Virginia Living Will Form

To establish a living will in the State of Virginia, concerned individual must accomplish this form. A living will allows for the selection of later-in-life medical treatments.Download

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VIRGINIA ADVANCE MEDICAL DIRECTIVE	
I, ___________________________________________________, willfully and vo\
luntarily make known my desire and do hereby declare:
Section 1. Appointment of Agent to Make Health Care Decisions
(Cross through this section if you do not want to appoint an agent to m\
ake health care decisions for you.)
I hereby appoint the following as my primary agent to make health care d\
ecisions on my behalf as authorized in this document:
 
Primary Agent	    	Telephone Number       
Fax Number
Address          
E-mail Address	
If the above named primary agent is not reasonably available or is unable or unwilling to act as my agent, then I appoint the following as 
successor agent to serve in that capacity:
 
Successor Agent	   	Telephone Number       
Fax Number
Address          
E-mail Address	
I hereby grant to my agent, named above, full power and authority to make health care decisions on my behalf as described below whenever 
I have been determined to be incapable of making an informed decision about providing, withholding or withdrawing medical treatment. The 
phrase “incapable of making an informed decision” means unable to understand the nature, extent and probable consequences of a proposed 
medical decision or unable to make a rational evaluation of the risks and benefits of a proposed medical decision as compared with the risks 
and benefits of alternatives to that decision, or unable to communicate such understanding in any way. My agent’s authority hereunder is 
effective as long as I am incapable of making an informed decision.
The determination that I am incapable of making an informed decision shall be made by my attending physician and a second physician or 
licensed clinical psychologist after a personal examination of me and shall be certified in writing. Such certification shall be required before 
treatment is withheld or withdrawn, and before, or as soon as reasonably practicable after, treatment is provided, and every 180 days thereafter 
while the treatment continues.
In exercising the power to make health care decisions on my behalf, my agent shall follow my desires and preferences as stated in this document 
or as otherwise known to my agent. My agent shall be guided by my medical diagnosis and prognosis and any information provided by my 
physicians as to the intrusiveness, pain, risks and side effects associated with treatment or nontreatment. My agent shall not authorize a course 
of  treatment  which  he  knows,  or  upon  reasonable  inquiry  ought  to  know,  is  contrary  to  my  religious  beliefs  or  my  basic  values,  whether 
expressed orally or in writing. If my agent cannot determine what treatment choice I would have made on my own behalf, then my agent 
shall make a choice for me based upon what he believes to be in my best interests. My agent shall not be liable for the costs of treatment that 
he/she authorizes, based solely on that authorization.
The powers of my agent shall include the following: 	(Cross through any powers below you do not want to give your agent.)	
A.  To consent to, or refuse or withdraw consent to, any type of medical care, treatment, surgical procedure, diagnostic procedure, medication 
and the use of mechanical or other procedures that affect any bodily function, including but not limited to artificial respiration, artificially 
administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the power to consent to 
the administration of dosages of pain-relieving medication in excess of recommended dosages in an amount sufficient to relieve pain, even if 
such medication carries the risk of addiction or inadvertently hastens m\
y death;
B.    To  request,  receive  and  review  any  information  (whether  verbal,  written,  printed  or  electronically  recorded)  regarding  my  physical  or 
mental health, including but not limited to medical, hospital and other records; and to consent to or authorize the use and disclosure of such 
information; and to otherwise serve as my personal representative for su\
ch purposes;
C.  To employ and discharge my health care providers;
D.  To authorize my admission to or discharge (including transfer to another facility) from any hospital, hospice, nursing home, assisted living 
facility or other medical care facility for services other than those for treatment of mental illness requiring admission procedures provided in 
Article 1 (§37.1-63 et seq.) of Chapter 2 of Title 37.1;
E.  To make decisions about who may visit me, subject to physician orders and\
 policies of any institution to which I am admitted;
F.  To take any lawful actions necessary to carry out these decisions, includ\
ing the granting of releases of liability to medical providers.	
—page 1 of 2—

Add below any additional powers you give your agent, limits you impose o\
n your agent or other information to guide your agent:
Section 2. “Living Will”
(Cross through this section if you do not want to make a "living will" \
in this form.)
If at any time my attending physician should determine that I have a terminal condition where the application 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 administration of medication or the performance of any medical procedure deemed necessary to provide me with 
comfort care or to alleviate pain. 	OPTION	: I specifically direct that the following procedures or treatments be\
 provided to me:	
In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration 
shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the 
consequences of such refusal.
Section 3. Appointment of Agent to Make Anatomical Gift
(Cross through this section if you do not want to appoint an agent to m\
ake an anatomical gift or organ, tissue or eye donation for you.)
Upon my death, I direct that an anatomical gift of all of my body, or certain organ, tissue or eye donation may be made pursuant to 
applicable Virginia law governing anatomical gifts and in accordance with my directi\
ons, if any. I hereby appoint as my agent
p Same agent named in Section 1 	OR	
p   
Primary Agent	    	Telephone Number       
Fax Number
Address          
E-mail Address	
to make any such anatomical gift or organ, tissue or eye donation follow\
ing my death. I	 further direct that:	
                          	     (Declarant’s directions, if any, concerning anatomical gift or organ, tissue or eye donation)	
You must complete the following portions of this form:
This  advance  directive  shall  not  terminate  in  the  event  of  my  disability.  By  signing  below,  I  indicate  that  I  am  emotionally  and  mentally 
competent to make this advance directive and that I understand the purpo\
se and effect of this document.
________________________________________     ___________________________\
____________________________________________________________
Date    Signature of declarant
The declarant signed the foregoing advance directive in my presence.
________________________________________Witness
This form is provided by the Virginia Hospital & Healthcare Association as a service to its members. (\
July 2005, 	vhha	)	
________________________________________Witness	
This form, with slight variations, is suggested for use by the Virginia General Assembly in the Health Care Decisions Act and satisfies the requirements of 
Virginia law. You may complete any or all of the three numbered sections of the form. If you have legal questions about this form, or would like to develop 
a different form to meet your particular needs, you are urged to talk with an attorney. It is your responsibility under Virginia law to provide a copy of your 
advance medical directive to your attending physician. You also should provide copies to your agent, close relatives and/or frie\
nds.	
—page 2 of 2—