COMMONWEALTH OF VIRGINIA
ADVANCE MEDICAL DIRECTIVE
(Living Will & Health-Care Power of Attorney)
[// GUIDANCE: This template is drafted to comply with the Virginia Health Care Decisions Act, VA. CODE ANN. § 54.1-2981 et seq. Customize bracketed items, add or delete provisions to meet the Principal’s specific wishes, and have the document reviewed by Virginia-licensed counsel before execution.]
TABLE OF CONTENTS
- Document Header
- Recitals
- Definitions
- Operative Provisions
4.1 Appointment of Health-Care Agent
4.2 Treatment Instructions (Living Will)
4.3 Anatomical Gifts (Optional)
4.4 Nomination of Guardian/Conservator (Optional) - Representations & Warranties
- Covenants & Restrictions
- Default, Immunities & Remedies
- Risk Allocation
- Revocation & Amendment
- Dispute Resolution
- General Provisions
- Execution Block & Witness Attestation
1. DOCUMENT HEADER
Advance Medical Directive (“Directive”)
Principal: [PRINCIPAL FULL LEGAL NAME], a resident of the Commonwealth of Virginia, currently residing at [ADDRESS] (“Principal”).
Effective Date: [DATE] (“Effective Date”).
Governing Law: Commonwealth of Virginia; VA. CODE ANN. § 54.1-2981 et seq.
Document Type: Integrated Living Will and Durable Power of Attorney for Health-Care Decisions.
2. RECITALS
A. Principal is an adult of sound mind and desires to ensure that health-care decisions made in the event of Principal’s incapacity reflect Principal’s wishes and best interests.
B. This Directive is executed pursuant to and in conformity with the Virginia Health Care Decisions Act.
C. Consideration is acknowledged by the mutual promises herein and the reliance of health-care providers and agents on this Directive.
3. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings set forth below.
“Advance Directive” or “Directive” means this instrument as originally executed and as amended, restated, or revoked from time to time.
“Agent” means the individual(s) designated in Section 4.1 to make health-care decisions on behalf of the Principal when the Principal is incapable of making an informed decision.
“Alternate Agent” means the backup individual(s) designated to act if the primary Agent is unable, unwilling, or reasonably unavailable to act.
“Attending Physician” means the physician who has primary responsibility for the Principal’s health care, or another physician acting at the request of the Attending Physician.
“Durable” means that the authority of the Agent remains effective notwithstanding the Principal’s subsequent incapacity.
“Good Faith” means honesty in fact and the observance of reasonable standards of health-care practice consistent with VA. CODE ANN. § 54.1-2988.
“Incapacity” or “Incapable of Making an Informed Decision” has the meaning assigned by VA. CODE ANN. § 54.1-2982.
“Life-Prolonging Procedure” means any medical procedure, treatment, or intervention that, in the judgment of the Attending Physician, would serve only to prolong the dying process.
“Principal” has the meaning given in Section 1.
“Qualified Organization” means a nonprofit eye bank, tissue bank, or organ procurement organization authorized under federal or state law.
4. OPERATIVE PROVISIONS
4.1 Appointment of Health-Care Agent
(a) Designation. Principal hereby appoints [PRIMARY AGENT FULL LEGAL NAME], currently residing at [ADDRESS], as Agent.
(b) Alternate Agents (in order of priority):
1. [ALTERNATE AGENT #1];
2. [ALTERNATE AGENT #2].
(c) Scope of Authority. The Agent shall have full authority, to the maximum extent permitted by Virginia law, to make any and all health-care decisions the Principal could make if able, including but not limited to:
(i) consenting to, refusing, or withdrawing any health-care or life-prolonging procedure;
(ii) accessing HIPAA-protected health information;
(iii) employing and discharging health-care providers;
(iv) authorizing admission to or discharge from any medical facility or hospice;
(v) signing any releases or waivers of liability required by providers acting in Good Faith;
(vi) making anatomical gift determinations under Section 4.3.
(d) Durability. This power of attorney is durable and shall remain in effect during the Principal’s incapacity unless revoked pursuant to Section 9.
[// GUIDANCE: Insert any limitations on Agent authority here, e.g., “Agent may not authorize electroconvulsive therapy.”]
4.2 Treatment Instructions (Living Will)
(a) General Intent. If at any time the Principal is incapable of making an informed decision and (i) is terminally ill, (ii) is in a persistent vegetative state, or (iii) has an irreversible condition causing death within a relatively short period without the continued application of life-prolonging procedures, then the following instructions shall apply:
1. Life-Prolonging Procedures: [SELECT ONE]
⎕ Decline all life-prolonging procedures.
⎕ Permit life-prolonging procedures if they offer a reasonable possibility of recovery to a quality of life acceptable to the Principal.
2. Artificial Nutrition & Hydration: [SELECT ONE]
⎕ Withhold or withdraw.
⎕ Provide if, in the physician’s judgment, benefits outweigh burdens.
3. Palliative Care / Comfort Measures: Provide medication or other measures necessary for relief of pain or discomfort, even if such measures may hasten death.
(b) Pregnancy Provision (if applicable). If I am pregnant, I direct that my health-care be carried out in accordance with [INSERT INSTRUCTIONS consistent with VA. CODE ANN. § 54.1-2983.3].
4.3 Anatomical Gifts (Optional)
(a) Election. [SELECT ONE]
⎕ I do not wish to make an anatomical gift.
⎕ I hereby donate the following organs/tissues: [SPECIFY] to any Qualified Organization for transplantation, therapy, research, or education.
(b) Execution. My Agent is authorized to execute all necessary documents to effectuate this gift.
4.4 Nomination of Guardian/Conservator (Optional)
If a court deems it necessary to appoint a guardian and/or conservator, I nominate my Agent (or Alternate Agent, in the order named) to serve, with priority over all others.
5. REPRESENTATIONS & WARRANTIES
The Principal represents and warrants that:
(a) Principal is at least eighteen (18) years of age and of sound mind.
(b) No undue influence or duress has been exerted in the creation of this Directive.
(c) All information supplied herein is true, correct, and complete as of the Effective Date.
6. COVENANTS & RESTRICTIONS
6.1 Principal covenants to notify health-care providers of the existence of this Directive.
6.2 Agent covenants to act in Good Faith, consistent with Principal’s expressed wishes, religious or moral beliefs, and best interests.
6.3 Neither Agent nor any Alternate Agent may delegate authority granted under this Directive except as expressly provided by law.
7. DEFAULT, IMMUNITIES & REMEDIES
7.1 Good-Faith Immunity. Any health-care provider or Agent acting in reliance on this Directive in Good Faith shall be immune from civil and criminal liability to the fullest extent permitted by VA. CODE ANN. § 54.1-2988.
7.2 Event of Default. Failure of any Agent to act in Good Faith or within the scope of authority shall constitute an Event of Default, upon which authority shall automatically pass to the next-named Alternate Agent.
7.3 Remedies. In addition to statutory remedies, any interested person may petition a court of competent jurisdiction for injunctive relief to enforce or enjoin acts inconsistent with this Directive.
8. RISK ALLOCATION
8.1 Indemnification of Providers. The Principal agrees to indemnify and hold harmless any health-care provider who follows this Directive in Good Faith from liability, save and except for gross negligence or willful misconduct.
8.2 Limitation of Liability. No Agent shall incur liability for decisions made in Good Faith and in accordance with the terms of this Directive or applicable law.
9. REVOCATION & AMENDMENT
9.1 Revocation by Principal. This Directive may be revoked in whole or in part at any time by:
(a) signed, dated writing;
(b) physical cancellation or destruction of the original Directive by the Principal or at Principal’s direction; or
(c) oral expression of intent to revoke, effective upon communication to the Attending Physician pursuant to VA. CODE ANN. § 54.1-2985.
9.2 Automatic Revocation of Agent’s Authority. Divorce or legal separation from a spouse appointed as Agent shall automatically revoke said spouse’s authority unless expressly reaffirmed thereafter in writing.
9.3 Amendment. The Principal may amend this Directive only by a signed, dated instrument executed in the same manner as this Directive.
10. DISPUTE RESOLUTION
Any dispute arising under or relating to this Directive shall be governed by the laws of the Commonwealth of Virginia. Venue shall lie in the circuit court of the city or county where the Principal receives health care. Nothing herein waives the right to seek emergency injunctive relief to protect the Principal’s health interests.
11. GENERAL PROVISIONS
11.1 Integration. This Directive constitutes the entire and final expression of the Principal’s advance medical instructions and supersedes all prior directives.
11.2 Severability. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.
11.3 Waiver. No waiver of any provision shall be deemed a waiver of any other provision or of the same provision on a future occasion.
11.4 Electronic & Counterpart Signatures. This Directive may be executed in counterparts and by electronic signature in compliance with the Uniform Electronic Transactions Act as adopted in Virginia.
12. EXECUTION BLOCK & WITNESS ATTESTATION
IN WITNESS WHEREOF, the Principal has executed this Advance Medical Directive as of the Effective Date.
Principal
[PRINCIPAL FULL LEGAL NAME]
Date: _______
Statement of Witnesses
We declare that the Principal, who is personally known to us, signed or acknowledged this Directive in our presence; that the Principal appears to be of sound mind and free from duress or undue influence; and that we are not (i) the Agent, (ii) related to the Principal by blood or marriage, or (iii) entitled to any portion of the Principal’s estate.
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______ Date: __
Print Name: ___ Address: ________ -
______ Date: __
Print Name: ___ Address: ________
[// GUIDANCE: Virginia requires two adult witnesses; notarization is optional but may facilitate out-of-state recognition.]
[// GUIDANCE: Retain original, provide copies to Agent(s), alternate Agent(s), primary care physician, and hospital records department. Periodically review and update to reflect changes in health status, personal preferences, or law.]