 
 
 
 
 
ADD OTHER 
INSTRUCTIONS, IF 
ANY, REGARDING 
YOUR ADVANCE 
CARE PLANS 
 
THESE 
INSTRUCTIONS CAN 
FURTHER ADDRESS 
YOUR HEALT H CARE 
PLANS, SUCH AS 
YOUR WISHES 
REGARDING 
HOSPICE 
TREATMENT, BUT 
CAN ALSO ADDRESS 
OTHER ADVANCE 
PLANNING ISSUES, 
SUCH AS YOUR 
BURIAL WISHES  
 
ATTACH 
ADDITIONAL PAGES 
IF NEEDED  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization. 
2 012 Revised.

12	 	
INDIANA ADVANCE DIR ECTIVE — PAGE  7 OF  8 
 
PART THREE: EXECUTION  
 
I, ______________________________________, the principal  and/or   
declarant , sign my name  or direct another person  to sign my name to  this   
 
instrument this _______ day  of ________________  20_____, and do 
hereby  declare to the undersigned witness (es) that I sign it willingly, and I 
execute it as my free and voluntary act for the purposes herein expressed, 
and that I am of sound mind, and under no constraint or undue influence.  I 
understand the full  importance of  this declaration.  
 
Signed _______________________________________________________  
 
City, County, and State of Residence __ ____________________________ 
 
_____________________________________________________________  
 
Notary   
 
Subscribed and acknowledged before  me by ________________________, 
 
the principal, this _____ day of  __________________________, 20______.  
 
 
  ________________________________________  
(notary public)  
My Commission expires __________________ 
 
 
 
 
 
 	
I further confirm that            , signing on behalf of  
 
          ,  the principle and/or declarant, did so at 
the principle and/or declarant’s direction.    	
 
 
________________________________________  
(notary public)  	
 
 
 
 
 
PRINT YOUR NAME  
 
 
 
PRINT THE DATE 
 
 
 
 
 
 
SIGN YOUR NAME  
 
PRINT YOUR CITY, 
COUNTY, AND 
STATE OF 
RESIDENCE  
 
 
 
YOUR FORM MUST 
BE WITNESSED BY 
A NOTARY IN 
ORDER TO GRANT 
YOUR HEALTH -CARE 
REPRESENTATIVE 
THE ADDITIONAL 
POWERS OF AN 
ATTORNEY -IN-FACT 
LISTED ON PAGE 3 
IN PART ONE 
(APPOINTMENT OF 
HEALTH -CARE 
REPRESENTATIVE)  
 
 
 
IF SOMEONE IS 
SIGNING THE FORM 
FOR YOU AT YOUR 
DIRECTION 
BECAUSE YOU ARE 
UNABLE TO SIGN, 
THE NOTARY MUST 
NOTE THAT HERE  
 
© 2005 National 
Hospice and 
Palliative Care 
Organization . 
2012 Revised.

13	 	
INDIANA ADVANCE DIRECTIVE  — PAGE 8  OF  8 
 
PART THREE: EXECUTION (continued)  
 
 
Witness( es) 
 
The declarant has been personally known to me, and I believe (him/her) 
to be of sound mind. I am competent and at least eighteen (18) years 
old.  
 
Witness   
 
___________________________________Date _______________   
 
 
Witness   
 
___________________________________ Date_______________    
 
 
I further attest that I did  not sign the declarant’s signature above for or 
at the direction of the declarant. I am not a parent, spouse, or child of 
the declarant. I am not entitled to any part of the declarant ’s estate or 
d irectly financially responsible for the declarant ’s medical care.   
 
Witness   
 
___________________________________Date _______________   
 
 
Witness   
 
___________________________________Date _______________   	
 
   
   
 
Courtesy of Caring Connections  
1731 King St. , Suite 100, Alexandria, VA  22314  
www.caringinfo.org, 800/658 -8898  	
 
 
 
YOUR FORM MUST 
BE WITNESSED  
 
TWO WITNESSES 
ARE REQUIRED IF 
YOU FILLED OUT 
PART TWO 
(DECLARATION)  
 
 
 
ONLY ONE WITNESS  
— WHO MAY BE A 
NOTARY PUBLIC  
SIGNING ON THE 
PREVIOUS PAGE  — 
IS REQUIRED IF 
YOU FILLED OUT 
ONLY PART ONE 
(APPOINTMENT  OF 
HEALTH -CARE 
REPRESENTATIVE)  
 
 
 
 
IF YOU CHOSE  THE 
LIVING WILL 
DECLARATION IN 
PART TWO , YOUR 
TWO WITNESSES 
MUST ALSO SIGN 
HERE  
 
 
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization. 
2012 Revised.

14	 	
 INDIANA  ORGAN DONATION FORM —  PAGE 1 OF  1 
 
Initial the line next to the statement below that best reflects your wishes. 
You do not have to initial any of the statements. If you do not initial any of 
the statements, your  health-care representative,  attorney for health care, 
proxy, or other agent, or your family may have the authority to  make a gift 
of all or part of your body under Indiana law.    
 
_____ I do not want to make an organ or tissue donation and I do not 
want my  attorney for health care, proxy, or other agent  or family to do so.  
_____ I have already signed a written agreement or donor card regarding 
organ and tissue donation with the following individual or institution:   	
 	
Name of individual/institution:_____________________  	
 	
_____ Pursuant to Indiana law, I hereby give, effective on my death:   
 	
_____ Any needed organ or parts.  
_____ The following part or organs listed below:   
 	
For (initial one):   	
 	
_____ Any legally authorized p urpose.  
_____ Transplant or therapeutic purposes only.   	
  
Declarant name: ______________________________________________  
 
Declarant signature: _________________________, Date: ____________  
 
 
The declarant voluntarily signed or directed another person to sign this 
writing in my presence. 
 
Witness  _______________________________Date__________________  
 
Address  ____________________________________________________              
              ____________________________________________________  
 
I am a disinteres ted party with regard to the declarant and his or her 
donation and estate.   The declarant voluntarily signed or directed another 
person to sign this writing in my presence.   
 
Witness  ________________________________Date_________________  
 
Address  ____________________________________________________  
               _____________________________________________________    	
 
Courtesy of Caring Connections  
1731 King St., Suite 100, Alexandria, VA  22314  
www.caringinfo.org, 800/658 -8898  	
 
ORGAN DONATION 
(OPTIONAL)  
 
 
 
 
 
 
 
INITIAL  THE 
OPTION THAT 
REFLECTS YOUR 
WISHES   
 
 
 
ADD NAME OR 
INSTITUTION (IF 
ANY)  
 
 
 
 
 
 
 
 
 
PRINT YOUR NAME, 
SIGN, AND DATE 
THE DOCUMENT  
 
 
 
 
YOUR  
WITNESSES  
MUST SIGN AND  
PRINT THEIR 
ADDRESSES  
 
 
 
AT LEAST ONE 
WITNESS MUST BE 
A DISINTERESTED 
PARTY  
 
 
 
© 2005 National  
Hospice and 
Palliative Care 
Organization 
2012 Revised.

15	 	
 	
You Have Filled Out Your Advance Directive, Now What? 
 
  1.   Your Indiana Advance Directive is an  important legal document.  Keep the 
original signed document in a secure but accessible place. Do not put the 
original document in a safe deposit box or any other security box that would 
k eep others from having access to  it. 
 
2.    Give photocopies of the signed original to your health- care representative and 
successor , doctor(s), family, close friends, clergy , and anyone else who might 
become involved in your health  care. If you enter a nursing home or hospital, 
have photocopies of your documents placed in your medical records.  
 
3.      Be sure to talk to your health- care representative and successor, doctor(s), 
clergy, and family and friends about your wishes concerning medical treatment. 
Discuss your wishes with them often, particularly if  your medical condition 
changes.  
 
4.    You may also want to save a copy of your form in an online personal health 
records application, program, or service that allows you to share your medical 
documents with your physicians, family, and others who you want to take an 
active role in your advance care planning.   
 
5.    If you want to change your document after it has  been signed and witnessed, 
you should complete  a new form.  
 
6.    Remember, you can always revoke your Indiana d ocument. 
 
7.      Be aware that your Indiana document will not be effective in the event of a 
medical emergency. Ambulance personnel are required to provide 
cardiopulmonary resuscitation (CPR) unless they are given a separate order that 
states otherwise. These  orders, commonly called  “non -hospital do -not -
resuscitate orders, ” are designed for people whose poor health gives them little 
chance of benefiting from CPR. These orders must be signed by your physician 
and instruct ambulance personnel not to attempt CPR if your heart or breathing 
should stop.   
 
Indiana law provides for an “Out of Hospital Do Not Resuscitate Declaration and 
Order.”   We suggest you speak to your physician  for more information. Caring 
Connections does not distribute these forms.
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