LIVING WILL / ADVANCE HEALTH CARE DIRECTIVE
State of Montana
[// GUIDANCE: This template is intended to comply with Montana’s “Rights of the Terminally Ill Act,” Mont. Code Ann. Title 50, ch. 9, and the Uniform Probate Code provisions governing powers of attorney for health care. Confirm statutory cites and update for later amendments before use.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Appointment of Health-Care Agent
3.2 Statement of Intent & Treatment Preferences
3.3 Ancillary Authorizations - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title. Living Will / Advance Health Care Directive (“Directive”).
1.2 Declarant. [FULL LEGAL NAME OF DECLARANT] (“Declarant”), residing at [ADDRESS].
1.3 Effective Date. This Directive becomes effective on the date executed below (“Effective Date”) and shall remain in effect until revoked pursuant to Section 9.1.
1.4 Governing Law. This Directive is executed pursuant to and shall be construed in accordance with the laws of the State of Montana, including Mont. Code Ann. Title 50, ch. 9 (“Governing Law”).
2. DEFINITIONS
The following terms, when capitalized, have the meanings set forth below:
“Agent” – The individual appointed in Section 3.1 to make Health-Care Decisions on the Declarant’s behalf.
“Alternate Agent” – A successor Agent designated in Section 3.1(c).
“Artificial Nutrition and Hydration” – Medically supplied food and fluids delivered invasively (e.g., via feeding tube or IV).
“Health-Care Decision” – Any decision regarding the diagnosis, treatment, or care of the Declarant’s physical or mental condition.
“Life-Sustaining Treatment” – Any medical intervention that serves only to prolong the dying process when death is imminent, including but not limited to CPR, mechanical ventilation, dialysis, and Artificial Nutrition and Hydration.
“Persistent Vegetative State” – A condition in which the Declarant is unconscious with no reasonable expectation of recovery, as certified in writing by two licensed physicians.
“Provider” – Any health-care professional, facility, or entity providing medical services to Declarant.
“Terminal Condition” – An incurable or irreversible condition that, without the administration of Life-Sustaining Treatment, will result in death within a relatively short time, as certified by the Attending Physician.
3. OPERATIVE PROVISIONS
3.1 Appointment of Health-Care Agent
(a) Primary Agent. Declarant hereby appoints:
• Name: [AGENT NAME]
• Address: [AGENT ADDRESS]
• Telephone: [PRIMARY] | [ALTERNATE]
to act as Agent with full authority to make Health-Care Decisions for Declarant when Declarant lacks decision-making capacity.
(b) Scope of Authority. The Agent’s authority includes, without limitation, the rights to:
(i) consent to, refuse, or withdraw any form of medical treatment;
(ii) employ or discharge health-care Providers;
(iii) access medical records;
(iv) authorize admission to or discharge from any facility; and
(v) execute any document required to implement these decisions.
(c) Alternate Agent(s). If the Agent is unavailable, unwilling, or unable to serve, the following individuals shall serve successively as Alternate Agent:
1. [ALTERNATE AGENT 1 NAME, CONTACT];
2. [ALTERNATE AGENT 2 NAME, CONTACT].
[// GUIDANCE: Insert as many alternates as the client desires.]
3.2 Statement of Intent & Treatment Preferences
(a) General Intent. If at any time Declarant is diagnosed with a Terminal Condition or is in a Persistent Vegetative State, Declarant directs that Life-Sustaining Treatment be withheld or withdrawn, and that death be permitted to occur naturally, except as expressly stated herein.
(b) Specific Directives. Declarant’s election regarding each treatment modality is indicated below (initial one choice per category):
-
Cardiopulmonary Resuscitation (CPR)
[ ] I WANT CPR [ ] I DO NOT WANT CPR -
Mechanical Ventilation
[ ] I WANT ventilation even long-term
[ ] I WANT ventilation for a limited trial period of [___] days
[ ] I DO NOT WANT ventilation -
Artificial Nutrition and Hydration
[ ] I WANT Artificial Nutrition and Hydration
[ ] I ONLY WANT IF NEEDED FOR COMFORT
[ ] I DO NOT WANT Artificial Nutrition and Hydration -
Dialysis
[ ] I WANT dialysis [ ] I DO NOT WANT dialysis
(c) Pain Management. Declarant requests aggressive palliative care and pain relief, even if such medication may hasten death.
(d) Pregnancy Provision. If Declarant is pregnant at the time this Directive would otherwise take effect:
[ ] Follow the above instructions regardless of pregnancy.
[ ] Sustain life support until the fetus is viable.
(e) Organ & Tissue Donation. Declarant hereby:
[ ] MAKES AN ANATOMICAL GIFT of any needed organs or tissues.
[ ] Limits the gift to: [SPECIFY].
[ ] Declines to make an anatomical gift.
3.3 Ancillary Authorizations
(a) Guardian Nomination. Declarant nominates the Agent as guardian of the person in any guardianship proceeding.
(b) HIPAA Release. Pursuant to 45 C.F.R. § 164.502, Declarant authorizes any Provider to release protected health information to the Agent.
(c) Access to Digital Health Records. Agent may access, manage, and direct the disclosure of Declarant’s electronic medical records.
4. REPRESENTATIONS & WARRANTIES
4.1 Competence. Declarant affirms being of sound mind, at least 18 years of age, and acting voluntarily without duress or undue influence.
4.2 Consistency with Governing Law. Declarant warrants that this Directive is intended to conform with the requirements of Mont. Code Ann. Title 50, ch. 9, and any other Applicable Law.
4.3 No Conflicting Directives. Declarant represents that any prior directives are revoked or superseded by this Directive.
5. COVENANTS & RESTRICTIONS
5.1 Agent’s Standard of Conduct. The Agent shall:
(a) act in good faith;
(b) follow Declarant’s expressed wishes; and
(c) if wishes are unknown, act in Declarant’s best interest, using substituted judgment.
5.2 Consultation. The Agent should consult with family members, clergy, or ethics committees as appropriate but retains final authority under this Directive.
6. DEFAULT & REMEDIES
6.1 Unavailability of Agent. If no Agent or Alternate Agent is available, Providers shall follow Declarant’s stated preferences herein.
6.2 Facility Non-Compliance. If a Provider declines to honor this Directive, the Provider shall promptly:
(a) notify the Agent or Declarant; and
(b) facilitate transfer to a willing Provider, consistent with Mont. Code Ann. § 50-9-205.
7. RISK ALLOCATION
7.1 Provider Protection & Indemnification. No Provider acting in good faith and in substantial compliance with this Directive shall be subject to civil or criminal liability or professional discipline. Declarant agrees to indemnify and hold harmless any such Provider from any claim arising out of good-faith compliance, except for gross negligence or willful misconduct.
7.2 Limitation of Liability. Any liability of a Provider acting in good faith under this Directive is limited to conduct amounting to gross negligence or willful misconduct (“Good-Faith Standard”).
[// GUIDANCE: Section 7 can be adjusted or omitted if the facility prefers to rely solely on statutory immunity.]
8. DISPUTE RESOLUTION
8.1 Governing Law. All questions concerning the construction, validity, and enforceability of this Directive are governed by the laws of the State of Montana.
8.2 Injunctive Relief. Because monetary damages are inadequate to remedy a violation of this Directive, injunctive or declaratory relief shall be available to enforce its terms.
[// GUIDANCE: Arbitration and jury-trial waivers are atypical for an advance directive and therefore omitted per the metadata.]
9. GENERAL PROVISIONS
9.1 Revocation. Declarant may revoke this Directive at any time by:
(a) executing a written revocation;
(b) verbally expressing intent to revoke in the presence of a Provider or witness; or
(c) physically destroying this document. Revocation is effective upon communication to the attending Provider.
9.2 Amendments. Declarant may amend this Directive in writing, signed, dated, and witnessed/notarized with the same formalities as the original.
9.3 Severability. If any provision is held invalid, the remaining provisions shall remain in full force, consistent with Declarant’s intent.
9.4 Reliance on Copies. Photostatic, facsimile, or electronically transmitted copies of this Directive shall be as valid as the original.
9.5 Integration. This Directive constitutes the entire expression of Declarant’s health-care wishes and supersedes all prior inconsistent statements.
9.6 Counterparts. This Directive may be executed in counterparts, each of which is deemed an original.
9.7 Electronic Signatures. Subject to Governing Law, electronic signatures are deemed original and enforceable.
10. EXECUTION BLOCK
I, [FULL LEGAL NAME], Declarant, sign my name to this Directive on the ___ day of __, 20, at [CITY], Montana.
Declarant:
Signature
Printed Name
Witness Attestation (two adult witnesses OR notary required; witnesses may not be Agent, Alternate Agent, or related health-care Provider)
- I declare that the Declarant is personally known to me, appears to be of sound mind, and signed or acknowledged the foregoing Directive in my presence.
Witness #1 Signature ____ Date _
Printed Name _____
Address _________
Witness #2 Signature ____ Date _
Printed Name _____
Address _________
OR
Notarial Acknowledgment
State of Montana )
County of ____ )
On this ___ day of __, 20, before me, the undersigned Notary Public, personally appeared [DECLARANT NAME], known to me or satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
Notary Public for the State of Montana
Residing at: ____
My Commission Expires: ______
[// GUIDANCE: File or distribute copies to (i) primary care physician, (ii) Agent and alternates, (iii) local hospital, and (iv) other relevant Providers. Encourage clients to upload a digital copy to any state registry or EHR system.]