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Kentucky Advance Health Care Directive Form 2

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Kentucky Advance Health Care Directive Form 2
Hosparus Inc.
Making Choices for End-of-Life Care
in Kentucky
Effective Date: 11/93 Attachment Page 1 of 3
Rev. Date: 01/08 JG, 04/10 EG
Whether you are a Hosparus patient, considering hospice care, or completely healthy right now,
it is never too soon to think about and plan for the kind of care you would like to receive if you
can no longer make decisions. Advances in medical science and technology have given us
complex choices for end of life care. Conversations about dying are difficult, but it is important
that you talk with your loved ones about your choices before a crisis occurs. In order to execute
any of the documents mentioned in this information, an individual must be an adult, at least
eighteen years old and have decision-making capacity.
This information is provided to help you understand your choices, make decisions and plan for
care that honors your wishes. Although an attorney is not required for many of your decisions,
you may want to talk with one before you sign these documents. Laws are complex and an
attorney can guide you and answer your questions about your legal choices.
Advance directive is the term that refers to your spoken and written instructions about your
future medical care and treatment. A Living Will is a written document that puts into words your
wishes in the event that you become terminally ill and unable to make and communicate your
wishes. Your advance directives may specify your wishes and may also include the name of a
person of your choice to make health care choices for you when you cannot make the choices
for yourself. Having advance directives does not take away your right to decide your current
health care. As long as you are able to decide and express your decisions, your advance
directives will not be used. Your advance directives also will not be implemented if you are
You may appoint a health care surrogate to make medical decisions on your behalf. If you
choose to designate a surrogate, make sure that you discuss your wishes with that person and
that they are someone you trust to carry out your wishes. Your designated surrogate must
follow any directions and limitations you specify in your Living Will and only in the absence of
directions will decide what life-prolonging treatments are to be withheld or withdrawn, taking into
account what decision would be in your best interest. It is recommended that you also appoint
an alternate health care surrogate in case your first choice is not available when decisions must
be made.
Based on your advance directives, your Living Will document may include your decision about:
The withholding or withdrawal of life-prolonging treatment
The withholding or withdrawal of artificially provided nutrition or hydration
The designation of a health care surrogate
The donation of all or any part of your body
If you wish to make a Living Will you may do so by filling out an appropriate form and signing it
in front of two witnesses or in front of a notary public. Your witnesses cannot be blood relatives
or anyone who would inherit your assets, your physician, an employee of a health care facility in
which you are a patient, any person financially responsible for your health care, or anyone
precluded from being a surrogate. These same people cannot serve as notary public except for
an employee of a health care facility in which you may be a patient. Hosparus staff/volunteers
may not serve as witnesses. Select Hosparus staff may serve as notary public.
Kentucky Advance Health Care Directive Form 2