[Health Care Directive] Nebraska

You Have Filled Out Your Health Care Directive, Now What?

1. Your Nebraska Advance Directive is an important legal Keep the original signed document in a secure but accessible place. Do not put the original document in a safe deposit box or any other security box that would keep others from having access to it.

2. Give photocopies of the signed original to your agent and alternate agent, doctor(s), family, close friends, clergy, and anyone else who might become involved in your health If you enter a nursing home or hospital, have photocopies of your document placed in your medical records.

3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes concerning medical treatment. Discuss your wishes with them often, particularly if your medical condition changes.

4. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

5. If you want to make changes to your documents after they have been signed and witnessed, you must complete a new document.

6. Remember, you can always revoke your Nebraska document.

7. Be aware that your Nebraska document will not be effective in the event of a medical Ambulance and hospital emergency department personnel are required to provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive that states otherwise. These directives called “prehospital medical care directives” or “do not resuscitate orders” are designed for people whose poor health gives them little chance of benefiting from CPR. These directives instruct ambulance and hospital emergency personnel not to attempt CPR if your heart or breathing should stop.

Currently not all states have laws authorizing these orders. We suggest you speak to your physician if you are interested in obtaining one.

Introduction to Your Nebraska Advance Directive

This packet contains a legal document, a Nebraska Advance Directive, that protects your right to refuse medical treatment you do not want, or to request treatment you do want, in the event you lose the ability to make decisions yourself. You may fill out Part I, Part II, or both, depending on your advance planning needs. You must complete Part III.

Part I is the Nebraska Powerof Attorney for Health Care. This part lets you name an adult, called your attorney in fact, to make decisions about your health care— including decisions about life-sustaining treatments—if you can no longer speak for yourself. The Power of Attorney for Health Care is especially useful because it appoints someone to speak for you any time you are unable to make your own health care decisions, not only at the end of life.

Part I goes into effect when your doctor determines that you are no longer able to understand and appreciate the nature and consequences of health care decisions or that you are unable to communicate in any manner an informed health care decision.

Part II is a Nebraska Declaration, which is your state’s living will. Part II lets you state your wishes about medical care in the event that you can no longer make your own health care decisions and you are either terminally ill or in a persistent vegetative state.

The declaration in Part II becomes effective once your attending physician determines that you are incapable of making decisions about the use of life- sustaining treatment, (2) determines that you are either in a persistent vegetative state or in a terminal condition, and (3) has notified a reasonably available member of your immediate family or your guardian, if you have one, of his or her intent to invoke your Declaration.

Part III contains the signature and witnessing provisions so that your document will be effective.

Following the advance directive is an Organ Donation Form.

The NebraskaAdvanceDirective does not expressly address mental illness. If you would like to make advance care plans regarding mental illness, you should talk to your physician and an attorney about a durable power of attorney tailored to your needs.

Note: These documents will be legally binding only if the person completing them, the person named as attorney in fact, and the two witnesses are all competent adult who are:

• atleast19 years old, OR
• married, OR
• have been married.

Instructions for Completing Your Advance Directive
How do I make my Nebraska Advance Directive legal?

The law requires that you have your NebraskaAdvanceDirective witnessed. You can do this in either of two ways:

1. Have your signature witnessed by a notary public you have not named as your attorney in fact or alternate attorney in fact,

OR

2. Sign your document in the presence of two adult Only one witness may be an administrator or employee of a health care provider who is providing treatment. Neither witness may be an employee of your health or life insurer. If you have filled out Part I, the power of attorney for health care, your witnesses may not be your spouse, parent, child, grandchild, sibling, your presumptive heir, any known devisee (someone who you have named in your will to inherit from your estate), your attending physician, or your attorney in fact or his/her alternate.

Whom should I appoint as my attorney in fact?

Your attorney in fact is the person you appoint to make decisions about your health care if you become unable to make those decisions yourself. Your attorney in fact does not have to be a lawyer and may be a family member or a close friend whom you trust to make serious decisions. The person you name as your attorney in fact should clearly understand your wishes and be willing to accept the responsibility of making health care decisions for you.

The person you appoint as your attorney in fact cannot be:

• your attending physician,
• an employee of your attending physician who is not related to you by blood, marriage, or adoption,
• an owner, operator or employee of your treating health care provider who is not related to you by blood, marriage, or adoption, or
• a person unrelated to you by blood, marriage, or adoption who is currently serving as an attorney in fact for ten or more people.

You can appoint a second person as your alternate attorney in fact. The alternate will step in if the first person you name as an attorney in fact is unable, unwilling, or unavailable to act for you.

Should I add personal instructions to my Nebraska Advance Directive?

One of the strongest reasons for naming an attorney in fact is to have someone who can respond flexibly as your health care situation changes and deal with situations that you did not foresee. If you add instructions to this document it may help your attorney in fact carry out your wishes, but be careful that you do not unintentionally restrict your attorney in fact’s power to act in your best interest. In any event, be sure to talk with your attorney in fact about your future medical care and describe what you consider to be an acceptable “quality of life.”

What if I change my mind?

You may revoke your Nebraska Advance Directive at any time and in any manner that reflects your intent to revoke, provided that you are competent. Your revocation is effective once you notify your health care provider, attending physician, or attorney in fact.

Unless you provide otherwise, making a new valid power of attorney for health care (Part I) will revoke any previously executed power of attorney for health care.

If you appoint your spouse as your attorney in fact, a decree of divorce or legal separation will automatically revoke that appointment, unless the decree specifically provides otherwise.

What other important facts should I know?

A direction to withhold or withdraw life-sustaining treatment from a pregnant patient will not be honored if it is probable that the fetus will develop to the point of live birth with continued life-sustaining treatment.

How do I make my Nebraska Organ Donation form legal?

You must sign your organ donation form in the presence of two witnesses. At least one of your witnesses must be disinterested, which means that he or she has no interest or claim on your estate or any anatomical gift you plan to make.

NEBRASKA ADVANCE DIRECTIVE – PAGE 1 OF 7

Part I: Power of Attorney for Health Care

I authorize my attorney in fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions, including decisions to withhold or withdraw life-sustaining treatment and artificially administered nutrition and hydration. I have read the warning which accompanies this document and understand the consequences of executing a power of attorney for health care.

When making health care decisions for me, my attorney in fact should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in this advance directive or other legal or nonlegal document, my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then my health care attorney in fact should make decisions for me that my health care attorney in fact believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.

NEBRASKA ADVANCE DIRECTIVE – PAGE 2 OF 7

Further Instructions. Attach additional pages as needed.

NEBRASKA ADVANCE DIRECTIVE – PAGE 3 OF 7

Part II: Declaration Relating to the Use of Life-Sustaining Treatment

If I should lapse into a persistent vegetative state or have an incurable and irreversible condition that, without the administration of life- sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Rights of the Terminally Ill Act, to:

((or))

((or))

NEBRASKA ADVANCE DIRECTIVE – PAGE 4 OF 7

I further direct that:

NEBRASKA ADVANCE DIRECTIVE – PAGE 5 OF 7

PART III: EXECUTION

This Health Care Directive will not be valid unless it is EITHER:

(A) Signed by two (2) adult witnesses who are present when you sign or acknowledge your signature.

Only one witness may be an administrator or employee of a health care provider who is providing treatment. Neither witness may be an employee of your health or life insurer.

If you have filled out Part I, the power of attorney for health care, your witnesses may not be your spouse, parent, child, grandchild, sibling, your presumptive heir, any known devisee (someone who you have named in your will to inherit from your estate), your attending physician, or your attorney in fact or his/her alternate. (Use Alternative 1, below (page ), if you decide to have your signature witnessed.)

OR

(B) Witnessed by a notary.

If you have filled out Part I, the power of attorney for health care, your document may not be notarized by your attorney in fact or his/her alternate. (Use Alternative 2, below (page ), if you decide to have your signature notarized.)

NEBRASKA ADVANCE DIRECTIVE – PAGE 6 OF 7

Alternative No. 1: Sign Before Witnesses

DECLARATION OF WITNESSES

We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care in our presence, that the principal appears to be of sound mind and not under duress or undue influence, and that neither of us nor the principal’s attending physician is the person appointed as attorney in fact by this document.

NEBRASKA ADVANCE DIRECTIVE – PAGE 7 OF 7

AlternativeNo.2: Sign Before a Notary Public

NEBRASKA ORGAN DONATION FORM – PAGE 1 OF 1

Initial the line next to the statement below that best reflects your wishes. You do not have to initial any of the statements. If you do not initial any of the statements, your attorney for health care, proxy, or other agent, or your family, may have the authority to make a gift of all or part of your body under Nebraska law.

You Have Filled Out Your Health Care Directive, Now What?

1. Your Nebraska Advance Directive is an important legal Keep the original signed document in a secure but accessible place. Do not put the original document in a safe deposit box or any other security box that would keep others from having access to it.

2. Give photocopies of the signed original to your agent and alternate agent, doctor(s), family, close friends, clergy, and anyone else who might become involved in your health If you enter a nursing home or hospital, have photocopies of your document placed in your medical records.

3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes concerning medical treatment. Discuss your wishes with them often, particularly if your medical condition changes.

4. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

5. If you want to make changes to your documents after they have been signed and witnessed, you must complete a new document.

6. Remember, you can always revoke your Nebraska document.

7. Be aware that your Nebraska document will not be effective in the event of a medical Ambulance and hospital emergency department personnel are required to provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive that states otherwise. These directives called “prehospital medical care directives” or “do not resuscitate orders” are designed for people whose poor health gives them little chance of benefiting from CPR. These directives instruct ambulance and hospital emergency personnel not to attempt CPR if your heart or breathing should stop.

Currently not all states have laws authorizing these orders. We suggest you speak to your physician if you are interested in obtaining one.