VERMONT HEALTH CARE POWER OF ATTORNEY
(Advance Directive for Health Care Decisions)
[// GUIDANCE: This template is drafted to comply with Vermont’s Advance Directive for Health Care statute, 18 V.S.A. ch. 231 (§ 9700 et seq.). Practitioners should review the final document with the client to ensure it reflects the Principal’s current wishes and meets all execution formalities under Vermont law.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Appointment of Health Care Agent
3.2 Grant of Authority
3.3 End-of-Life Instructions
3.4 Mental Health Treatment Authority (Optional)
3.5 HIPAA Authorization
3.6 Organ & Tissue Donation (Optional)
3.7 Nomination of Guardian (Optional)
3.8 Durability; Activation & Effectiveness
3.9 Revocation & Amendment - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
Title: Vermont Health Care Power of Attorney (Advance Directive)
Parties:
• Principal: [PRINCIPAL LEGAL NAME], of [ADDRESS] (“Principal”)
• Agent: [PRIMARY AGENT LEGAL NAME], of [ADDRESS] (“Agent”)
• Successor Agent(s): [SUCCESSOR AGENT NAME(S)] (if any)
Effective Date: This instrument is effective as provided in Section 3.8 below.
Governing Law: This instrument is governed by the Vermont Advance Directive for Health Care Act, 18 V.S.A. ch. 231, and other applicable Vermont laws (“State Health-Care Law”).
Forum Selection: Any proceeding arising under or relating to this instrument shall be brought exclusively in the appropriate Vermont Probate Division (“State Probate Court”).
2. DEFINITIONS
For purposes of this instrument:
“Act” means the Vermont Advance Directive for Health Care Act, 18 V.S.A. ch. 231 (§ 9700 et seq.).
“Advance Directive” has the meaning set forth in 18 V.S.A. § 9701(1).
“Agent” means any person designated in Section 3.1 to make Health-Care Decisions for the Principal.
“Good-Faith” means honesty in fact and the observance of reasonable health-care standards.
“Health-Care Decision” has the meaning set forth in 18 V.S.A. § 9701(10).
“HIPAA” means the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, including 45 C.F.R. Parts 160 & 164.
“Principal” means the individual executing this instrument.
“Qualified Physician” means a physician licensed to practice medicine in Vermont.
All other capitalized terms have the meanings assigned in context.
3. OPERATIVE PROVISIONS
3.1 Appointment of Health Care Agent
a. The Principal hereby appoints the Agent to make Health-Care Decisions on the Principal’s behalf in accordance with this instrument and the Act.
b. If the Agent resigns, dies, becomes incapacitated, or is otherwise unavailable, the authority granted herein shall pass to the Successor Agent(s) in the order listed above.
[// GUIDANCE: Vermont allows the appointment of co-agents, but sequential successor designations are less prone to conflict. Customize as appropriate.]
3.2 Grant of Authority
a. Scope. The Agent is authorized to make any and all Health-Care Decisions the Principal could make if capable, including, without limitation:
i. Consenting to, refusing, or withdrawing medical or surgical procedures;
ii. Admitting the Principal to or discharging the Principal from any health-care facility;
iii. Accessing, reviewing, and disclosing medical records; and
iv. Employing and discharging health-care providers.
b. Limitations. The Agent’s authority is subject to any express limitations set forth herein or under State Health-Care Law.
3.3 End-of-Life Instructions
[PLACEHOLDER: Insert detailed preferences regarding life-prolonging treatment, artificial nutrition and hydration, cardiopulmonary resuscitation, pain management, and palliative care.]
Example Clause (edit or replace):
“If I am diagnosed in writing by two Qualified Physicians as being in a terminal condition with no reasonable expectation of recovery, I direct that life-prolonging procedures be withheld or withdrawn, and that I receive only comfort care to relieve pain, even if such care hastens my death.”
[// GUIDANCE: Clear, specific language reduces ambiguity and eases surrogate decision-making.]
3.4 Mental Health Treatment Authority (Optional)
[PLACEHOLDER: State any special instructions regarding psychiatric medications, inpatient treatment, electroconvulsive therapy, or other mental-health interventions.]
3.5 HIPAA Authorization
In accordance with 45 C.F.R. § 164.502 and applicable State Health-Care Law, the Principal authorizes any covered entity to disclose protected health information (“PHI”) to the Agent, enabling the Agent to exercise the powers granted herein. This authorization is effective immediately and survives the Principal’s incapacity.
3.6 Organ & Tissue Donation (Optional)
[PLACEHOLDER: Specify whether the Principal wishes to donate organs or tissues and any conditions thereon.]
3.7 Nomination of Guardian (Optional)
The Principal nominates the Agent to serve as guardian of the Principal’s person should guardianship become necessary.
3.8 Durability; Activation & Effectiveness
a. Durability. This power of attorney is durable and shall not be affected by the Principal’s subsequent incapacity.
b. Activation. The Agent’s authority becomes effective upon the Principal’s incapacity as certified in writing by a Qualified Physician, or earlier if the Principal so directs here: [YES/NO].
3.9 Revocation & Amendment
a. The Principal may revoke or amend this instrument at any time and in any manner permitted under 18 V.S.A. § 9704, including by creating a new Advance Directive or by physically destroying or defacing this document.
b. Any revocation becomes effective upon communication to the Agent and the Principal’s attending health-care provider.
4. REPRESENTATIONS & WARRANTIES
4.1 Principal’s Capacity. The Principal affirms that, as of the Effective Date, the Principal is of sound mind and under no duress or undue influence.
4.2 Voluntary Execution. The Principal executes this instrument voluntarily, intending to create a valid Advance Directive in conformity with State Health-Care Law.
4.3 Agent’s Acceptance. By signing below, the Agent represents that the Agent:
a. Is at least 18 years of age and not presently disqualified under 18 V.S.A. § 9703;
b. Accepts the appointment and duties imposed; and
c. Will act in Good-Faith and in accordance with the Principal’s known wishes and best interests.
5. COVENANTS & RESTRICTIONS
5.1 Agent’s Fiduciary Duties. The Agent shall:
a. Act in Good-Faith and consistently with the Principal’s expressed wishes;
b. Consult with health-care providers and family members as reasonable;
c. Keep reasonably contemporaneous records of significant Health-Care Decisions; and
d. Avoid conflicts of interest that would impair the Agent’s impartiality.
5.2 Notice Obligations. The Agent shall promptly inform the Principal’s health-care providers of the existence of this instrument and any subsequent amendments or revocations.
6. DEFAULT & REMEDIES
6.1 Events of Default. The following constitute default by the Agent:
a. Acting outside the scope of authority granted herein;
b. Failing to act in Good-Faith; or
c. Breaching fiduciary duties under State Health-Care Law.
6.2 Remedies. Upon default, any interested person may petition the State Probate Court to:
a. Remove the Agent;
b. Appoint a Successor Agent or temporary guardian;
c. Enjoin actions contrary to this instrument; and/or
d. Award costs and reasonable attorney fees.
[// GUIDANCE: Vermont probate courts have statutory jurisdiction to enforce Advance Directives.]
7. RISK ALLOCATION
7.1 Indemnification. The Principal shall indemnify and hold the Agent harmless from any civil liability arising from Good-Faith acts or omissions under this instrument, except for willful misconduct or gross negligence (“Agent Good-Faith Indemnity”).
7.2 Limitation of Liability. In no event shall the Agent be liable for monetary damages in excess of actual out-of-pocket losses resulting from actions taken in bad faith or with reckless disregard for the Principal’s wishes (“Good-Faith Standard Liability Cap”).
8. DISPUTE RESOLUTION
8.1 Governing Law. This instrument and any dispute hereunder shall be governed by State Health-Care Law.
8.2 Forum Selection. Exclusive venue lies in the State Probate Court.
8.3 Arbitration. Not available.
8.4 Jury Waiver. Not applicable.
8.5 Injunctive Relief. Nothing herein limits the court’s power to grant injunctive or declaratory relief necessary to enforce Health-Care Decisions.
9. GENERAL PROVISIONS
9.1 Amendment; Waiver. Any amendment must comply with Section 3.9. No waiver of rights under this instrument is effective unless in a signed writing referring specifically to the provision waived.
9.2 Assignment. The Agent’s authority is personal and may not be delegated or assigned except as expressly provided herein or by court order.
9.3 Successors & Assigns. This instrument binds and benefits the Principal, the Agent, and their respective heirs, executors, administrators, and permitted assigns.
9.4 Severability. If any provision is held invalid, the remaining provisions shall remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to achieve the parties’ intent.
9.5 Entire Instrument. This document constitutes the Principal’s entire Advance Directive, superseding all prior inconsistent directives.
9.6 Copies; Electronic Signatures. Photocopies, facsimiles, and electronically signed counterparts shall be treated as originals for all purposes.
10. EXECUTION BLOCK
10.1 Principal
[PRINCIPAL LEGAL NAME]
Date: _______
10.2 Witnesses
[Two adult witnesses required under 18 V.S.A. § 9703]
Witness #1: ____ Date: _
Printed Name: ____
Address: _________
Witness #2: ____ Date: _
Printed Name: ____
Address: _________
[// GUIDANCE: Witnesses must not be (i) the Agent, (ii) the Principal’s health-care provider or employee thereof, (iii) an owner, operator, or employee of a residential care facility where the Principal resides, or (iv) anyone entitled to more than a de minimis part of the Principal’s estate.]
10.3 Notarization (Optional but Recommended)
State of Vermont )
County of _)
On this _ day of __, 20__, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument, and acknowledged that he/she executed the same for the purposes therein contained.
Notary Public
My commission expires: ____
10.4 Agent Acceptance
I, [AGENT NAME], have read this Health Care Power of Attorney and accept my appointment as Agent. I understand my duties and agree to act in accordance with the Principal’s wishes and State Health-Care Law.
[AGENT NAME]
Date: _______
(Add separate acceptance lines for any Successor Agent(s).)
[// GUIDANCE: File the executed document with the Vermont Advance Directive Registry (optional but advisable) and provide copies to the Agent, Successor Agent(s), primary care provider, and any relevant health-care facilities.]