Vermont Advance Directive (Living Will) Form

Generally speaking, an advance directive form in Vermont is a document that permits an individual to choose a medical agent, establish end-of-life options, and donate organs. It is also known as a living will. The form may be downloaded and completed on your own time, after which it should be signed and utilized under applicable state rules.

Vermont advance directive

Vermont Advance Directive (Living Will) Form

Laws and Statutes to adhere to

Title 18, Chapter 231 of the Statutes provides that a person may make advance directives for health care and disposition of remains. 

The requirements needed to complete the signing process (18 V.S.A. 9703) are as follows: a minimum of two (2) witnesses, each of whom must be above the age of eighteen (18) should be present during signing and also append their signature

State Definition of Advanced Directive (18 V.S.A. § 9701(1))- The completion of a written document under Section 9703 of this chapter that may include the designation of an agent, the designation of a preferred primary care practitioner, instructions on health care wants or treatment objectives, anatomical donation, disposition of remains, and funeral products and services. In this area, you will find documents such as an advanced directive for health care or a terminal care agreement, among others.

How to write a Vermont advance directive


 (1) As the Vermont Declarant, you should identify yourself as such.   It is assumed that you authored these claims yourself as soon as you sign this document. On the first line, your whole name is to be written.

(2) End-of-Life Instructions. If your sickness has been declared terminal, and no amount of life-saving treatment can prevent death, then it's appropriate to let yourself die naturally. If this is the case, then initial the first statement.

3) Life-Support During the Final Stages of Illness.  Whenever a Vermont Physician determines that a Vermont Patient's illness provides a terminal prognosis and that there will be a death, regardless of any treatment, that Vermont Patient has the choice of having their life extended as far as it is possible. Your initials may will give this directive your mark of approval (TPA).

Medical Illness Or Injury That Is Not Reversible

Item 4 or Item 5 may be authorized.

(4) Comfy Care. There are other medical scenarios in which a disease responds to life-sustaining operations but remains incurable, severely incapacitates you, and necessitates your reliance on life-support systems or techniques. Terminally sick patients may issue a statement that they reject any life-saving treatments administered to them, but rather want for their death to occur on their terms by giving Vermont Medical Professionals the authority to remove any presently in use.

(5) Life-Supporting Instruction. If you desire to be kept alive for a long while, regardless of your underlying medical condition, begin the second statement.

More Specific Instructions

(6) Vermont Patient Directives Provisions.  The conditions under which you accept or reject a therapy or even arrange for lifesaving procedures like tube feedings or experimental treatment may all be discussed in detail. While you're filling out this form, it's a good idea to discuss your options for treatment with your doctor.

With no Medical Power of Attorney in place,

(7) Health Care Surrogate in Vermont. If your intention is not to have to nominate a Vermont Health Care or Medical Attorney-in-Fact, a Health Care Surrogate may function as your Agent. 

Vermont Signatory to the Declaration

(8) Signatures.  The principal must sign and make sure you have two people who can attest to what you're about to do present when you do this.

(9) The Date of the Signature.

(10) Specifics about the place where you live. You should sign all of this information. Also, the date of your signing should accompany it.

Statement of a Victim

(11) The signature of Witness 1 is required. To be a reliable source of evidence, you'll need two adults as witnesses, but one of them can't be a health care provider or employee who is directly related to you by blood or marriage. First, the statement must be signed on the first signature line that appears on the document.

(12) The signature of Witness 2 here. Adults who saw you signing this document as a second witness are required. It is a guarantee of the truthfulness of the Witness's story if he or she signs his or her name to it.

A Person Who Provides Medical Services

(13) Principal of the school in Vermont. The next portion of this directive allows you to choose a representative to communicate your healthcare choices and requests to a Vermont Medical Professional. Begin the process of becoming a Vermont school principal by submitting your name and claiming the position as your own.

(14) Vermont Health and Human Services.  There is no way to override your living will's instructions, but if you name a Vermont Health Care Agent in your living will, they can assist you in providing the authorization and instruction that you must give at the time of treatment admission and make treatment decisions over topics you have not discussed.

(15) Health Care Providers in Vermont and How to Reach Them.

Restrictions on the Power to Make Decisions

(16) Your Vermont health care agent is being restricted- Signing this document gives your Vermont Health Care Agent the authority to act on your behalf when it comes to making medical choices. What therapies you'll get, when and where you'll get them, and whether or not your preferences will be carried out will all be in his or her hands. By declaring specifically what actions you would take in certain situations, or by noting the amount to which you have reduced or deleted a certain key power, you have the option of limiting any or all of these abilities

Alternate Vermont agent

(17) First Alternate Health Care Agent in Vermont.  As a result, it's critical to remember that if your Vermont Health Care Agent is unable or unwilling to represent your medical directives, you will be without a Vermont Health Care Agent to secure and issue your directives. If you have an Alternate Vermont Agent on hand, he or she may be able to act on your behalf using this paper. Your Vermont Health Care Agent will immediately provide the principal authority (and any applicable constraints) to your Vermont Alternate Agent as soon as you select them. Only your Vermont First Alternate Agent has the power to seize the document.

(18) The provision of an additional source of health-care services is made possible. To reiterate, your medical treatment may not be able to be decided by Vermont Medical Attorney-in-Fact or Health Care Agent due to the limitations imposed by this agreement. Your Vermont Reviewers' First Alternate Agent will be contacted as a result of this. If your first alternate Vermont agent is unable, ineligible, or otherwise unavailable, you may be able to get medical guidance from a Second Alternate Vermont Agent. As long as you supply this Party's name and contact information when these documents are requested, he or she will have the same authority over your medical treatment as his or her predecessors did.

Preserving Documentation

(19) The place where the directive is kept. A health care proxy is a person you select to speak on your behalf to Vermont health care providers in the event you are unable to talk, unconscious (permanently), or suffering from a terminal or untreatable medical condition. When this form is completed, we need to know where to keep the original copy. The Party or Entity's name, address, phone number, and email should be entered in the box provided to verify that your original copy of this directive is secure.

(20) The location of the copies. For future reference, a copy of the original instruction should be retained. It's important to keep track of every person or organization that will be given a copy of your directive. As you make revisions or changes to your directive, be careful to get rid of any additional copies.


(21) Expiration of Vermont Health Care Agent Powers. a.k.a There is no expiration date on any of the State of Vermont health care instructions and appointments stated above (or until your death or formal revocation of this paperwork). You have the option to set an expiration date for your directives while they are in this condition. After this date has passed, any powers granted or medical instructions provided will be deemed void since they are out of date or erroneous. This is optional, however, you may set an expiration or termination date here if you wish the document to cease to be valid on a certain day in the future without further action on your side. To avoid any confusion, the original and copies that you have given out must be returned.

The signature of the principal of Vermont

Signing with a Notary

(22) Date of Calendar signing-Signed.  For this directive to take effect, the State of Vermont needs your signature. The presence of a witness who can testify to your aware state of mind is required. This kind of proof requires the inclusion of a signature and a date. A Vermont patient's signature on this document should include the current date.

(23) Counties In Which The Document Is Signed. It's important to record where you signed this paper.

(24) The executing signature of Vermont has been added to the list. Notary Public (registered and recognized by the State of Vermont) or two adults who are acting as Witnesses are acceptable.

(25) Make a note of the name.

(26) A notary public may take part in the activity. In a separate section, this paper has been notarized. Once it has been signed, take this document to a Notary Public to ensure compliance with the requirements of this section. Do not include this portion in your case, and instead, provide it to your current witnesses.

(27) Vermont Patient Signature Date. To get your signature authenticated by two Witnesses, they must both be present when you sign and be in the same place. The Vermont Patient ID number is the first step.

(28) Execution in the City and State. The city and state where you and the two witnesses have gathered for this signing should get a payment.

(29) This is a Vermont patient's signature. You should only sign your name when you comprehend what you've done and two witnesses are there to verify it.

(30) Name as it appears on official papers.

The Statement of the First Witness

(31) The first witness must sign the document.  Both the First Witness's signature and address must be included on this form.

(32) The signing date of the first witness. Your signature and First Witness's signature must be on the same day of the week, and there must be no differences.

The Second Witness's Signature

(33) Signature testimony from a second witness.  After reading his or her statement on his or her Vermont statutory qualifications for this employment, the Second Witness will next witness to your accurate state of mind when you signed the contract. Whenever the First Witness is convinced that the evidence is true, he or she should sign his or her name and offer his or her name and address in writing.

(34) The date on which the second witness's signature was obtained. The second Witness' signature should be documented after he or she has delivered this testimony's required signature.

DNR orders were given outside of a medical facility

(35) The Vermont declarant's name. Doctors are required to assist you in issuing a Do Not Resuscitate Order. There are two ways this document may be issued: by the Vermont Declarant or someone designated by the Declarant. If you're the Issuing Party, please put your full name at the top of the page. Thank you for your cooperation. If you are acting on behalf of a Vermont patient, you must give their full name at the beginning of this portion of the directive.

(36 ) The date of birth must be included in the application process. Patients' names and birthdates must be included in an individual's name.

(37) The sex of the individual. Identifying a Vermont patient's gender is as simple as ticking the appropriate box.

An Adult's Self-Declaration

(38) The signatures of. Section A of the declaration instructs Vermont doctors not to attempt resuscitation or restart of your heart or lungs in the case of cardiopulmonary failure. Section A of this document must be signed by the Vermont Patient making this statement.

(39) When the signature was acquired.

(40) Printing of one's name.

B. Adult's legal guardian, agent, or proxy.

(41) Legal Guardian. Section B.

In the next section.

If you are the legal guardian of the Vermont patient listed above, you must check the first box.

(42) Agent In Medical Power Of Attorney. The second box in Section B should be ticked if you are the Vermont patient's chosen attorney-in-fact.

(43) A proxy. When executing this under a patient's executed Living Will, choose the third checkbox if you are the patient's authorized proxy.

(44) Getting Signed. For patients who refuse CPR (e.g., defibrillation, CPR, etc.), you are required to sign your full name after identifying yourself accurately.

(45) The time.

(46) The name that appears on the document.

C. A Qualified Relative Declares

(47) Assertion of marital status. If you are very positive that this is following the desires of a family member, you may use this form to issue a DNR on their behalf. To begin, one must first establish one's identity. You may identify your relationship to the Vermont Patient by checking the appropriate box in Section C if you are the spouse, adult child, parent, or another close living family.

(48) The signature serves as an indication of agreement. Section D requires your signature as proof that you are communicating the wishes of the Vermont patient by issuing this DNR.

(49) The date.

(50) Printed Name

D. Physician's Declaration based on the Directive

(51) Evidence that has been verified. This document must be authenticated by a licensed physician. For Vermont medical responders and other healthcare practitioners, this verification procedure is essential. The first box in Section D must be checked by the Licensed Physician signing this form if he or she has read the Vermont Patient's given directive.

(52) There was evidence of a release. There is a DNR option for Vermont patients who are unable to fill out the documents, but it is not mandatory. if the physician has seen the Vermont patient provide spoken instructions in front of two witnesses, the second option should be checked.

(53) Doctor. The attending physician must write his or her name to testify to the veracity of how he or she learned about the Vermont Patient's DNR request (as mentioned above).

(54) Issuing date

(55) names were printed out.

(56) Vehicle Identification Number. The Attending Physician's medical license number must be accurately recorded if he or she provides the date of signing and his or her written name.

E. Minor's Declaration of Interest

(57) A Vermont patient's mother or father. If you are the patient's parent in Vermont, you must tick the first box to indicate so.

(58) In this case, the legal guardian is. Choose option 2 if the patient is a minor to demonstrate that you are their legal guardian.

(59) Conservator in charge.  If you are filling out this paperwork on behalf of a Vermont patient who is a juvenile and for whom you have been appointed as the Legal Conservator, be sure to tick the third checkbox.

(60) Signed by.  In the case of cardiopulmonary failure, the patient's parent, legal guardian, or conservator may attest to the patient's authorization to decline resuscitation attempts by completing this form.

(61) Date

In the presence of two witnesses,

(63) Witness 1's signature, date, and name are all included in this paragraph.  There must be two Witnesses who are neutral to the Vermont patient's condition for this order to be signed by the executing signature (whether Vermont Patient or a distinct Party functioning on his or her behalf). Witness 1 is in charge of identifying the pertinent portion and then providing his or her testimonial signature (printed name), signing date, and place. This is his or her job.

(64) The signature, date, and name of Witness 2. During the day of your Vermont Patient's DNR execution, have Witness 2 locate Witness 2's signature area and sign, print, and disburse the current date.

(65) Notary Public. A Notary Public may verify the execution of the order as long as it is not the result of an oral directive from the patient. There is just one component of the notarization process that may be completed by a Notary Public in attendance.

Attending Notary Publics are only permitted to finish the notarization part.

a statement from a doctor

(66) The signature of the doctor.  Medical orders for Vermont First Responders must be signed by a doctor who is familiar with the patient's medical history and conditions. It is necessary to have a person's consent for this to occur.

(67) The printed version of the name.

(68) Date of birth

(69) The license number is. The attending physician's medical license number must be known.

Two Physicians' Declaration of Intent on behalf of an Adult

(70) Signature of Attending Physician.  Resuscitation may be a burden, contradict the patient's known wishes, or generally not in the best interest of the Vermont patient if the Vermont Physician caring for tha patient has developed a "reasonable judgment" about it. A doctor must sign and date this DNR as long as it is being given by a doctor. Vermont doctors who visited the patient and gave their approval must then put their name and license number in writing and submit it with the order. This is a legal requirement.

(71) Signed by a Second Physician.  This judgment call must be confirmed by another Vermont Physician before the Vermont Physician administers therapy to the patient and delivers these papers as official medical orders. This Second Vermont Physician will need to sign and date the document to prove his or her permission. Such verification will be provided by having the Second Physician sign off on the form with his or her name and medical license number.

Acknowledgment Of Success

(72) Signed by a specific individual. It's vital for Vermont physicians to have confidence in the material they receive and that it is supported by reliable evidence. This is just for the benefit of the patient. A patient in Vermont who wants to be kept alive in the event of life-threatening medical emergencies would sign a document stating that he or she does not want to be resuscitated. Assuming you are the Vermont patient behind this DNR-OOH, you must sign your name and then send it over for additional signatures.

(73) The guardian/agent/signature. proxy's Vermont Patients may have a lawfully appointed guardian, agent, or acting proxy sign this document on their behalf. This isn't always the case. A witness's signature is required to show that this document was made lawfully and accurately represents the wishes of the Vermont patient if this scenario is true.

(74) The signature of a doctor. To verify that their signatures were entered properly, everyone who previously signed the form must do so once again.

(75) Signature of a Second Physician.

(76) First Witness Signature- a witness testified to the document's signature. The final confirmation portion of the document must be signed by each of the two Witnesses who authenticated this document.

(77) 2nd Witness's Signature

(78) Notary Public- For this DNR-OOH to be authenticated, the signature of the Notary Public who testified in favor of its authenticity must be notarized.

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Download our free Vermont advance directive in an instant to create a legally binding document.

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