FLORIDA ADVANCE HEALTH CARE DIRECTIVE
(Living Will & Designation of Health-Care Surrogate)
[Effective Date: [MM/DD/YYYY]]
TABLE OF CONTENTS
- Definitions
- Recitals & Statement of Intent
- Living-Will Directives
3.1 Terminal Condition
3.2 Persistent Vegetative State
3.3 End-Stage Condition
3.4 Artificial Nutrition & Hydration
3.5 Pain Management & Palliative Care
3.6 Pregnancy Provision
3.7 Anatomical Gifts
3.8 HIPAA Authorization - Designation of Health-Care Surrogate
- Good-Faith Immunity, Indemnification & Liability Cap
- Revocation & Amendment
- General Provisions
- Execution & Attestation
[// GUIDANCE: Replace all bracketed, bolded placeholders before use. Confirm the client’s wishes in writing. Retain original signatures and provide copies to the surrogate, primary physician, and any relevant facility.]
1. DEFINITIONS
For purposes of this Advance Health Care Directive (the “Directive”), the following capitalized terms shall have the meanings set forth below. Terms not defined herein shall have the meanings assigned by Chapter 765, Florida Statutes, as amended.
“Advance Directive” or “Directive” means this document executed in accordance with Fla. Stat. § 765.302.
“Artificially Provided Nutrition and Hydration” means the medical provision of food and liquids through tubes, intravenous lines, or other medical technology.
“Attending Physician” means the physician who has primary responsibility for the care of the Principal.
“End-Stage Condition” has the meaning given in Fla. Stat. § 765.101(4).
“Life-Prolonging Procedure” means any medical procedure, treatment, or intervention that sustains, restores, or supplants a spontaneous vital function, as described in Fla. Stat. § 765.101(10).
“Persistent Vegetative State” has the meaning given in Fla. Stat. § 765.101(12).
“Principal” means [FULL LEGAL NAME], the person executing this Directive.
“Surrogate” means the individual designated in Section 4 to make health-care decisions on the Principal’s behalf upon the conditions set forth herein.
“Terminal Condition” has the meaning given in Fla. Stat. § 765.101(21).
2. RECITALS & STATEMENT OF INTENT
A. I, [FULL LEGAL NAME], residing at [ADDRESS], being of sound mind and over the age of eighteen (18) years, voluntarily execute this Directive under the authority of Chapter 765, Florida Statutes.
B. I intend that this Directive:
1. Serve as my “living will,” stating my wishes concerning the use, withholding, or withdrawal of life-prolonging procedures; and
2. Designate a health-care surrogate to make decisions consistent with my instructions when I am unable to communicate.
C. I direct that all health-care providers act in accordance with this Directive. If any part is held invalid, I intend the remainder to be enforced to the fullest extent permitted by law.
3. LIVING-WILL DIRECTIVES
I declare the following wishes regarding medical treatment should my Attending Physician and a second consulting physician determine that I am incapacitated and: (a) have a Terminal Condition; (b) am in a Persistent Vegetative State; or (c) have an End-Stage Condition.
3.1 Terminal Condition
If I have a Terminal Condition, I direct that life-prolonging procedures [SELECT ONE]:
- ☐ be withheld or withdrawn;
- ☐ be continued.
3.2 Persistent Vegetative State
If I am in a Persistent Vegetative State, I direct that life-prolonging procedures [SELECT ONE]:
- ☐ be withheld or withdrawn;
- ☐ be continued.
3.3 End-Stage Condition
If I have an End-Stage Condition, I direct that life-prolonging procedures [SELECT ONE]:
- ☐ be withheld or withdrawn;
- ☐ be continued.
3.4 Artificial Nutrition & Hydration
Regarding Artificially Provided Nutrition and Hydration, I direct [SELECT ONE]:
- ☐ WITHHOLD / WITHDRAW if same may only prolong dying;
- ☐ CONTINUE regardless of prognosis.
3.5 Pain Management & Palliative Care
I desire adequate medication to alleviate pain, even if such medication may hasten death, provided it is administered in accordance with accepted medical standards.
3.6 Pregnancy Provision
If I am pregnant at the time this Directive would otherwise take effect, I direct that it [SELECT ONE]:
- ☐ shall not be implemented if it would result in termination of pregnancy;
- ☐ shall be implemented in accordance with my wishes regardless of pregnancy.
3.7 Anatomical Gifts
Upon my death, I [SELECT ONE]:
- ☐ authorize the donation of any needed organs or tissues;
- ☐ limit donation to [SPECIFY ORGANS/TISSUES];
- ☐ do not authorize organ or tissue donation.
3.8 HIPAA Authorization
I authorize my Surrogate and any Alternate Surrogate(s) to obtain my protected health information and communicate with health-care providers as permitted by 45 C.F.R. § 164.508.
4. DESIGNATION OF HEALTH-CARE SURROGATE
-
Primary Surrogate
Name: [SURROGATE NAME]
Address: [ADDRESS]
Phone: [PHONE]
Relationship: [RELATIONSHIP] -
Alternate Surrogate (if Primary is unwilling or unable to act)
Name: [ALTERNATE NAME]
Address: [ADDRESS]
Phone: [PHONE]
Relationship: [RELATIONSHIP] -
Authority Granted
The Surrogate is authorized to:
a. Consent, refuse, or withdraw consent to any medical procedure, treatment, or intervention, including life-prolonging procedures;
b. Apply for public benefits to defray the cost of care;
c. Authorize admission to or discharge from health-care facilities;
d. Access medical records;
e. Obtain court intervention, including injunctive relief, to enforce this Directive. -
Limitations (optional)
[INSERT ANY EXPRESS LIMITATIONS OR INSTRUCTIONS]
[// GUIDANCE: Advise the client to provide complete contact information and discuss expectations with the designated surrogate.]
5. GOOD-FAITH IMMUNITY, INDEMNIFICATION & LIABILITY CAP
A. Any health-care provider, facility, or surrogate acting in good faith reliance on this Directive shall be indemnified and held harmless by my estate to the fullest extent permitted by Fla. Stat. § 765.110.
B. No provider or surrogate shall incur civil or criminal liability for withholding or withdrawing life-prolonging procedures in good-faith compliance with this Directive.
C. Liability, if any, for actions taken in bad faith or contrary to this Directive shall be limited to direct damages proven by clear and convincing evidence.
6. REVOCATION & AMENDMENT
- I may revoke or amend this Directive at any time by:
a. A signed, dated written statement;
b. Physical destruction of this document with the intent to revoke;
c. An oral expression of intent to revoke in the presence of two (2) witnesses; or
d. Execution of a subsequent Advance Directive. - Any revocation or amendment shall be effective upon communication to the Surrogate, my Attending Physician, or other health-care personnel, consistent with Fla. Stat. § 765.104.
7. GENERAL PROVISIONS
A. Governing Law. This Directive shall be governed by and construed in accordance with the laws of the State of Florida, without regard to conflict-of-laws principles.
B. Copies. A photocopy or electronically transmitted copy of this Directive shall have the same effect as the original.
C. Severability. If any provision is held invalid, the remaining provisions shall remain in full force and effect.
D. No Waiver. Failure to enforce any provision shall not constitute a waiver of the right to enforce the same or any other provision at a later time.
8. EXECUTION & ATTESTATION
I have read and understand the contents of this Directive. I sign it willingly, free from duress, fraud, or undue influence.
[PRINCIPAL SIGNATURE BLOCK]
Signature of Principal, [FULL NAME]
Date: [MM/DD/YYYY]
WITNESS ATTESTATION
[At least two (2) adult witnesses required; at least one (1) witness must NOT be the Principal’s spouse or blood relative. Fla. Stat. § 765.302(1)(b).]
We declare that the Principal is personally known to us, appears to be of sound mind, and signed this Directive voluntarily in our presence.
Witness #1 (NOT spouse or blood relative)
Name: ______
Address: ______
Signature: __ Date: _
Witness #2
Name: ______
Address: ______
Signature: __ Date: _
OPTIONAL NOTARIZATION
[Not required under Florida law but recommended for out-of-state recognition.]
State of Florida
County of [_]
The foregoing instrument was acknowledged before me this _ day of _, 20_ by [FULL NAME], who is personally known to me or who has produced ___ as identification and who did/did not take an oath.
Notary Public, State of Florida
Print Name: ____
My Commission Expires: __
[// GUIDANCE:
1. Provide executed copies to the Surrogate, Alternate Surrogate(s), primary physician, and relevant medical facilities.
2. Upload a copy to any available electronic medical-record portal.
3. Review this Directive periodically, especially after major life events or diagnosis changes.
4. Advise the client about compatibility with any pre-existing Do-Not-Resuscitate Order (DNRO) on form DH 1896.]