Advance Healthcare Directive & Living Will Generator

ADVANCE HEALTHCARE DIRECTIVE AND LIVING WILL STATE OF CALIFORNIA I, Eleanor Vance Montgomery, residing in the State of California, being of sound mind and willfully desiring to make known my wishes regarding medical care in the event I become unable to communicate or participate in medical decisions, hereby execute this Advance Healthcare Directive and Living Will on this _____ day of __________________, 20____. PART I: APPOINTMENT OF HEALTHCARE AGENT (POWER OF ATTORNEY FOR HEALTHCARE) 1. PRIMARY AGENT I designate and appoint David Thomas Montgomery (my Spouse) as my healthcare agent ("Agent") to make all healthcare decisions on my behalf when I lack medical decision-making capacity. 2. ALTERNATE AGENT If my primary agent is not reasonably available, is unable, or refuses to act, I designate Sarah Montgomery Brooks (my Adult Daughter) as my successor alternate healthcare agent. 3. AGENT'S AUTHORITY My Agent is authorized to make all healthcare decisions on my behalf, including: consenting, refusing, or withdrawing consent to medical tests, procedures, medications, surgery, and life-sustaining treatment; selecting healthcare facilities, hospitals, hospices, or nursing homes; and hiring or discharging physicians. 4. HIPAA MEDICAL INFORMATION AUTHORIZATION I expressly authorize any physician, healthcare facility, or insurer to release to my Agent any confidential health information, medical records, and protected health information (PHI) governed by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (45 C.F.R. § 164.502). PART II: LIVING WILL (HEALTHCARE INSTRUCTIONS) 5. END-OF-LIFE TREATMENT PREFERENCES If I am diagnosed by two qualified physicians to be in a terminal condition, permanently unconscious, or in a persistent vegetative state with no reasonable medical expectation of cognitive recovery: (a) Life-Sustaining Treatment: I direct that my healthcare providers withhold or withdraw life-sustaining treatment (including cardiopulmonary resuscitation, mechanical ventilation, dialysis, and invasive interventions) that serves only to prolong the dying process. (b) Artificial Nutrition & Hydration: I direct that artificial nutrition and hydration (feeding tubes and intravenous feeding) be withheld or withdrawn if they serve only to prolong the natural process of dying. (c) Maximum Pain Relief: I direct that pain-relieving medication and palliative comfort care be administered to me generously to keep me free of pain and physical distress, even if such medication hastens the moment of death. 6. ANATOMICAL GIFTS (ORGAN DONATION) Upon my death, I make an anatomical gift of any needed organs, tissues, or parts for transplantation, therapy, medical research, or education. PART III: GENERAL PROVISIONS 7. REVOCATION OF PRIOR DIRECTIVES I revoke any prior healthcare powers of attorney, living wills, or medical directives previously executed by me. 8. SEVERABILITY AND LIABILITY SHIELD No physician, hospital, or healthcare provider who relies in good faith upon this Directive or the instructions of my designated Agent shall incur civil or criminal liability. IN WITNESS WHEREOF, I have executed this Advance Healthcare Directive on the date set forth above. __________________________________________________ Signature of Principal: Eleanor Vance Montgomery STATEMENT OF WITNESSES We declare under penalty of perjury that the principal is personally known to us, signed this directive in our presence, appeared to be of sound mind, and is under no duress or undue influence. Witness 1: Signature: ___________________________________ Date: ________________________ Printed Name: ________________________________ Address: _____________________ Witness 2: Signature: ___________________________________ Date: ________________________ Printed Name: ________________________________ Address: _____________________ NOTARY PUBLIC ACKNOWLEDGMENT State of California, County of ___________________ On this _____ day of ____________, 20___, before me, the undersigned notary public, personally appeared Eleanor Vance Montgomery, known to me to be the person who signed the within instrument. _______________________________________________ Notary Public, State of California (Seal)