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You have the right to:
1. Name someone else to make health care decisions for you when or if you are unable to make them
2. Give instructions about what types of health care you want or do not want.
It is important to talk with those people closest to you and with your health care providers about your goals,
wishes and preferences for treatment.
You may use this form in its entirety or you may use any part of it. For example, if you only want to choose an
agent in Part One, you may ﬁll out just that section and then go to Part Five to sign in the presence of appro-
You are free to use another form so long as it is properly witnessed. More detailed forms providing greater
options and information regarding mental health care preference can be found on the VEN website at
Vermont Advance Directive
for Health Care
Prepared by the Vermont Ethics Network, July 2011
Part ONE of this form allows you to name a person
as your “agent” to make health care decisions for
you if you become unable or unwilling to make your
own decisions. You may also name alternate agents.
You should choose someone you trust, who will be
comfortable making what might be hard decisions
on your behalf. They should be guided by your values
in making choices for you and agree to act as your
agent. You may ﬁll out the Advance Directive form
stating your medical preferences
even if you do not
identify an agent
. Medical providers will follow your
directions in the Advance Directive without an agent
to their best ability, but having a person designated
as your agent to make decisions for you will help
medical providers and those who care for you make
the best decisions in situations that may not have
been detailed in your Advance Directive. According to
Vermont law, next-of-kin will not automatially make
decisions on your behalf if you are unable to do so.
That is why it is best to appoint someone of your
choosing in advance.
Part TWO of this form lets you state Treatment
Goals & Wishes. Choices are provided for you to
express your wishes about having, not having, or
stopping treatment under certain circumstances.
Space is also provided for you to write out any
additional or speciﬁc wishes based on your values,
health condition or beliefs.
Part THREE of this form lets you express your
wishes about Limitations of Treatment. These treat-
ments include CPR, breathing machines, feeding
tubes, and antibiotics. There is space for you to write
any additional wishes. NOTE: If you DO NOT want
CPR, a breathing machine, a feeding tube, or antibi-
otics, please discuss this with your doctor, who can
complete a DNR/COLST order (Do Not Resuscitate/
Clinician Order for Life Sustaining Treatment) to
ensure that you do not receive treatments you do not
want, especially in an emergency. Emergency Medical
Personnel are required to provide you with life-saving
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