New Mexico Living Will Form

The New Mexico Living Will Form is used as a legal document that is required for setting up a living will in the State of New Mexico.

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Page 1 of  8Statutory Advance Directive For New Mexico Residents_______________________________       _____________________________Print Full Name                                      Date of BirthYour right (when age 18 or older): To Document Your Personal Wishes, and to have these wishes followed ~~ The New Mexico state legislature has provided statutes guiding the construction of both aHealth Instruction (living will) and a Power of Attorney for Health Care for use by the public. Collectively, these documents are known as “advance directives.”   As the content of thesedocuments was drawn from the Uniform Health Care Decisions Act, it is in compliance with allapplicable statutes and laws.  There is an introduction that summarizes the scope and purpose of the documents, as wellas providing further directions for completion.  Read it carefully to ensure that your advancedirective is fully and properly filled out.  Understanding Your Directive  To make the best choices for your medical care, your physician needs to know yourwishes.  In fact, the law requires doctors to seek your permission before giving you anytreatment.  However, if you are ever unable to make decisions due to severe illness or injury, thismay not be possible.  Completing this Directive will help your family and physicians know whoshould speak for you, and understand what you want if you cannot make this known yourself.  You can revoke (cancel) this directive at any time by:  1) writing “revoked” across thefront of the directive, followed by your signature and date, and the signature of at least onewitness aged 18 years or older ;  or 2) by completing a Notice of Revocation; or 3) by telling anadult witness that you want it revoked (who must then sign and date a statement, which becomeseffective only when given to your doctor or health care provider);  or 4) by simply completing anew directive in which you state that any prior directive is no longer valid (as is already stated inthis directive).  You can limit your directive and the authority of anyone named in it, but no changes arerecommended after the document is witnessed.  Any scope-of-authority or content changesneeded after your directive has been witnessed should be made by completing a new directive. First-time changes can be made by lining out anything in the directive and writing “deleted”beside that clause or section (or initialing above any word(s) you have lined out), followed byyour signature, and the signature of at least one of the persons serving as a witness to thisdocument, placed in the margin immediately beside the change.  If you are unable to write, you may tell your directive witnesses what you want to have

Page 2 of  8excluded, limited, or added to this directive.  They must then sign, date, witness and/or notarizethe statement of the limitations and exclusions as you have described them.  Remember, unlessyou direct otherwise, this directive will only be used to guide your family and doctors if you areunable to make and communicate medical treatment decisions for yourself.  Instructions for Completing the Directive:This directive is written in two parts. While it is best if you fill out the whole document,you may choose to complete only Section I, leaving just a statement of your values and wishes. Or you may complete only Section II, just naming someone to speak for you. However, this mayleave your family and others without any evidence to support your wishes in the future, or leavethem unsure who is to make decisions and speak for you.  Thus, omitting either section maycause your loved ones difficulty if they must eventually make medical choices in your behalf. So, you are strongly encouraged to complete the entire directive.  To complete each document, you should initial in the underlined spaces provided besideall the questions that are asked, and fill in any blank lines as directed.  Feel free to write “No,” “None,” or “Does Not Apply” in areas that would otherwise be left blank. NEW MEXICOADVANCE HEALTH-CARE DIRECTIVE(Optional Form)(Pursuant to NMSA Chapter 24, Article 7A, 24-7A-1 through 24-7A-18)ExplanationYou have the right to give instructions about your own health care. You also have the right toname someone else to make health-care decisions for you. This form lets you do either or both ofthese things. It also lets you express your wishes regarding the designation of your primaryphysician. THIS FORM IS OPTIONALEach paragraph and word of this form is also optional. If you use this form, you may cross out,complete or modify all or any part of it. You are free to use a different form. If you use this form,be sure to sign it and date it. PART 1 of this form is a power of attorney for health care.  PART 1 lets you name anotherindividual as agent to make health-care decisions for you if you become incapable of makingyour own decisions or if you want someone else to make those decisions for you now eventhough you are still capable. You may also name an alternate agent to act for you if your firstchoice is not willing, able or reasonably available to make decisions for you. Unless related toyou, your agent may not be an owner, operator or employee of a health-care institution at whichyou are receiving care. Unless the form you sign limits the authority of your agent, your agent may make all health-caredecisions for you. This form has a place for you to limit the authority of your agent. You need not

Page 3 of  8limit the authority of your agent if you wish to rely on your agent for all health-care decisions thatmay have to be made. If you choose not to limit the authority of your agent, your agent will havethe right to: a) consent or refuse consent to any care, treatment, service or procedure to maintain,diagnose or otherwise affect a physical or mental condition; b) select or discharge health-care providers and institutions; c) approve or disapprove diagnostic tests, surgical procedures, programs of medicationand orders not to resuscitate; and d) direct the provision, withholding or withdrawal of artificial nutrition and hydration andall other forms of health care. PART 2 of this form lets you give specific instructions about any aspect of your health care.Choices are provided for you to express your wishes regarding life-sustaining treatment,including the provision of artificial nutrition and hydration, as well as the provision of pain relief.In addition, you may express your wishes regarding whether you want to make an anatomical giftof some or all of your organs and tissue. Space is also provided for you to add to the choices youhave made or for you to write out any additional wishes. PART 3 of this form lets you designate a physician to have primary responsibility for your healthcare.  After completing this form, sign and date the form at the end. It is recommended but not requiredthat you request two other individuals to sign as witnesses. Give a copy of the signed andcompleted form to your physician, to any other health-care providers you may have, to anyhealth-care institution at which you are receiving care and to any health-care agents you havenamed. You should talk to the person you have named as agent to make sure that he or sheunderstands your wishes and is willing to take the responsibility. You have the right to revoke this advance health-care directive or replace this form at any time. * * * * * * * * * * * * * * * * * * * * *PART 1:POWER OF ATTORNEY FOR HEALTH CARE1.   DESIGNATION OF AGENT:       Be it known that I, Full Legal Name: ______________________________________________________Date of Birth: _________________________________________________________Street Address: ________________________________________________________City:  ______________________________ County: __________________________State: ______________________________ Zip Code: ________________________

Page 4 of  8    ~~ designate the following individual as my agent to make health-care decisions for me: 2. Name of Agent: __________________________________________________Address: ________________________________________________________Telephone: Home:_____________________  Work:______________________Cell Phone or Pager: ___________________  E-mail: ____________________3.  First Alternate Agent:  If I revoke my agent's authority or if my agent is not willing, able orreasonably available to make a health-care decision for me, I designate as my firstalternate agent: Name of Alternate #1:_____________________________________________Address: ________________________________________________________Telephone: Home:_____________________  Work:______________________Cell Phone or Pager: ___________________  E-mail: ____________________4.  Second Alternate Agent:  If I revoke the authority of my agent and first alternate agent or ifneither is willing, able or reasonably available to make a health-care decision for me, Idesignate as my second alternate agent: Name of Alternate #2: ____________________________________________Address: ________________________________________________________Telephone: Home:_____________________  Work:______________________Cell Phone or Pager: ___________________  E-mail: ____________________5.   AGENT'S AUTHORITY: My agent is authorized to obtain and review medical records,reports and information about me and to make all health-care decisions for me, includingdecisions to provide, withhold or withdraw artificial nutrition, hydration and all otherforms of health care to keep me alive, except as I state here: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ (Add additional sheets if needed.) 6.  WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authoritybecomes effective when my primary physician and one other qualified health-careprofessional determine that I am unable to make my own health-care decisions. If I initialthis box [ ], my agent's authority to make health-care decisions for me takes effectimmediately. 7.  AGENT'S OBLIGATION: My agent shall make health-care decisions for me in accordancewith this power of attorney for health care, any instructions I give in Part 2 of this formand my other wishes to the extent known to my agent. To the extent my wishes areunknown, my agent shall make health-care decisions for me in accordance with what my

Page 5 of  8agent determines to be in my best interest. In determining my best interest, my agent shallconsider my personal values to the extent known to my agent. 8.  NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for meby a court, I nominate the agent designated in this form. If that agent is not willing, ableor reasonably available to act as guardian, I nominate the alternate agents whom I havenamed, in the order designated. * * * * * * * * * * * * * * * * * * * * *PART 2:INSTRUCTIONS FOR HEALTH CAREIf you are satisfied to allow your agent to determine what is best for you in making end-of-lifedecisions, you need not fill out this part of the form. If you do fill out this part of the form, youmay cross out any wording you do not want. 9.  END-OF-LIFE DECISIONS: If I am unable to make or communicate decisions regardingmy health care, and IF (i) I have an incurable or irreversible condition that will result in my death withina relatively short time, OR (ii) I become unconscious and, to a reasonable degree of medical certainty, I willnot regain consciousness, OR (iii) the likely risks and burdens of treatment would outweigh the expectedbenefits, THEN  10.  I direct that my health-care providers and others involved in my care provide,withhold or withdraw treatment in accordance with the choice I have initialedbelow in one of the following three boxes: A)[_____]  I CHOOSE NOT To Prolong Life: I do not want my life to be prolonged. B)[_____]  I CHOOSE To Prolong Life: I want my life to be prolonged as long as possible withinthe limits of generally accepted health-care standards. C)[_____] I CHOOSE To Let My Agent Decide My agent under my power of attorney for health care maymake life-sustaining treatment decisions for me.

Page 6 of  811.  ARTIFICIAL NUTRITION AND HYDRATION: If I have chosen above NOT to prolonglife, I also specify by marking my initials below: A) [_____] I DO NOT want artificial nutrition, OR B) [_____] I DO want artificial nutrition. C) [_____] I DO NOT want artificial hydration unless required for mycomfort, OR D) [_____] I DO want artificial hydration. 12.  RELIEF FROM PAIN:  Regardless of the choices I have made in this form and except as Istate in the following space, I direct that the best medical care possible to keep me clean,comfortable and free of pain or discomfort be provided at all times so that my dignity ismaintained, even if this care hastens my death: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 13.  ANATOMICAL GIFT DESIGNATION:  Upon my death I specify as initialed belowwhether I choose to make an anatomical gift of all or some of my organs or tissue: A) [_____] I CHOOSE to make an anatomical gift of all of my organs or tissue to be determined by medical suitability at the time of death,and artificial support may be maintained long enough for organs tobe removed. B)  [_____] I CHOOSE to make a partial anatomical gift of some of my organs and tissue as specified below, and artificial support may bemaintained long enough for organs to be removed. ____________________________________________________ ____________________________________________________ C)  [_____] I REFUSE to make an anatomical gift of any of my organs or tissue. D) [_____] I CHOOSE to let my agent decide. 14.  OTHER WISHES: (If you wish to write your own instructions, or if you wish to add to theinstructions you have given above, you may do so here.) I direct that: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ (Add additional sheets if needed.)

Page 7 of  8* * * * * * * * * * * * * * * * * * * * *PART 3PRIMARY PHYSICIAN15.  I designate the following physician as my primary physician: Name:__________________________________________________________Facility/Office: ____________________________________________________Address _________________________________________________________Phone:  (_______) _______ - _____________If the physician I have designated above is not willing, able or reasonably available to actas my primary physician, I designate the following physician as my primary physician: Name:__________________________________________________________Facility/Office: ____________________________________________________Address _________________________________________________________Phone:  (_______) _______ - _____________* * * * * * * * * * * * * * * * * * * * 16.  EFFECT OF COPY: A copy of this form has the same effect as the original. 17.  REVOCATION: I understand that I may revoke this OPTIONAL ADVANCE HEALTH-CARE DIRECTIVE at any time, and that if I revoke it, I should promptly notify mysupervising health-care provider and any health-care institution where I am receiving careand any others to whom I have given copies of this power of attorney. I understand that Imay revoke the designation of an agent either by a signed writing or by personallyinforming the supervising health-care provider. 18.  SIGNATURES: Sign and date the form here: Signed:__________________________________Date: _______________________ At:  (City) _______________________________(State) ______________________19.  SIGNATURES OF WITNESSES (Optional): 1 Witness:__________________________________________________________ st(Signature) ________________________________________________________(Name Printed)(Date)__________________________________________________________(Residence Address)

Page 8 of  82 Witness:__________________________________________________________ nd(Signature) ________________________________________________________(Name Printed)(Date)__________________________________________________________(Residence Address)20. INDIVIDUALS AND INSTITUTIONS WHO HAVE BEEN GIVEN COPIES OF THISADVANCE DIRECTIVEName:_______________________________Name: ____________________________Address ______________________________Address: _____________________________________________________________________________________Phone(_____) ______ - ________________Phone (_____) ______ - ______________Fax:(_____) ______ - ________________Fax:    (_____) ______ - ______________E-mail: ______________________________E-mail: ___________________________Name:_______________________________Name: ____________________________Address ______________________________Address: _____________________________________________________________________________________Phone(_____) ______ - ________________Phone (_____) ______ - ______________Fax:(_____) ______ - ________________Fax:    (_____) ______ - ______________E-mail: ______________________________E-mail: ___________________________For additional copies of this directive, or other related materials, please contact LifecareDirectives, LLC, at:  Lifecare Directives, LLC5348 Vegas Drive Las Vegas, NV 89108 (877) 559-0527 www.lifecaredirectives.com