Vermont Advance Directive For Health Care
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8Vermont Advance Directive
for Health Care
Prepared by the Vermont Ethics Network, July 2011
E
& i
xplanation
nstructions
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
yourself.
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-
priate witnesses.
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
Part ONE of this form allows you to name a person
Part TWO of this form lets you state Treatment
as your “agent” to make health care decisions for
Goals & Wishes. Choices are provided for you to
you if you become unable or unwilling to make your
express your wishes about having, not having, or
own decisions. You may also name alternate agents.
stopping treatment under certain circumstances.
You should choose someone you trust, who will be
Space is also provided for you to write out any
comfortable making what might be hard decisions
additional or specific wishes based on your values,
on your behalf. They should be guided by your values
health condition or beliefs.
in making choices for you and agree to act as your
agent. You may fill out the Advance Directive form
Part THREE of this form lets you express your
stating your medical preferences even if you do not
wishes about Limitations of Treatment. These treat-
identify an agent. Medical providers will follow your
ments include CPR, breathing machines, feeding
directions in the Advance Directive without an agent
tubes, and antibiotics. There is space for you to write
to their best ability, but having a person designated
any additional wishes. NOTE: If you DO NOT want
as your agent to make decisions for you will help
CPR, a breathing machine, a feeding tube, or antibi-
medical providers and those who care for you make
otics, please discuss this with your doctor, who can
the best decisions in situations that may not have
complete a DNR/COLST order (Do Not Resuscitate/
been detailed in your Advance Directive. According to
Clinician Order for Life Sustaining Treatment) to
Vermont law, next-of-kin will not automatially make
ensure that you do not receive treatments you do not
decisions on your behalf if you are unable to do so.
want, especially in an emergency. Emergency Medical
That is why it is best to appoint someone of your
Personnel are required to provide you with life-saving
choosing in advance.
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