GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE

(Living Will & Health-Care Agent Designation)
(Prepared pursuant to O.C.G.A. § 31-32-1 et seq.)

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
 A. Appointment of Health-Care Agent
 B. Treatment Preferences & Instructions
 C. Guardianship Nomination (Optional)
 D. Anatomical Gift Election (Optional)
 E. Duration & Effectiveness
IV. Declarant Statements & Certifications
V. Covenants & Restrictions of Health-Care Agent
VI. Revocation, Default & Remedies
VII. Risk Allocation & Provider Protection
VIII. Dispute Resolution & Governing Law
IX. General Provisions
X. Execution Block (Signature, Witnesses, Notary)

[// GUIDANCE: This template consolidates the statutory “Advance Directive for Health Care” and traditional “Living Will.” Georgia’s statutory form is not mandatory; attorneys may modify language so long as the requirements of O.C.G.A. § 31-32-5 are met. Review carefully for client-specific medical, religious, and family considerations.]

I. DOCUMENT HEADER

1. Declarant: [DECLARANT FULL LEGAL NAME], residing at [DECLARANT ADDRESS] (“Declarant”).
2. Effective Date: [EFFECTIVE DATE] (“Effective Date”).
3. Jurisdiction: State of Georgia; governed by the Georgia Advance Directive Act, O.C.G.A. § 31-32-1 et seq. (the “Act”).
4. Purpose & Consideration: Declarant executes this Advance Directive to (a) designate a health-care agent, (b) provide binding health-care instructions, and (c) confer limited immunity upon Providers acting in good faith reliance hereon.

II. DEFINITIONS

For purposes of this Directive, capitalized terms have the meanings set forth below.

“Advance Directive” or “Directive” – this instrument as executed and any duly executed amendment or restatement hereof.
“Declarant” – the individual executing this Advance Directive.
“Health-Care Agent” or “Agent” – the person(s) appointed in Section III-A with authority under the Act.
“Health-Care Decision” – any consent, refusal, withdrawal, or limitation of medical treatment, services, or procedures.
“Health-Care Provider” or “Provider” – any person or entity licensed, certified, or otherwise authorized to provide health-care services.
“Life-Sustaining Treatment” – medical interventions that serve only to prolong the dying process when death is imminent or the individual is in a persistent vegetative state, including without limitation ventilatory support, CPR, dialysis, and artificially administered nutrition/hydration.
“Persistent Vegetative State” – a medical condition of unconsciousness with no reasonable expectation of recovery, as determined under prevailing medical standards.
“Primary Physician” – [PRIMARY PHYSICIAN NAME] or, if unavailable, the attending physician at the relevant time.
“Surrogate” – any individual authorized under O.C.G.A. § 31-9-2 when no Agent is available.
[// GUIDANCE: Add or delete definitions to align with client’s instructions.]

III. OPERATIVE PROVISIONS

A. Appointment of Health-Care Agent

1. Primary Agent: [PRIMARY AGENT FULL LEGAL NAME], [RELATIONSHIP], whose address is [ADDRESS] and phone [PHONE].
2. Successor Agent(s) (in order of priority):
   a. [FIRST SUCCESSOR AGENT NAME]
   b. [SECOND SUCCESSOR AGENT NAME]

3. Grant of Authority: To the fullest extent permitted by the Act, the Agent may make any and all Health-Care Decisions the Declarant could make if capable, including, without limitation:
   a. Consent to, withdraw, or refuse any care, treatment, service, or procedure;
   b. Hire and fire medical personnel;
   c. Access medical records and HIPAA-protected information;
   d. Authorize admission to or discharge from health-care facilities;
   e. Consent to pain relief or palliative care, even if hastening death;
   f. Make decisions regarding autopsy, organ donation, and final disposition unless otherwise specified herein.

4. Limits & Guidance to Agent:
   a. Faithful Adherence – The Agent shall act consistently with Declarant’s expressed wishes herein and any known verbal instructions.
   b. Best Interest Standard – Where wishes are unclear, Agent shall act in Declarant’s best interest, considering physical comfort, dignity, and spiritual preferences.
   c. Financial Authority Excluded – This Directive does not grant any authority over Declarant’s property or finances.
   [// GUIDANCE: Insert any additional limitations (e.g., no withdrawal of artificial nutrition).]

B. Treatment Preferences & Instructions

1. End-Stage Condition / Terminal Illness
   If my attending physician determines that I have an incurable or irreversible condition that will result in my death within a relatively short period of time, it is my preference that:
   [ ] a. Life-Sustaining Treatment be WITHHELD or WITHDRAWN.
   [ ] b. Life-Sustaining Treatment be PROVIDED.
   [ ] c. My Agent decide.

2. Persistent Vegetative State
   If I am in a Persistent Vegetative State as certified by two physicians, it is my preference that:
   [ ] a. Life-Sustaining Treatment be WITHHELD or WITHDRAWN.
   [ ] b. Life-Sustaining Treatment be PROVIDED.
   [ ] c. My Agent decide.

3. Artificial Nutrition & Hydration
   Regardless of the above, with respect to medically administered nutrition and hydration:
   [ ] a. I ACCEPT such measures.
   [ ] b. I DECLINE such measures.
   [ ] c. My Agent may decide.

4. Pain Relief / Palliative Care
   I - [ ] AUTHORIZE / [ ] DO NOT AUTHORIZE – medication and procedures necessary for comfort even if they may unintentionally hasten my death.

5. Other Specific Instructions:

C. Guardianship Nomination (Optional)

If a court deems a guardian necessary, I nominate my Agent (or in the alternative [ALTERNATE GUARDIAN NAME]) to serve, with bond waived.

D. Anatomical Gift Election (Optional)

[ ] I elect to be an organ and tissue donor for any legally authorized purpose.
[ ] I restrict my donation to the following: ________.
[ ] I decline to make an anatomical gift.

E. Duration & Effectiveness

This Directive becomes effective upon execution and remains effective until revoked pursuant to Section VI. An Agent’s authority begins when the Declarant’s attending physician determines that the Declarant lacks decision-making capacity, unless the Declarant initial-checks the following box:
[ ] Agent may act IMMEDIATELY after execution, including while I retain capacity.

IV. DECLARANT STATEMENTS & CERTIFICATIONS

1. Capacity: I am of sound mind and at least eighteen (18) years old.
2. Voluntariness: I execute this Directive voluntarily and not as a condition of treatment or insurance coverage.
3. Informed Decision: I have discussed my wishes with the individual(s) I have appointed as Agent(s).
4. Revocation of Prior Directives: This instrument revokes any prior Georgia advance directive or living will executed by me.

V. COVENANTS & RESTRICTIONS OF HEALTH-CARE AGENT

1. Agent accepts appointment and covenants to:
   a. Act in good faith, consistent with Declarant’s expressed wishes;
   b. Consult, when practicable, with family members and relevant faith advisors;
   c. Keep contemporaneous records of material Health-Care Decisions; and
   d. Avoid conflicts of interest and self-dealing.
2. Agent shall not be personally liable for health-care costs incurred on Declarant’s behalf absent separate written agreement.

VI. REVOCATION, DEFAULT & REMEDIES

1. Revocation by Declarant: This Directive may be revoked at any time by:
   a. A signed, dated writing;
   b. Physical destruction of the original by Declarant or at Declarant’s direction;
   c. An oral statement of revocation in the presence of a witness 18 years or older; or
   d. Execution of a subsequent advance directive.
2. Divorce: Unless otherwise indicated, dissolution of Declarant’s marriage to an Agent revokes that Agent’s authority.
3. Default Decision-Making: If every appointed Agent is unavailable, decision-making shall proceed under O.C.G.A. § 31-9-2.
4. Reliance & Remedies: Providers acting in good-faith reliance on this Directive or instructions of an authorized Agent are insulated from civil, criminal, and professional liability to the maximum extent allowed by law.

VII. RISK ALLOCATION & PROVIDER PROTECTION

1. Provider Indemnification: Declarant agrees to indemnify and hold harmless any Provider who, in good-faith reliance on this Directive, provides, withholds, or withdraws treatment (“Provider Protection”).
2. Limitation of Liability: No Provider or Agent shall be liable for damages so long as actions are taken in good faith and in substantial compliance with this Directive and applicable law (“Good-Faith Standard”).
3. Force Majeure: Unavailability of a treatment modality due to factors beyond the Provider’s control shall not constitute noncompliance.

VIII. DISPUTE RESOLUTION & GOVERNING LAW

1. Governing Law: This Directive and any disputes arising hereunder shall be governed by the substantive and procedural law of the State of Georgia (“state_healthcare_law”).
2. Forum: Not applicable—health-care directives are inherently non-contractual.
3. Injunctive Relief: Any interested person may petition a court of competent jurisdiction for declaratory or injunctive relief to enforce or interpret this Directive (“healthcare_directive”).

IX. GENERAL PROVISIONS

1. Amendment: Declarant may amend this Directive in writing at any time in accordance with Section VI.
2. Severability: If any provision is held invalid, the remainder shall nevertheless be given full effect to the maximum extent permissible.
3. Integration: This document constitutes the entire Advance Directive of Declarant and supersedes all prior instruments on the same subject matter.
4. Copies: Photocopies, facsimiles, and electronically transmitted counterparts are as valid as the original.
5. HIPAA Release: For purposes of 45 C.F.R. § 164.502(a)(1)(i), Declarant authorizes Providers to release protected health information to any Agent named herein.

X. EXECUTION BLOCK

[// GUIDANCE: Georgia requires two (2) qualified witnesses. Neither witness may be (i) the Agent, (ii) a person who will inherit from or financially benefit by the Declarant’s death, nor (iii) directly involved in the Declarant’s health-care. Notarization is optional but recommended when the Directive may be used in states that require notarization.]

A. Declarant Signature

I, [DECLARANT NAME], sign my name to this Advance Directive on this _ day of _, 20____, in the presence of the undersigned witnesses.

Declarant Signature

B. Witness Attestation

We declare that the Declarant signed or acknowledged this Directive in our presence; that the Declarant appears to be of sound mind and not under duress, fraud, or undue influence; and that we are not disqualified witnesses under Georgia law.
| Witness | Signature | Printed Name | Address | Date |
|---------|-----------|--------------|---------|------|
| 1. | ___ | ___ | ____ | __ |
| 2. | ____ | ____ | ____ | ____ |

C. OPTIONAL NOTARIZATION

State of Georgia )
County of __ )

On __, 20__, before me, the undersigned Notary Public, personally appeared [DECLARANT NAME], who acknowledged executing the foregoing Advance Directive.

Notary Public
My commission expires: ___

[// GUIDANCE:
1. Distribute copies to the Agent, alternates, primary physician, and appropriate family members.
2. Encourage clients to review this Directive every 2–3 years and upon major life events.
3. Verify consistency with separate financial POA and estate-planning documents to avoid conflict.]