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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