A Minnesota Advance Directive Form, also known as a living will, is a formal document that is used by an individual to communicate their treatment preferences and to also choose the medical agents they would like to take care of them during this period of illness. To notarize this document, it must be signed in the presence of two witnesses (see (§ 145C.03)).
This advanced directive usually consists of:
The selection of medical personnel to act as a care agent
A directive on the kind of medical attention the principal/patient would like to receive (see Chapter 145C (Health Care Directives) )
First enter correctly the full name of the principal, i.e. the patient who is at the receiving end of the advanced directive.
Enter the name of your preferred medical personnel (patient advocate) who you want to be in charge of your treatment; this person must be recognized by the state of Minnesota.
State what relationship you as a patient has with the medical personnel named above.
Enter the phone numbers of every person involved in the advance directive form.
Then enter the home address of the medical agent.
In cases where your preferred medical personnel is unavailable for certain reasons, it is advisable to name alternate medical personnel (also known as a patient advocate) to replace the original.
State what your relationship is with the newly named agent.
Provide the contact information including the address and phone number of the persons (you, the original patient advocate, and the substitute patient advocate) involved in the living will form.
Spell out the decisions your health representative can make on your behalf.
As a principal, you are allowed to give your patient advocate the authority to donate your organs (this is called Anatomical Gifts) upon your death. You are to deliver your initials as proof that you authorized this declaration.
As a principal, you may give someone the authority to dispose of your body (either via burial, cremation, or organ donation) in case of death. You are to deliver your initials as proof that you authorized this declaration.
After providing the above information, you can then add additional information as regards what you desire from your medical personnel.
State what you intend to achieve from the health care received.
Also, spell out the likelihood that certain disadvantages might result from the health care given.
On the document, a tab has been opened to allow you to state your religious or traditional position/belief.
The next area of this document is optional and it circles your thoughts about when life would no longer be worth living.
You will then be opportune to state whether your current condition will in any way affect your family.
You are to spell out what sort of health care you would like to receive if you had slim chances of recovering.
You are to spell out your wishes about your health care if you had no chance of recovering and were dying.
If you are at a point of unconsciousness where you are unable to communicate with anyone and had to fully depend on life support, what kind of medical care would you prefer to receive? You are also to state your opinion on this.
Also, you are to state the kind of treatment you would like to receive if you are at a point where you are unable to properly maintain your physical health and hygiene
There are several ways to manage pain during illness; choose the method you will prefer is used for you and make mention of it in this section.
State your preferences as regards your general health care.
Make a specific request (by providing a means of communicating with them) for medical personnel to be informed about your illness and state whether treatment tips can be obtained from him.
You will be allowed to choose the facility where you would like to receive treatment. To do this, state the name of the facility, its address, and call number.
You are then to make mention of any wishes for or what you would like to obtain from the medical care to be received.
Again, you are to state whether you would like your organs to be donated after your death or not; and for what purpose you would be donating them.
In this section, you are to state your burial wishes; would you like to be buried underground or cremated? Where would you prefer that this be done? Who would you prefer to be in charge of this (you are then to provide the person’s number or a means to reach them)?
You are expected to make mention of any other thing you might need as regards health care
As the patient/principal making use of this form, you are expected to bring this document into full legal effect; this can be done by imprinting your signature on the document. Following these are, the date the signature was imprinted, your birth date, and your home address.
In cases where you are unable to sign this document, someone else may sign it in your place (in your presence). This person is expected to provide their full name after signing. Note that regardless of this, every detail required in the signature section must be provided.
The imprinting of the signature must be done in the presence of recognized and authorized officials (known as the Notary Public). These officials are then expected to confirm your name and date as provided on the document, then sign. Note that finding these officials is less burdensome than finding witnesses.
A section is provided for two witnesses. The first witness is to agree to the statement in this section and finish it off with his/her signature, birth date, and home address. If this witness is a health care provider in the facility where you are being treated, he/she is to enter their initial in the tab provided in IV.
A section is then provided for the second witness. He/she is expected to read through this section carefully and provide specific information as regards themselves. This is to be followed by his/her signature, date of birth, and home address. If this witness is medical personnel in the facility where you are being treated, he/she will be required to put his initials in a box (IV) provided on the document.
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