VERMONT ADVANCE DIRECTIVE FOR HEALTH CARE

(a/k/a “Living Will”)

[// GUIDANCE: This template complies with 18 V.S.A. §§ 9700–9720 and incorporates Vermont-specific execution, revocation, and provider-protection requirements. Replace bracketed text with client-specific information. Review carefully before use.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
   3.1 Appointment of Health Care Agent
   3.2 Treatment Instructions & Preferences
   3.3 Anatomical Gifts
   3.4 Nomination of Guardian (Optional)
   3.5 Effectiveness & Duration
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block
11. Witness Certificates / Notarial Acknowledgment
12. Optional Health Care Provider Acknowledgment

1. DOCUMENT HEADER

This Vermont Advance Directive for Health Care (“Directive”) is made this ___ day of _, 20 (“Effective Date”) by [PRINCIPAL FULL LEGAL NAME] (“Principal”), a resident of the State of Vermont, pursuant to 18 V.S.A. §§ 9700 et seq.

Recitals:
A. Principal is at least eighteen (18) years of age or an emancipated minor, is of sound mind, and desires to direct future health care and end-of-life decisions.
B. Principal desires to appoint a trusted individual to make health-care decisions if Principal lacks Decision-Making Capacity.
C. Principal executes this Directive to ensure that Principal’s wishes are honored, to relieve ambiguity, and to protect Health Care Providers acting in good faith reliance hereon.

2. DEFINITIONS

For purposes of this Directive, the following terms have the meanings set forth below. Undefined capitalized terms have the meanings assigned in 18 V.S.A. § 9701.

“Advance Directive Registry” means the secure statewide database established under 18 V.S.A. § 9708.

“Agent” means the person designated in Section 3.1, and any Successor Agent, authorized to make Health Care Decisions for Principal.

“Decision-Making Capacity” has the meaning given in 18 V.S.A. § 9701(7).

“End-of-Life Condition” means a terminal or irreversible condition reasonably expected to result in death within six (6) months.

“Good Faith” means honesty in fact in the conduct or transaction concerned.

“Health Care Provider” or “Provider” has the meaning provided in 18 V.S.A. § 9701(12).

“Life-Sustaining Treatment” includes, without limitation, artificial nutrition or hydration, mechanical ventilation, dialysis, and cardiopulmonary resuscitation (“CPR”).

“Principal” means the individual executing this Directive.

“Successor Agent” means the alternate agent(s) designated in Section 3.1(c).

“Witness” means an individual qualified under 18 V.S.A. § 9703(d) to witness execution of this Directive.

3. OPERATIVE PROVISIONS

3.1 Appointment of Health Care Agent

a. Primary Agent. Principal appoints [PRIMARY AGENT NAME], whose address is [ADDRESS], and phone [PHONE], as Principal’s Agent for all lawful purposes permitted under 18 V.S.A. § 9702.
b. Scope of Authority. Agent is authorized to make any and all Health Care Decisions, including consenting to, refusing, or withdrawing Life-Sustaining Treatment, subject to the limitations in Section 3.2.
c. Successor Agents. If the Primary Agent is unavailable, unwilling, or unable to act, authority shall pass in the following order:
1. [SUCCESSOR AGENT #1 NAME & CONTACT]
2. [SUCCESSOR AGENT #2 NAME & CONTACT]
d. Independent Authority. Each Successor Agent shall act independently unless Principal initials here ____ to require joint decision-making.

3.2 Treatment Instructions & Preferences

[// GUIDANCE: Substitute or supplement the options below to fit client preferences.]

a. End-of-Life Care. If I am in an End-of-Life Condition and lack Decision-Making Capacity, I direct:
☐ Maintain Life-Sustaining Treatment as long as medically feasible.
☐ WITHHOLD or WITHDRAW Life-Sustaining Treatment if it only prolongs dying. (Initial choice) _____

b. Cardiopulmonary Resuscitation (CPR):
☐ Attempt CPR.
☐ Do NOT Attempt Resuscitation (DNR). (Initial choice) _____

c. Artificial Nutrition/Hydration:
☐ Provide.
☐ Withhold unless needed for comfort. (Initial choice) _____

d. Pain Relief & Comfort Care. I direct maximum pain relief, even if it may hasten death, unless I initial here ____ to limit narcotics.

e. Mental Health Treatment Instructions (Optional): ______

3.3 Anatomical Gifts

Upon death, I:
☐ DO NOT wish to make anatomical gifts.
☐ DO wish to donate the following organs/tissues: ____
☐ Authorize Agent to decide. (Initial choice) _____

3.4 Nomination of Guardian (Optional)

If a court finds a guardian necessary, I nominate my Agent (or Successor Agent) to serve, with full authority over my person and estate, unless I initial here ____ to limit to personal decisions only.

3.5 Effectiveness & Duration

a. This Directive is effective immediately upon execution but Agent’s authority commences only upon a determination, pursuant to 18 V.S.A. § 9706, that Principal lacks Decision-Making Capacity, unless Principal initials here ____ to grant immediate authority.
b. This Directive remains in effect until revoked pursuant to Section 9.2.

4. REPRESENTATIONS & WARRANTIES

4.1 Capacity. Principal represents that Principal fully understands the nature and consequences of executing this Directive.

4.2 No Undue Influence. Execution is voluntary and free from duress or undue influence.

4.3 Conflicts Disclosed. Principal has disclosed to Agent any known conflicts of interest that could impair decision-making.

4.4 Reliance. Providers and other third parties may rely on copies or electronic images of this Directive to the same extent as an original.

5. COVENANTS & RESTRICTIONS

5.1 Agent’s Fiduciary Duties. Agent shall (i) act in Good Faith, (ii) base decisions on Principal’s expressed wishes or, if unknown, Principal’s best interests, and (iii) avoid self-dealing.

5.2 Record Access. Agent shall have HIPAA-compliant access to Principal’s medical records.

5.3 Nomination Acceptance. By signing in Section 10, each Agent accepts the appointment and fiduciary obligations herein.

5.4 Religious or Ethical Objections. If a Provider has a conscientious objection, the Provider shall promptly transfer care per 18 V.S.A. § 9708(b).

6. DEFAULT & REMEDIES

6.1 Agent Unavailability. If all Agents are unavailable, Providers shall follow the best evidence of Principal’s wishes expressed herein or otherwise.

6.2 Dispute Resolution Among Agents. Conflicting instructions create an Event of Default; the earliest-designated available Agent’s decision prevails.

6.3 Injunctive Relief. Because monetary damages are inadequate, any party in interest may seek injunctive or declaratory relief in a court of competent jurisdiction to enforce this Directive.

6.4 Attorneys’ Fees. A prevailing party enforcing this Directive shall be entitled to reasonable attorneys’ fees and costs.

7. RISK ALLOCATION

7.1 Provider Protection & Indemnification. A Provider who, in Good Faith, relies on this Directive or Agent’s instructions shall be indemnified and held harmless by Principal’s estate against liability arising therefrom, except for gross negligence or willful misconduct.

7.2 Limitation of Liability. No Provider or Agent shall be liable for actions taken in Good Faith compliance with this Directive beyond the limits set forth under 18 V.S.A. § 9713.

7.3 Insurance. Principal encourages Providers to maintain professional liability insurance but imposes no independent obligation herein.

7.4 Force Majeure. No party shall be liable for non-performance caused by events beyond reasonable control, including but not limited to natural disasters, war, or systemic failure of medical facilities.

8. DISPUTE RESOLUTION

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

8.2 Forum Selection. Any judicial proceeding relating to this Directive shall be brought exclusively in the Superior Court of the State of Vermont having jurisdiction over the Principal’s residence at the time of filing.

8.3 Arbitration & Jury Trial. Arbitration provisions and jury-trial waivers are expressly inapplicable.

8.4 Injunctive Relief. See Section 6.3.

9. GENERAL PROVISIONS

9.1 Amendment. Principal may amend this Directive by executing a subsequent writing that satisfies the execution requirements of 18 V.S.A. § 9703.

9.2 Revocation. Principal may revoke this Directive, or any portion thereof, at any time and in any manner that clearly indicates an intent to revoke, including oral statement, physical destruction, or execution of a new directive. Revocation is effective upon communication to the Agent or a Provider.

9.3 Assignment. Agent’s authority is personal and non-assignable.

9.4 Severability. If any provision is held invalid, the remaining provisions shall remain in full force to the maximum extent permitted.

9.5 Integration. This Directive supersedes all prior advance directives or durable powers of attorney for health care executed by Principal.

9.6 Copies & Electronic Signatures. Photocopies, facsimiles, and electronic signatures shall be deemed originals.

9.7 Counterparts. This Directive may be executed in counterparts, each of which is deemed an original, and all of which constitute one instrument.

10. EXECUTION BLOCK

I, [PRINCIPAL NAME], sign my name to this Directive on the date first written above and, being duly sworn (if notarized) or affirmed, declare that I am of sound mind and free from duress.

Signature of Principal

Printed Name: ___
Date of Birth: ___
Address: _________

AGENT & SUCCESSOR AGENT ACCEPTANCE

By signing below, the undersigned acknowledge acceptance of the appointment and fiduciary duties set forth herein.

1. ______ Date: __
   [PRIMARY AGENT NAME]

2. ______ Date: __
   [SUCCESSOR AGENT #1 NAME]

3. ______ Date: __
   [SUCCESSOR AGENT #2 NAME]

11. WITNESS CERTIFICATES / NOTARIAL ACKNOWLEDGMENT

[// GUIDANCE: Vermont requires EITHER (A) two qualified Witnesses OR (B) a Notary Public. Choose ONE method and strike the other.]

A. Two-Witness Method

We declare that the Principal, to the best of our knowledge, is at least 18 years of age (or an emancipated minor), appears to understand the nature of this Directive, and signed or acknowledged it in our presence. We further declare that we:
• are at least 18 years of age;
• are not anyone appointed as Agent or Successor Agent;
• are not Principal’s spouse, partner, parent, adult sibling, child, or grandchild;
• are not Principal’s health-care provider, nor employed at the facility where Principal is receiving care; and
• are not financially responsible for Principal’s health care.

Witness #1: _____ Date: _
Printed Name & Address: ____

Witness #2: _____ Date: _
Printed Name & Address: ____

- OR -

B. Notary Method

State of Vermont )
County of _ ) ss.

On this ___ day of _, 20, before me, the undersigned notary public, personally appeared [PRINCIPAL NAME], known to me (or satisfactorily proven) to be the person whose name is subscribed to this Directive, and acknowledged that he/she/they executed the same for the purposes herein contained.

Notary Public
My commission expires: _______

12. OPTIONAL HEALTH CARE PROVIDER ACKNOWLEDGMENT

[// GUIDANCE: Not required by statute but may increase provider reliance.]

The undersigned Provider has reviewed this Directive, finds it consistent with professional standards, and has entered it into the medical record.

_____ Date: ____
[PRINTED NAME & CREDENTIALS]

Facility: ____

[// GUIDANCE: Filing with the Vermont Advance Directive Registry is optional but recommended. Attach the required registration form if desired.]