[Health Care Directive] Montana

Using these Materials

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may receive health care.

2. These materials include:
   • Instructions for preparing your advance directive, please read all the instructions.
   • Your state-specific advance directive forms, which are the pages with the gray instruction bar on the left side.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so you will have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide you through the process.

3. Talk with your family, friends, and physicians about your advance Be sure the person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy the form and give it to the person you have appointed to make decisions on your behalf, your family, friends, health care providers and/or faith leaders so that the form is available in the event of an emergency.

5. The Montana End-of-Life Registry is your state’s advance directive By filing your advance directive with the registry, your health care provider and loved ones may be able to find a copy of your directive in the event you are unable to provide one. You can read more about the registry, including instructions on how to file your advance directive, at http://www.endoflife.mt.gov.

6. 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.

Introduction to Your Montana Advance Directive

This packet contains a legal document—the Montana Advance Directive, which is based on the form developed by the Montana Department of Justice, Office of Consumer Protection—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 complete any or all of the first four parts, depending on your advance planning needs. You must complete Part 5 in order to make your advance directive valid.

Part 1, the Terminal Conditions Declaration, is your state’s living will. Part 1 allows you to make decisions regarding your health care in the event you can no longer make decisions yourself and you have developed a terminal condition.

Part 2 is an optional description of Chronic Illness or Serious Disability. This part allows you to describe any chronic illness or serious disability that you have that should not be misinterpreted as a terminal condition. This part also allows you to give special directions regarding your condition as well as the contact information for your treating physician.

Part 3 is a Power of Attorney for Health Care that allows you to choose an adult representative to make health care decisions for you. Part 3 is especially useful, because it allows your representative to make decisions for you at any time you are unable to make or communicate your health care decisions, not just when you are in a terminal condition.

Part 4 is a section that allows you to state Special Directions with regard to your advance planning, such as your spiritual preferences, organ donation, and the final disposition of your remains. Part 4 also allows you to state whether you plan to register your advance directive with the Montana End-of-Life Registry and to whom you plan to give copies of your document.

Part 5 contains the signature and witnessing provisions so that your document will be effective.

This form 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 is a competent adult (at least 18 years old).

Instructions for Completing Your Montana Advance Directive
Whom should I appoint as my representative?

Your representative is the person you appoint to make decisions about your health care if you become unable to make those decisions yourself. Your representative may be a family member or a close friend whom you trust to make serious decisions. The person you name as your representative should clearly understand your wishes and be willing to accept the responsibility of making health care decisions for you.

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

How do I make my Montana Advance Directive legal?

The law requires that you sign your advance directive, or direct another to sign it, in the presence of two witnesses.

Should I add personal instructions to my Montana Advance Directive?

One of the strongest reasons for naming a representative 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 representative carry out your wishes, but be careful that you do not unintentionally restrict your representative’s power to act in your best interest. In any event, be sure to talk with your representative 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 Montana Advance Directive at any time and in any manner, regardless of your mental or physical condition. Your revocation becomes effective once you, or a witness to your revocation, notify your doctor, advanced practice registered nurse, or other health care provider.

Your representative’s powers under a Power of Attorney for Health Care are automatically revoked if your spouse is your representative and you are legally separated or divorced.

What other important facts should I know?

Instructions to withhold or withdraw life-sustaining treatment from a pregnant patient will not be honored if it is probable that the fetus will survive to live birth with continuing life-sustaining treatment.

MONTANA ADVANCE DIRECTIVE – PAGE 1 OF 7

Part 1. Terminal Conditions (Living Will)

I provide these directions in accordance with the Montana Rights of the Terminally Ill Act. These are my wishes for the kind of treatment I want if I cannot communicate or make my own decisions. These directions are only valid if both of the following two conditions exist:

1. I have a terminal condition, and

2. in the opinion of my attending physician, I will die in a relatively short time without life sustaining treatment that only prolongs the dying process.

I authorize my Representative, if I have appointed one, to make the decision to provide, withhold, or withdraw any health care treatment.

General Treatment Directions

Check the boxes that express your wishes: (Check only one)

MONTANA ADVANCE DIRECTIVE – PAGE 2 OF 7

Part 2. Chronic Illness or Serious Disability (Optional)

My chronic illness or disability can complicate an acute illness, but should not be misinterpreted as a terminal condition.

MONTANA ADVANCE DIRECTIVE – PAGE 3 OF 7

Part 3. Health Care Representative (Power of Attorney for Health Care)

This health care power of attorney becomes effective upon my disability or incapacity. My representative has authority to make any health care decision that I could make, including decisions regarding the withholding or withdrawing of life-sustaining treatment and artificial administration of nutrition or hydration. My representative’s authority to make these decisions is operative at any time I am unable to make or communicate my health care decisions, regardless of whether I am expected to recover or not.

When making health care decisions for me, my representative should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in this 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 representative should make decisions for me that my representative believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.

If, for any reason, I should need a guardian of my person designated by a court, I nominate my representative, or alternate representative(s), named below.

MONTANA ADVANCE DIRECTIVE – PAGE 4 OF 7

Part 3. Health Care Representative (Power of Attorney for Health Care)

(B) Alternate Representative(s)

If: 1. I revoke my representative’s authority; or

2. My representative becomes unwilling or unable to act for me; or
3. My representative is my spouse and I become legally separated or divorced,

I name the following person(s) as alternates to my representative in the order listed:

MONTANA ADVANCE DIRECTIVE – PAGE 5 OF 7

Part 4. Special Directions (Optional)

C. Donation of Organs at My Death (check one of the following):

D. After-Death Care (care of my body, burial, cremation, funeral home preference)

E. Additional Directions (use additional pages if necessary)

MONTANA ADVANCE DIRECTIVE – PAGE 6 OF 7

F. Distributing this Advance Directive

I plan to deposit this Advance Directive in the Montana End-of-Life

Other

Clergy

MONTANA ADVANCE DIRECTIVE – PAGE 7 OF 7

Part 5. Signing and Witnessing this Advance Directive

A. Your Signature

Ask two people to watch you sign and have them sign below.

1. I revoke any prior health care advance directive or directions.
2. This document is intended to be valid in any jurisdiction in which it is presented.
3. A copy of this document is intended to have the same effect as the original.
4. Those who act as I have directed in this document shall be free from legal liability for having followed my directions.
5. If my attending physician is unwilling or unable to comply with my wishes as stated in this document, I direct my care be transferred to a physician who will.

B. Ask Your Witnesses to Read and Sign

I declare that I am over the age of 18 and the person who signed this document is personally known to me, and has signed these health care advance directives in my presence, and appears to be of sound mind and under no duress, fraud or undue influence.

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

1. Your Montana 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 representative and alternate representative, doctor(s), family, close friends, clergy, and anyone else who might become involved in your health care. 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 representative(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. The Montana End-of-Life Registry is your state’s advance directive By filing your advance directive with the registry, your health care provider and loved ones may be able to find a copy of your directive in the event you are unable to provide one. You can read more about the registry, including instructions on how to file your advance directive, at http://www.endoflife.mt.gov.

5. 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.

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

7. Remember, you can always revoke your Montana document.

8. Be aware that your Montana 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.