[Health Care Directive] Rhode Island

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. 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 RHODE ISLAND ADVANCE DIRECTIVE

This packet contains a legal document, a Rhode Island 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 complete Part I, Part II, or both, depending on your advance-planning needs. You must complete Part III.

Part I contains a Rhode Island Durable Power of Attorney for Health Care. This part lets you name someone to make decisions about your medical care—including decisions about life-sustaining procedures—if you can no longer speak for yourself. The durable 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 medical decisions, not only at the end of life.

Your durable power of attorney for health care goes into effect when your doctor determines that you are no longer able to make or communicate your health care decisions.

Part II contains a Rhode Island Declaration, which is your state’s living will. Your declaration lets you state your wishes about health care in the event that you can no longer make your own health care decisions and you are terminally ill.

Your living will goes into effect when your doctor determines that you are no longer able to make or communicate your health care decisions and you are terminally ill.

Part III 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 an advance directive tailored to your needs.

Note: This document will be legally binding only if the person completing it is an individual of sound mind who is 18 years or older.

Completing Your Rhode Island Advance Directive

How do I make my Rhode Island Advance Directive legal?

If you complete Part I (Durable Power of Attorney), this document must be either

1. Witnessed by two (2) qualified adult None of the following may be a witness:
   1. A person you designate as your agent or alternate agent,
   2. A health care provider,
   3. An employee of a health care provider,
   4. The operator of a community care facility,
   5. An employee of an operator of a community care facility.

In addition, one of your witnesses must be unrelated to you and not entitled to any portion of your estate.

OR

2. Witnessed by a notary public. Your Notary Public must be unrelated to you and not entitled to any portion of your estate. 

If you complete Part II (Declaration), you must have your advance directive witnessed by two (2) qualified adult witnesses, both of whom must be unrelated to you and not entitled to any portion of your estate. If you completed ONLY Part II, your witnesses are subject only to the restriction that they must be unrelated to you and not entitled to any portion of your estate.

Whom should I appoint as my agent?

Your agent is the person you appoint to make decisions about your health care if you become unable to make those decisions yourself. Your agent may be a family member or a close friend whom you trust to make serious decisions. The person you name as your agent 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 agent. The alternate will step in if the first person you name as an agent is unable, unwilling, or unavailable to act for you.

The person you appoint as your agent cannot be:

• your treating health care provider,
• an employee of your treating health care provider who is not related to you,
• an operator of a community care facility, or
• an employee of an operator of a community care facility who is not related to you.

Should I add personal instructions to my Rhode Island Advance Directive?

One of the strongest reasons for naming an agent 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 agent carry out your wishes, but be careful that you do not unintentionally restrict your agent’s power to act in your best interest. In any event, be sure to talk with your agent 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 Rhode Island 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, communicate it to your doctor or any health care provider.

RHODE ISLAND ADVANCE DIRECTIVE — PAGE 1 OF 10

PART I: DURABLE POWER OF ATTORNEY FOR HEALTH CARE

This is an important legal document which is authorized by the general laws of this state. Before executing this document, you should know these important facts:

You must be at least eighteen (18) years of age and a resident of the state of Rhode Island for this document to be legally valid and binding.

This document gives the person you designate as your agent (the attorney in fact) the power to make health care decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known.

Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.

Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection at the time, and health care necessary to keep you alive may not be stopped or withheld if you object at the time.

This document gives your agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. This power is subject to any statement of your desires and any limitation that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your agent to make health care decisions for you if your agent:

• Authorizes anything that is illegal,
• Acts contrary to your known desires, or
• Where your desires are not known, does anything that is clearly contrary to your best interests.

Unless you specify a specific period, this power will exist until you revoke it. Your agent’s power and authority ceases upon your death except to inform your next of kin of your desire to be an organ and tissue donor.

You have the right to revoke the authority of your agent by notifying your agent or your treating doctor, hospital, or other health care provider orally or in writing of the revocation.

RHODE ISLAND ADVANCE DIRECTIVE — PAGE 2 OF 10

Your agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document.

This document revokes any prior durable power of attorney for health care.

You should carefully read and follow the witnessing procedure described at the end of this form. This document will not be valid unless you comply with the witnessing procedure.

If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.

Your agent may need this document immediately in case of an emergency that requires a decision concerning your health care. Either keep this document where it is immediately available to your agent and alternate agents or give each of them an executed copy of this document. You may also want to give your doctor an executed copy of this document.

RHODE ISLAND ADVANCE DIRECTIVE — PAGE 3 OF 10

1. DESIGNATION OF HEALTH CARE AGENT.

(insert name, address, and telephone number of one individual only as your agent to make health care decisions for you. None of the following may be designated as your agent: (1) your treating health care provider, (2) a non- relative employee of your treating health care provider, (3) an operator of a community care facility, or (4) a non-relative employee of an operator of a community care facility.) as my attorney in fact (agent) to make health care decisions for me as authorized in this document. For the purposes of this document, “health care decision” means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual’s physical or mental condition.

2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH
CARE. By this document I intend to create a durable power of attorney for health care.

3. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I hereby grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, including, but not limited to, my desires concerning obtaining or refusing or withdrawing life- prolonging care, treatment, services, and procedures and informing my family or next of kin of my desire, if any, to be an organ or tissue donor. (If you want to limit the authority of your agent to make health care decisions for you, you can state the limitations in paragraph 4 [“Statement of Desires, Special Provisions, and Limitations”] below. You can indicate your desires by including a statement of your desires in the same paragraph.)

RHODE ISLAND ADVANCE DIRECTIVE — PAGE 4 OF 10

4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND
LIMITATIONS. (Your agent must make health care decisions that are consistent with your known desires. You can, but are not required to, state your desires in the space provided below. You should consider whether you want to include a statement of your desires concerning life-prolonging care, treatment, services, and procedures. You can also include a statement of your desires concerning other matters relating to your health care. You can also make your desires known to your agent by discussing your desires with your agent or by some other means. If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limit in any other way the authority given your agent by this document, you should state the limits in the space below. If you do not state any limits, your agent will have broad powers to make health care decisions for you, except to the extent that there are limits provided by law.)

In exercising the authority under this durable power of attorney for health care, my agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated below:

RHODE ISLAND ADVANCE DIRECTIVE — PAGE 5 OF 10

If you wish to make a gift of any bodily organ you may do so pursuant to the Uniform Anatomical Gift Act.

RHODE ISLAND ADVANCE DIRECTIVE — PAGE 6 OF 10

7. DURATION. (Unless you specify a shorter period in the space below, this power of attorney will exist until it is revoked.)

RHODE ISLAND ADVANCE DIRECTIVE – PAGE 7 OF 10

PART II: DECLARATION (LIVING WILL)

RHODE ISLAND ADVANCE DIRECTIVE — PAGE 8 OF 10

If you complete Part I, this document must be either

1. Witnessed by two (2) qualified adult None of the following may be used as a witness:
   6. A person you designate as your agent or alternate agent,
   7. A health care provider,
   8. An employee of a health care provider,
   9. The operator of a community care facility,
   10. An employee of an operator of a community care facility.

In addition, one of your witnesses must be unrelated to you and not entitled to any portion of your estate.

OR

2. Witnessed by a notary public.

If you complete Part II, you must have your advance directive witnessed by two (2) qualified adult witnesses, both of whom must be unrelated to you and not entitled to any portion of your estate. If you completed ONLY Part II, your witnesses are subject only to the restriction that they must be unrelated to you and not entitled to any portion of your estate.

IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS ADVANCE DIRECTIVE.

RHODE ISLAND ADVANCE DIRECTIVE — PAGE 9 OF 10

Alternative No. 1.  Sign Before Witnesses.

RHODE ISLAND ADVANCE DIRECTIVE — PAGE 10 OF 10

Alternative No. 2.  Sign Before a Notary Public

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

1. Your Rhode Island 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 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 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 Rhode Island document.

7. Be aware that your Rhode Island 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,” “do not resuscitate orders,” or “medical orders for life sustaining treatment (MOLST)” 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.