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 TENNESSEE ADVANCE DIRECTIVE

This packet contains a legal document, known as a Tennessee 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. This document is based on forms created by the Tennessee Department of Health.

Page one includes an Appointment of Health Care Agent. This lets you name someone, called an agent, to make decisions about your medical care — including decisions about life support — if you can no longer speak for yourself. An agent can speak for you any time you are unable to make your own medical decisions, not only at the end of life.

Pages two and three contain an Individual Instruction that lets you provide your wishes regarding medical care in the event that you can no longer speak for yourself. In addition to health care decisions, the individual instruction portion of the form also allows you to give instructions regarding your other advance planning concerns, such as your burial wishes. Finally, the individual instruction portion of the form allows you to make a declaration of your wishes regarding organ donation.

Your advance directive goes into effect when your designated physician determines that you are no longer able to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision.

This form does not expressly address mental illness. If you would like to make advance care plans involving mental illness, you should talk to your physician and an attorney about a Declaration for Mental Health Treatment. The Tennessee Department of Mental Health and Developmental Disabilities has published a form declaration for mental health treatment at www.state.tn.us/mental/t33/DHMT_FORM.pdf and a guide to the form at  www.state.tn.us/mental/t33/DMHT_bro.pdf.

Note: These documents will be legally binding only if the person completing them is a competent adult, 18 years or older, or an emancipated minor.

COMPLETING YOUR TENNESSEE ADVANCE DIRECTIVE

Whom should I appoint as my agent?

Your agent is the person you appoint to make decisions about your medical 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 medical 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.

How do I make my Tennessee Advance Directive legal?

You must sign your advance directive. Your signature must either be notarized or witnessed by two competent adults. Either option is available with this form.

If you have your signature witnessed, the witnesses cannot be the person you name as your agent. In addition, at least one of your witnesses must be a person 1) who is not related to you by blood, marriage, or adoption; and 2) who will not inherit any part of your estate.

Should I add personal instructions to my Tennessee Advance Directive?

One of the strongest reasons for naming an agent is to have someone who can respond flexibly as your medical 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 all or part of your advance directive, except for the designation of an agent, at any time you have capacity and in any manner that communicates an intent to revoke. This could include tearing, burning, or otherwise destroying the document or simply stating orally that you intend to revoke your advance directive.

You may revoke the designation of your agent only by a signed writing or by personally informing your supervising health care provider. If your spouse is your agent, a decree of annulment, divorce, dissolution of marriage, or legal separation automatically revokes his or her power, unless you specify otherwise in your advance directive.

You can also draft a new advance directive. An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.

TENNESSEE ADVANCE DIRECTIVE PAGE 1 OF 5
APPOINTMENT OF HEALTH CARE AGENT

Alternate Agent

TENNESSEE ADVANCE DIRECTIVE PAGE 2 OF 5
INDIVIDUAL INSTRUCTION

If my condition is irreversible – that is, it will not improve – I direct that medically appropriate treatment be provided as indicated below. If I mark “No” below, I authorize the withholding or withdrawal of such care:

TENNESSEE ADVANCE DIRECTIVE PAGE 3 OF 5
OTHER INSTRUCTIONS

Organ Donation (Optional)

TENNESSEE ADVANCE DIRECTIVE PAGE 4 OF 5
SIGNATURE

Your signature must either be witnessed by two competent adults (Option A, below) or notarized (Option B, below). If witnessed, neither witness may be the person you appointed as your agent, and at least one of the witnesses must be someone who is not related to you by blood, marriage, or adoption or entitled to any part of your estate.

OPTION A: SIGN WITH WITNESSES

TENNESSEE ADVANCE DIRECTIVE PAGE 5 OF 5
OPTION B: SIGN BEFORE A NOTARY

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

1. Your Tennessee 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 Tennessee document.

7. Be aware that your Tennessee 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 non-hospital do-not-resuscitate orders. We suggest you speak to your physician if you are interested in obtaining this form.