Free Living Will and Designation of Healthcare Surrogate
In this difficult time, DeLoach, Hofstra & Cavonis, P.A., wants to help make sure our clients are prepared for a downturn in health. As such, we are offering this free Living Will and Designation of Healthcare Surrogate for your review and signature.
Simply fill out the form to get your free documents to get started.
Directions for Your Living Will and Healthcare Surrogate
Living Will Component:
Your Living Will is your written statement as to end of life wishes. Would you want machines and other medical interventions in the event you are not able to make your own healthcare decisions? This contains “pull the plug” type desires and instructions on withholding water, food and medical procedures. Please Note that this document only goes into effect if you are very, very sick. Your decisions to withhold medical treatment by circling the “No” option does not apply when you are healthy or otherwise doing well. It is our general belief that people who circle “Yes” on the form probably do not have a firm grasp of the medical procedures, and their consequences, involved.
A Living Will allows you to document your wishes concerning medical treatment at the end of life. Living Wills are a very important piece to your estate plan, but it should be noted that a Living Will does not replace the conversation you should have with your healthcare surrogate and your family. A Living Will cannot take into account all of your desires, wishes, and it will not be able to succinctly say what gives you a quality of life. This is what your conversation with your family will do – give clarification and strength to your Living Will. You may even want to complete this with your nominated healthcare surrogate.
Designation of Healthcare Surrogate Component:
This names the person who you would want to make your healthcare decisions and follow your living will. You must trust your surrogate, the surrogate must be willing and able to serve, and they should probably live locally. If you do not think that your surrogate would follow your wishes, you probably would not want to name them in this role.
-Rep DeLoach, Certified Respecting Choices Advanced Care Planning Facilitator
FREQUENTLY ASKED QUESTIONS
Please review the following common questions and answers on creating your own advance directives:
- Why should I have a Living Will?
By establishing a Living Will while you are well, you can make sure that your end-of-life wishes are honored in the event you become unable to speak for yourself.
- Does a Living Will encourage my death?
NO. You are not signing an agreement that says that you wish to die. You are making a choice for the future, about medical treatment (artificial ventilation and/or nutrition, surgery, antibiotics, etc.) when there is little or no hope for recovery. The Living Will becomes active ONLY when you cannot tell your doctor and loved ones what your choices are about medical treatments.
- Why would anyone want "No CPR?" Isn't that a form of suicide?
No. The success rate of cardiopulmonary resuscitation (CPR) is much less than people think.
- For individuals over 60 years of age, the success rate of CPR in hospitalized patients is 10 to 15%.
- For victims of heart arrest outside a hospital, CPR is successful only 3 to 5% of the time.
- For those over age 85, the success rate is 3% for patients who suffer a heart attack in a hospital and only 1% survive if the arrest occurs outside a hospital.
For a dying individual, cardiac arrest with no attempt at resuscitation (which is typically painless, like going to sleep or passing out), is usually the most merciful method of dying. By saying that one does not want CPR when death is near, one says that, "when my time comes I do not want to prevent the natural way of dying." Many patients dying from cancer, terminal heart or lung disease, or with Alzheimer's disease, or individuals who are healthy but have reached an advanced age, may not want doctors to prevent them from dying a natural, peaceful death. Their choices may include a “Do Not Resuscitate Order” (DNRO) order. Further, even if CPR is desired, the patient will likely then need to be placed on a respirator and be intubated for some time, a condition that few desire.
- If I have a Living Will, does that automatically mean that I won't be resuscitated if my heart and lungs stop?
NO. Medical personnel will ALWAYS attempt resuscitation UNLESS you have a Do Not Resuscitate Order (“DNRO”) in place. Decisions regarding CPR should always be discussed with your physician. If you do not want CPR, you should ask your doctor for a DNRO order to be entered in your hospital medical record. Currently, in the State of Florida, a separate form (DH Form 1896) must be signed by you (or your health care surrogate, if you are unable to sign), and by your physician. This yellow form must be with you at all times to ensure that CPR will not be performed in a non-hospital situation.
- Where can I get a Florida Do Not Resuscitate Order Form (DH Form 1896)?
Your physician should provide you with the Form. Remember, you must also have your doctor sign the Form to prevent unwanted CPR outside of the hospital.
- What if I am really sick, but there is a chance that I can "beat it?"
Living Wills come into use ONLY under certain conditions when one reaches a stage in life where you can no longer think and communicate and when it is clear that you have little or no chance of recovery. Living Wills do not apply when there is a chance for recovery.
In Florida, the patient's physician must determine the patient's condition cannot be made any better before life-prolonging procedures may be withheld or withdrawn. Your requests to withhold treatments in your Living Will do not apply when there is a reasonable chance of cure or improvement that allows you to recover to a meaningful life. Doctors are trained to fight illness and death and tend to err on the side of continuing aggressive, curative efforts until they find out that you have no chance of recovery.
- Why would I not want a feeding tube with artificial feedings at the end-of-life when I can no longer eat? Wouldn't I "starve to death?"
A feeding tube is a small tube placed through the nose and into the stomach to deliver artificial liquid feedings. A more permanent form of feeding tube that is placed through the wall of the abdomen and the stomach is called a gastric tube. Putting in a gastric tube is a surgical procedure. In many cases, people stop eating and drinking because the dying body no longer has a need to do so. People who are permanently unconscious, in a vegetative state, or who have end-stage dementia (permanent, severe confusion) lose all feeling of thirst or hunger. There is no medical evidence that not using a feeding tube with artificial feedings leads to a more painful death. In fact, the research says just the opposite. Artificial feedings through a tube may prolong dying and make it more uncomfortable.
8. Who should I name as my surrogate?
You would want to name a good, trustworthy person and an alternate. DO NOT name co-surrogates! Here is a list of decisions to make in choosing a health care surrogate.
9. What other documents do I need?
You should have a durable power of attorney and last will and testament. You may want a living trust to avoid probate upon your death. Your durable power of attorney gives your agent the power to pay your bills and manage your financial affairs. This is very important!
10. I did my living will and surrogate 5 years ago. Are they still good?
We strongly prefer this new document to older documents. If you have come to see us within the last 5 years, your health care surrogate and living will are just fine.
11. Where was this Living Will and Health Care Surrogate form created?
This is the Advance Directive provided from Empath Health, which is a part of the Hospice of the Florida Suncoast. It was created through the consultation of many health care professionals, as well as with input from our own attorney, D. “Rep” DeLoach III, the former chair of Empath Choices for Care.
SIGNING THIS DOCUMENT:
Please follow the signing procedure in the presence of two witnesses. Keep a copy for yourself and give a copy to your nominated surrogate.