**Tennessee Advance Directive for Health Care
(Living Will & Appointment of Health Care Agent)
Template – Court-Ready Draft for Attorney Customization
[// GUIDANCE: This template is designed to satisfy the requirements of Tenn. Code Ann. § 68-11-1801 et seq. and related provisions (collectively, the “Tennessee Health Care Decision Act”). Confirm no subsequent statutory changes before finalizing.]
TABLE OF CONTENTS
I. Document Header
II. Definitions
III. Operative Provisions
A. Appointment of Health Care Agent
B. Living Will / Treatment Instructions
C. Organ & Tissue Donation (Optional)
D. Access to Medical Information (HIPAA)
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions (Including Revocation)
X. Execution Block (Signature, Witnesses/Notary)
I. DOCUMENT HEADER
1.1 Title. Tennessee Advance Directive for Health Care (the “Advance Directive”).
1.2 Principal. This Advance Directive is made by [PRINCIPAL NAME], residing at [ADDRESS] (the “Principal”).
1.3 Effective Date. This Advance Directive becomes effective on the date executed below (the “Effective Date”) and shall remain in force until revoked pursuant to Section IX.
1.4 Governing Law. This document is governed by, and shall be construed in accordance with, the Tennessee Health Care Decision Act and other applicable federal and state laws and regulations relating to health-care decision-making (collectively, the “Governing Law”).
1.5 Purpose & Consideration. The Principal executes this Advance Directive to provide legally-binding instructions for future health-care decision-making, to appoint a Health Care Agent, and to ensure that health-care providers may rely on these instructions in good faith without incurring liability.
II. DEFINITIONS
For purposes of this Advance Directive, capitalized terms have the meanings set forth below.
“Agent” or “Health Care Agent” – The individual(s) designated in Section III-A to make health-care decisions on the Principal’s behalf when the Principal lacks decision-making capacity.
“Artificial Nutrition and Hydration” – Medically provided food and fluids (e.g., via feeding tube or IV) intended to sustain life.
“Good Faith” – Honesty in fact in the conduct or transaction concerned.
“Health-care Provider” – Any individual or facility licensed, certified, or otherwise authorized by Tennessee to provide health-care services.
“Life-Sustaining Treatment” – Any medical procedure, medication, or intervention that, when administered to a patient in a terminal condition or persistent vegetative state, will serve only to prolong the dying process.
“Persistent Vegetative State” – A condition of permanent and irreversible unconsciousness in which there is no evidence of self-awareness or of awareness of the environment.
“Principal” – The individual executing this Advance Directive.
“Terminal Condition” – An incurable or irreversible condition that, without the administration of Life-Sustaining Treatment, will, in the opinion of the attending physician, result in death within a relatively short time.
“Witness” – An individual who satisfies the qualifications set forth in Section X and Tenn. Code Ann. § 68-11-1803.
[// GUIDANCE: Add or delete definitions to align with client preferences or evolving statutory terminology.]
III. OPERATIVE PROVISIONS
A. Appointment of Health Care Agent
3.1 Designation. The Principal hereby appoints:
• Primary Agent: [PRIMARY AGENT NAME], presently residing at [ADDRESS], telephone [PHONE];
• Alternate Agent: [ALTERNATE AGENT NAME] (to serve only if the Primary Agent is unavailable, unwilling, or legally unable to act).
3.2 Authority. Subject to the limitations below, the Agent shall have full authority under Governing Law to make any and all health-care decisions the Principal could make if capable, including (without limitation) decisions regarding Life-Sustaining Treatment, placement in or discharge from health-care facilities, pain management, organ donation, and autopsy.
3.3 Limitations. The Agent’s authority is expressly limited by Sections III-B and V and by any handwritten limitations inserted by the Principal:
[PLACEHOLDER – INSERT SPECIFIC LIMITATIONS OR “None.”]
3.4 Nomination of Guardian. If a court ever considers appointing a guardian for the Principal, the Principal nominates the Agent (or alternate Agent) to serve.
B. Living Will / Treatment Instructions
3.5 Statement of Intent. If at any time the Principal (i) has a Terminal Condition, (ii) is in a Persistent Vegetative State, or (iii) experiences another condition specified below, the following instructions shall apply:
a. Life-Sustaining Treatment.
☐ (Initial here) [____] I direct that all Life-Sustaining Treatment be WITHHELD or WITHDRAWN, and that I be permitted to die naturally.
OR
☐ (Initial here) [____] I direct that Life-Sustaining Treatment be PROVIDED to prolong my life to the greatest extent possible within accepted medical standards.
b. Artificial Nutrition and Hydration.
☐ (Initial here) [____] WITHHOLD OR WITHDRAW artificial nutrition and hydration.
☐ (Initial here) [____] PROVIDE artificial nutrition and hydration.
c. Pain Relief. I direct that adequate pain relief be provided at all times, even if it may hasten death.
d. Pregnancy. (If applicable under Governing Law) I understand that certain directives may be limited if I am pregnant and continuation of treatment is required to preserve the life or health of the fetus.
[// GUIDANCE: Tennessee permits detailed, scenario-specific instructions. Add additional check-boxes or narrative space as desired.]
C. Organ & Tissue Donation (Optional)
3.6 Gift. Upon death, I make the following anatomical gift under applicable organ-donation laws:
☐ Any needed organs/tissues
☐ Only the following: [SPECIFY]
☐ I do NOT wish to donate organs/tissues.
D. Access to Medical Information (HIPAA)
3.7 HIPAA Authorization. The Agent is hereby designated as the Principal’s “personal representative” for purposes of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and may obtain, disclose, and direct the disclosure of the Principal’s protected health information.
IV. REPRESENTATIONS & WARRANTIES
4.1 Capacity & Voluntariness. The Principal represents that he/she (a) is at least 18 years of age, (b) is of sound mind, and (c) executes this Advance Directive voluntarily and free of duress or undue influence.
4.2 No Conflicting Directives. The Principal affirms that any prior living will, health-care power of attorney, or other advance directive is either revoked or, if not revoked, is identified herewith and deemed subordinate to this document to the extent of conflict.
4.3 Accuracy of Information. All information provided in this Advance Directive is, to the best of the Principal’s knowledge, true, complete, and accurate.
V. COVENANTS & RESTRICTIONS
5.1 Compliance with Governing Law. The Agent and all Health-care Providers shall comply with all applicable requirements of the Governing Law, including any waiting periods, certifications, and documentation obligations.
5.2 Pregnancy Restriction. This Advance Directive shall be interpreted in accordance with any statutory limitation on withdrawal of Life-Sustaining Treatment from a pregnant patient.
5.3 Religious or Ethical Objection. A Health-care Provider who has a conscientious objection must, in Good Faith, promptly transfer care or otherwise comply with Tenn. Code Ann. § 68-11-1807.
5.4 No Compensation. The Agent shall serve without compensation, but may be reimbursed for reasonable expenses incurred in carrying out duties hereunder.
VI. DEFAULT & REMEDIES
6.1 Events of Default. For purposes of this document, an “Event of Default” occurs if (a) a Health-care Provider fails or refuses to honor the directives herein in Good Faith, or (b) any person interferes with the Agent’s lawful authority.
6.2 Notice & Cure. Upon an Event of Default, the Agent (or any interested person) shall notify the non-complying party in writing and demand immediate compliance.
6.3 Remedies. In addition to remedies available under the Governing Law, the Agent or any interested person may seek injunctive or declaratory relief to enforce this Advance Directive.
6.4 Attorney Fees. A court may, in its discretion, award reasonable attorney fees and costs to the prevailing party in any action to enforce this Advance Directive.
VII. RISK ALLOCATION
7.1 Provider Protection & Indemnification. Any Health-care Provider, institution, or individual who, in Good Faith, acts in reliance on this Advance Directive, or who declines to act based on a Good Faith belief that it is invalid or has been revoked, shall be indemnified and held harmless by the Principal’s estate to the fullest extent permitted under Tenn. Code Ann. § 68-11-1806.
7.2 Limitation of Liability. No Health-care Provider acting in Good Faith and in accordance with Governing Law shall incur civil or criminal liability or be subject to discipline for unprofessional conduct solely for complying with, or refusing to comply with, this Advance Directive.
7.3 Force Majeure. Obligations herein are excused to the extent performance is impossible due to Acts of God, war, civil unrest, or similar circumstances materially impairing the provision of health-care services.
VIII. DISPUTE RESOLUTION
8.1 Governing Law. All disputes arising under or relating to this Advance Directive shall be governed by the laws of the State of Tennessee, without regard to conflict-of-laws rules.
8.2 Forum Selection. Any judicial proceeding shall be brought in a court of competent jurisdiction located in the county where the Principal receives care or, if different, the county of the Principal’s residence.
8.3 Arbitration & Jury Waiver. Not applicable (per user metadata).
8.4 Injunctive Relief. Nothing herein shall limit the right of the Principal, the Agent, or any interested person to seek temporary, preliminary, or permanent injunctive relief to enforce the terms of this Advance Directive.
IX. GENERAL PROVISIONS (INCLUDING REVOCATION)
9.1 Revocation. The Principal may revoke this Advance Directive at any time by (a) executing a subsequent written revocation, (b) physically destroying the original, or (c) communicating an intent to revoke to the attending physician or Health-care Provider. Revocation is effective upon communication to the attending physician or other Health-care Provider.
9.2 Amendment. This Advance Directive may be amended only by a later-dated instrument executed with the same formalities required for execution of an advance directive under Tennessee law.
9.3 Copies. A copy or facsimile of this executed Advance Directive has the same effect as the original.
9.4 Severability. If any provision of this Advance Directive is held invalid, the remaining provisions shall remain in full force and effect to the greatest extent possible.
9.5 Integration/Merger. This document constitutes the entire advance directive of the Principal and supersedes all prior inconsistent directives.
9.6 Successors & Assigns. References to the Agent include any duly appointed successor under Section III-A.
9.7 Electronic Signatures. To the extent permitted by the Governing Law, electronic signatures or counterparts shall be deemed originals.
X. EXECUTION BLOCK
[// GUIDANCE: Tennessee permits EITHER two qualified witnesses OR a notary public. DO NOT use both.]
Option 1 – Two (2) Qualified Witnesses
IN WITNESS WHEREOF, the Principal has executed this Advance Directive on [DATE].
Principal Signature: ______
Printed Name: ___________
We, the undersigned Witnesses, affirm that (i) the Principal is personally known to us or has provided satisfactory proof of identity, (ii) the Principal signed or acknowledged this Advance Directive in our presence, (iii) at the time of execution the Principal appeared to be of sound mind and acting voluntarily, and (iv) we are not (a) related to the Principal by blood, marriage, or adoption, (b) entitled to any portion of the Principal’s estate, (c) directly financially responsible for the Principal’s health care, or (d) the Principal’s attending physician or an employee of the attending physician or health-care facility.
Witness #1 Signature: ____ Date: __
Printed Name & Address: _________
Witness #2 Signature: ____ Date: __
Printed Name & Address: _________
Option 2 – Notary Public
STATE OF TENNESSEE )
COUNTY OF ____ )
On this ___ day of ____, 20__, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], personally known to me or satisfactorily proven to be the person whose name is subscribed to the foregoing Advance Directive, and acknowledged that he/she executed the same for the purposes therein contained.
Witness my hand and official seal.
Notary Public Signature: ______
My Commission Expires: _______
[// GUIDANCE:
1. Distribute copies to the Principal’s primary care physician, Agent(s), and close family.
2. Consider uploading to the Tennessee Advance Directive Registry (if available) or including it in the Principal’s electronic medical record.
3. Review at least every two years or upon major life changes.]