UTAH ADVANCE HEALTH CARE DIRECTIVE

(Living Will & Appointment of Health-Care Agent)

[// GUIDANCE: This template is drafted to comply with the Utah Advance Health Care Directive Act, Utah Code Ann. §§ 75-2a-101 et seq. Customize bracketed fields, then remove guidance comments before final execution.]

Effective Date: [MM/DD/YYYY]
Governing Law: State of Utah
Declarant: [FULL LEGAL NAME] (“Declarant”)
Date of Birth: [MM/DD/YYYY]
Primary Residence: [STREET, CITY, STATE, ZIP]

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
    A. Appointment of Agent
    B. Treatment Preferences & Instructions
    C. Organ & Tissue Donation
    D. Nomination of Guardian (Optional)
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Revocation, Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block (Signatures, Witnesses, Notary)

I. DOCUMENT HEADER

WHEREAS, Declarant is an adult of sound mind and desires to ensure that health-care decisions made on Declarant’s behalf conform to Declarant’s wishes and Utah law; and

WHEREAS, Declarant executes this Advance Health Care Directive (“Directive”) pursuant to the Utah Advance Health Care Directive Act, Utah Code Ann. §§ 75-2a-101 et seq., to designate an agent, state treatment preferences, and provide for enforcement thereof;

NOW, THEREFORE, Declarant hereby declares, directs, and agrees as follows:

II. DEFINITIONS

Unless the context clearly indicates otherwise, capitalized terms have the meanings set forth below and apply throughout this Directive.

“Act” means the Utah Advance Health Care Directive Act, Utah Code Ann. §§ 75-2a-101 et seq.

“Agent” means the individual designated in Section III-A to make health-care decisions for Declarant.

“Alternate Agent” means the substitute decision-maker(s) designated in Section III-A(2).

“Artificial Nutrition and Hydration” means medically assisted feeding or fluids (e.g., via feeding tube or IV).

“Directive” has the meaning set forth in the Document Header and includes all amendments and restatements.

“Good Faith” means honesty in fact in the conduct or transaction concerned and reasonable belief that the action is in accordance with this Directive and the Act.

“Health-Care Provider” means any person or facility licensed, certified, or otherwise authorized to administer health care in Utah.

“Life-Sustaining Treatment” means any medical treatment, medication, or mechanical intervention that utilizes artificial means to sustain, restore, or replace a vital bodily function.

“Qualified Witness” has the meaning assigned in Section X-C.

“Revocation” means any act authorized under Section VI-A resulting in termination of this Directive.

[// GUIDANCE: Expand definitions as needed for specialized instructions (e.g., “Palliative Care,” “Persistent Vegetative State”).]

III. OPERATIVE PROVISIONS

A. Appointment of Agent

1. Primary Agent
   Name: [AGENT FULL LEGAL NAME]
   Address: [STREET, CITY, STATE, ZIP]
   Telephone: [PRIMARY PHONE]
   Relationship to Declarant: [RELATIONSHIP]

2. Alternate Agent(s) (in the order listed)
   a. Name: [ALTERNATE #1] | Phone: [PHONE]
   b. Name: [ALTERNATE #2] | Phone: [PHONE]

3. Grant of Authority
   a. The Agent may make any and all health-care decisions Declarant could make if able, including consent, refusal, or withdrawal of treatment, subject to the limitations herein.
   b. The Agent’s authority becomes effective upon a determination by the attending physician or advanced practice registered nurse that Declarant lacks decisional capacity, or earlier if Declarant expressly requests.

4. Limitations on Agent’s Authority
   [INSERT ANY LIMITS OR SPECIAL INSTRUCTIONS—e.g., “Agent shall not authorize psychosurgery.”]

5. Access to Information
   The Agent is Declarant’s personal representative for purposes of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and may receive all protected health information necessary to fulfill Agent’s duties.

B. Treatment Preferences & Instructions

1. General Intent
   Declarant desires care that will allow the maximum opportunity for recovery consistent with Declarant’s goals, values, and faith, but does not desire care that merely prolongs the dying process without reasonable hope of recovery.

2. End-of-Life Decisions
   a. If Declarant is terminally ill or in a persistent vegetative state and lacks capacity:
   ☐ (Initial) Direct WITHHOLD/WITHDRAW Life-Sustaining Treatment.
   ☐ (Initial) Direct PROVIDE Life-Sustaining Treatment.
   b. Artificial Nutrition and Hydration:
   ☐ (Initial) WITHHOLD/WITHDRAW
   ☐ (Initial) PROVIDE

3. Pain Management
   Declarant desires adequate pain relief even if such relief may indirectly hasten death, unless otherwise specified: [ADDITIONAL INSTRUCTIONS].

4. Pregnancy Provision (if applicable)
   [PLACEHOLDER—include instructions if Declarant is pregnant.]

[// GUIDANCE: Utah law presumes treatment unless otherwise directed. Ensure Declarant initials each choice.]

C. Organ & Tissue Donation

1. Intent
   ☐ (Initial) Declarant does wish to make an anatomical gift.
   ☐ (Initial) Declarant does NOT wish to make an anatomical gift.

2. Scope of Gift
   [E.g., “Any needed organs for transplant, therapy, research, or education.”]

3. Agent’s Role
   The Agent may amend or revoke this gift only if Declarant has not indicated otherwise.

D. Nomination of Guardian (Optional)

If a court must appoint a guardian, Declarant nominates the Agent (or Alternate Agent, in order) to serve as guardian of Declarant’s person.

IV. REPRESENTATIONS & WARRANTIES

1. Declarant affirms having the legal capacity to execute this Directive voluntarily and free from duress.
2. Declarant understands the nature and consequences of signing this Directive and has had an opportunity to consult counsel.
3. Each Agent and Alternate Agent warrants that he or she:
   a. Is at least 18 years of age;
   b. Is willing and able to act; and
   c. Will act in Good Faith, consistent with Declarant’s instructions and best interests.

V. COVENANTS & RESTRICTIONS

1. Agent shall:
   a. Act consistently with Declarant’s expressed wishes and religious or moral beliefs;
   b. Consult with appropriate medical professionals;
   c. Keep interested family members reasonably informed unless Declarant instructs otherwise.

2. Agent shall not:
   a. Delegate authority except as expressly permitted by the Act;
   b. Authorize actions contrary to Declarant’s explicit instructions.

3. Health-Care Providers covenant to honor this Directive in accordance with Utah Code Ann. § 75-2a-106, subject to conscientious objection procedures under § 75-2a-110.

VI. REVOCATION, DEFAULT & REMEDIES

A. Revocation by Declarant

1. Declarant may revoke this Directive at any time by:
   a. A signed, dated writing;
   b. Physical destruction of the original;
   c. Oral expression of intent to revoke in the presence of two adults; or
   d. Executing a subsequent directive.
   (See Utah Code Ann. § 75-2a-117.)

2. Revocation is effective upon communication to the attending Health-Care Provider or Agent.

B. Provider or Agent Non-Compliance

1. If a Provider or Agent fails to comply with this Directive, any interested person may seek:
   a. Temporary, preliminary, or permanent injunctive relief ordering compliance; and/or
   b. Declaratory judgment recognizing the Directive’s validity.

2. Prevailing party may recover reasonable attorney fees and costs.

VII. RISK ALLOCATION

1. Indemnification of Provider
   Declarant’s estate shall indemnify any Health-Care Provider who, in Good Faith, complies with this Directive against claims, damages, and expenses, except for gross negligence or willful misconduct.

2. Limitation of Liability
   No Health-Care Provider, Agent, or facility acting in Good Faith and in accordance with this Directive shall incur civil or criminal liability or be subject to professional discipline for such actions (Utah Code Ann. § 75-2a-119).

3. Insurance
   [OPTIONAL PLACEHOLDER for facility malpractice insurance confirmation.]

VIII. DISPUTE RESOLUTION

1. Governing Law
   This Directive shall be governed by and construed in accordance with the laws of the State of Utah, without regard to conflict-of-laws principles.

2. Forum Selection
   Any action arising under or relating to this Directive shall be brought in a court of competent jurisdiction in the State of Utah.

3. Arbitration & Jury Waiver
   Not applicable.

4. Injunctive Relief
   Nothing herein limits the right of any party to seek injunctive or other equitable relief to enforce this Directive.

IX. GENERAL PROVISIONS

1. Amendment
   Declarant may amend this Directive by a signed, dated writing that complies with the Act.

2. Waiver
   Failure to enforce any provision does not constitute waiver of future enforcement.

3. Assignment
   Rights and duties hereunder are personal to the Agent and may not be assigned.

4. Severability
   If any provision is invalid or unenforceable, the remaining provisions shall remain in full force and effect.

5. Integration
   This Directive constitutes the entire understanding of the parties with respect to its subject matter and supersedes all prior directives.

6. Counterparts & Electronic Signatures
   This Directive may be executed in counterparts, including by electronic signature, each of which shall be deemed an original.

X. EXECUTION BLOCK

A. Declarant Signature

I, the undersigned Declarant, sign my name to this Directive on the date below and declare that I am of sound mind and under no constraint or undue influence.

Signature: _________
Name: [PRINT NAME]
Date: [MM/DD/YYYY]

B. Agent & Alternate Agent Acceptance

By signing below, each Agent acknowledges and accepts the appointment and the duties set forth herein.

Primary Agent Signature: ___ Date: _//__
Alternate Agent #1 Signature: __ Date: _//__
Alternate Agent #2 Signature: __ Date: _/_/______

C. Witness Attestation (Choose EITHER witnesses OR notarization)

We declare that the Declarant is personally known to us, appears to be of sound mind, and signed or acknowledged this Directive in our presence. We are at least 18 years of age and are not: (i) related to the Declarant by blood or marriage, (ii) entitled to any portion of the Declarant’s estate, (iii) directly financially responsible for the Declarant’s health care, nor (iv) the attending Health-Care Provider or an employee thereof.

1. Witness #1
   Signature: ____
   Printed Name: _____
   Address: ____
   Date: _/_/______

2. Witness #2
   Signature: ____
   Printed Name: _____
   Address: ____
   Date: _/_/______

[// GUIDANCE: Utah requires TWO qualified witnesses OR a notary. At least ONE witness must be disinterested as defined above.]

D. Notary Public (Optional Alternative to Witnesses)

State of Utah )
County of ______ ) ss.

On this ___ day of _, 20_, before me, the undersigned Notary Public, personally appeared ________, known or satisfactorily proven to me to be the Declarant whose name is subscribed to the above instrument, and acknowledged that he/she executed the same for the purposes therein contained.

Notary Public Signature: _____
Printed Name: _____
My Commission Expires: _/_/______

(Seal)

[// GUIDANCE: Retain the original executed Directive in a readily accessible location and provide copies to the appointed Agent(s), primary care physician, and preferred hospital. Encourage clients to upload an electronic copy to Utah’s online registry if available.]