Office of the Revisor of Statutes
Minnesota Session Laws - 1999, Regular Session
Key: (1) language to be deleted (2) new language
CHAPTER 14-S.F.No. 301
An act relating to health; modifying the suggested
health care directive form, amending Minnesota
Statutes 1998, section 145C.16.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
Section 1. Minnesota Statutes 1998, section 145C.16, is
amended to read:
145C.16 [SUGGESTED FORM.]
The following is a suggested form of a health care
directive and is not a required form.
HEALTH CARE DIRECTIVE
I, ..........................., understand this document
allows me to do ONE OR BOTH of the following:
PART I: Name another person (called the health care agent)
to make health care decisions for me if I am unable to decide or
speak for myself. My health care agent must make health care
decisions for me based on the instructions I provide in this
document (Part II), if any, the wishes I have made known to him
or her, or must act in my best interest if I have not made my
health care wishes known.
AND/OR
PART II: Give health care instructions to guide others
making health care decisions for me. If I have named a health
care agent, these instructions are to be used by the agent.
These instructions may also be used by my health care providers,
others assisting with my health care and my family, in the event
I cannot make decisions for myself.
PART I: APPOINTMENT OF HEALTH CARE AGENT
THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS
FOR ME IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF
(I know I can change my agent or alternate agent at any
time and I know I do not have to appoint an agent or an
alternate agent)
NOTE: If you appoint an agent, you should discuss this health
care directive with your agent and give your agent a copy. If
you do not wish to appoint an agent, you may leave Part I blank
and go to Part II.
When I am unable to decide or speak for myself, I trust and
appoint .......................... to make health care decisions
for me. This person is called my health care agent.
Relationship of my health care agent to me: .........
...............................................................
Telephone number of my health care agent: ...........
...............................................................
Address of my health care agent: ....................
..............................................................
(OPTIONAL) APPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If
my health care agent is not reasonably available, I trust and
appoint .................... to be my health care agent instead.
Relationship of my alternate health care agent to me:
...............................................................
Telephone number of my alternate health care agent:
...............................................................
Address of my alternate health care agent: .........
...............................................................
THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO
DO IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF
(I know I can change these choices)
My health care agent is automatically given the powers
listed below in (A) through (D). My health care agent must
follow my health care instructions in this document or any other
instructions I have given to my agent. If I have not given
health care instructions, then my agent must act in my best
interest.
Whenever I am unable to decide or speak for myself, my
health care agent has the power to:
(A) Make any health care decision for me. This includes
the power to give, refuse, or withdraw consent to any care,
treatment, service, or procedures. This includes deciding
whether to stop or not start health care that is keeping me or
might keep me alive, and deciding about intrusive mental health
treatment.
(B) Choose my health care providers.
(C) Choose where I live and receive care and support when
those choices relate to my health care needs.
(D) Review my medical records and have the same rights that
I would have to give my medical records to other people.
If I DO NOT want my health care agent to have a power
listed above in (A) through (D) OR if I want to LIMIT any power
in (A) through (D), I MUST say that here:
..............................................................
...............................................................
...............................................................
My health care agent is NOT automatically given the powers
listed below in (1) and (2). If I WANT my agent to have any of
the powers in (1) and (2), I must INITIAL the line in front of
the power; then my agent WILL HAVE that power.
... (1) To decide whether to donate any parts of my body,
including organs, tissues, and eyes, when I die.
... (2) To decide what will happen with my body when I die
(burial, cremation).
If I want to say anything more about my health care agent's
powers or limits on the powers, I can say it here:
.................................................................
.................................................................
.................................................................
PART II: HEALTH CARE INSTRUCTIONS
NOTE: Complete this Part II if you wish to give health care
instructions. If you appointed an agent in Part I, completing
this Part II is optional but would be very helpful to your
agent. However, if you chose not to appoint an agent in Part I,
you MUST complete some or all of this Part II if you wish to
make a valid health care directive.
These are instructions for my health care when I am unable
to decide or speak for myself. These instructions must be
followed (so long as they address my needs).
THESE ARE MY BELIEFS AND VALUES ABOUT MY HEALTH CARE
(I know I can change these choices or leave any of them
blank)
I want you to know these things about me to help you make
decisions about my health care:
My goals for my health care: ..............................
.................................................................
.................................................................
My fears about my health care: ............................
.................................................................
.................................................................
My spiritual or religious beliefs and traditions: .........
.................................................................
.................................................................
My beliefs about when life would be no longer worth
living: ........................................................
.................................................................
.................................................................
My thoughts about how my medical condition might affect my
family: ........................................................
.................................................................
.................................................................
THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE
(I know I can change these choices or leave any of them
blank)
Many medical treatments may be used to try to improve my
medical condition or to prolong my life. Examples include
artificial breathing by a machine connected to a tube in the
lungs, artificial feeding or fluids through tubes, attempts to
start a stopped heart, surgeries, dialysis, antibiotics, and
blood transfusions. Most medical treatments can be tried for a
while and then stopped if they do not help.
I have these views about my health care in these situations:
(Note: You can discuss general feelings, specific
treatments, or leave any of them blank)
If I had a reasonable chance of recovery, and were
temporarily unable to decide or speak for myself, I would want:
.................................................................
.................................................................
.................................................................
If I were dying and unable to decide or speak for myself, I
would want: ....................................................
.................................................................
.................................................................
If I were permanently unconscious and unable to decide or
speak for myself, I would want: ................................
.................................................................
.................................................................
If I were completely dependent on others for my care and
unable to decide or speak for myself, I would want: ............
.................................................................
.................................................................
In all circumstances, my doctors will try to keep me
comfortable and reduce my pain. This is how I feel about pain
relief if it would affect my alertness or if it could shorten my
life: ..........................................................
.................................................................
.................................................................
There are other things that I want or do not want for my
health care, if possible:
Who I would like to be my doctor: .........................
.................................................................
.................................................................
Where I would like to live to receive health care:
.................................................................
.................................................................
.................................................................
Where I would like to die and other wishes I have about
dying: .........................................................
.................................................................
.................................................................
My wishes about donating parts of my body when I die: .....
.................................................................
.................................................................
My wishes about what happens to my body when I die
(cremation, burial): ...........................................
.................................................................
.................................................................
Any other things: .........................................
.................................................................
.................................................................
PART III: MAKING THE DOCUMENT LEGAL
This document must be signed by me. It also must either be
verified by a notary public (Option 1) OR witnessed by two
witnesses (Option 2). It must be dated when it is verified or
witnessed.
I am thinking clearly, I agree with everything that is
written in this document, and I have made this document
willingly.
..........................................
My Signature
Date signed: .....................
Date of birth: .....................
Address: ...................................
...................................
If I cannot sign my name, I can ask someone to sign this
document for me.
..........................................
Signature of the person who I asked to sign this document for me.
..........................................
Printed name of the person who I asked to sign this document for
me.
Option 1: Notary Public
In my presence on .................... (date),
....................... (name) acknowledged his/her signature on
this document or acknowledged that he/she authorized the person
signing this document to sign on his/her behalf. I am not named
as a health care agent or alternate health care agent in this
document.
..............................
(Signature of Notary) (Notary Stamp)
Option 2: Two Witnesses
Two witnesses must sign. Only one of the two witnesses can
be a health care provider or an employee of a health care
provider giving direct care to me on the day I sign this
document.
Witness One:
(i) In my presence on ............... (date),
............... (name) acknowledged his/her signature on this
document or acknowledged that he/she authorized the person
signing this document to sign on his/her behalf.
(ii) I am at least 18 years of age.
(iii) I am not named as a health care agent or an alternate
health care agent in this document.
(iv) If I am a health care provider or an employee of a
health care provider giving direct care to the person listed
above in (A), I must initial this box: [ ]
I certify that the information in (i) through (iv) is true
and correct.
......................................
(Signature of Witness One)
Address: ..........................................
..........................................
Witness Two:
(i) In my presence on .............. (date),
................. (name) acknowledged his/her signature on this
document or acknowledged that he/she authorized the person
signing this document to sign on his/her behalf.
(ii) I am at least 18 years of age.
(iii) I am not named as a health care agent or an alternate
health care agent in this document.
(iv) If I am a health care provider or an employee of a
health care provider giving direct care to the person listed
above in (A), I must initial this box: [ ]
I certify that the information in (i) through (iv) is true
and correct.
....................................
(Signature of Witness Two)
Address: .........................................
.........................................
REMINDER: Keep this document with your personal papers in a
safe place (not in a safe deposit box). Give signed copies to
your doctors, family, close friends, health care agent, and
alternate health care agent. Make sure your doctor is willing
to follow your wishes. This document should be part of your
medical record at your physician's office and at the hospital,
home care agency, hospice, or nursing facility where you receive
your care.
Presented to the governor March 12, 1999
Signed by the governor March 16, 1999, 2:23 p.m.
Official Publication of the State of Minnesota
Revisor of Statutes