WEST VIRGINIA ADVANCE DIRECTIVE
(Combined Living Will & Medical Power of Attorney)
[// GUIDANCE: This template integrates West Virginia’s statutory Living Will and Medical Power of Attorney forms (W. Va. Code § 16-30-1 et seq.) into a single, comprehensive Advance Directive. Bracketed language must be customized before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Appointment of Health Care Agent
3.2 Treatment Instructions (Living Will)
3.3 Anatomical Gifts
3.4 Pregnancy Directive
3.5 Revocation & Amendment - Representations & Warranties
- Covenants & Restrictions of Health Care Agent
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
Advance Directive of: [FULL LEGAL NAME OF DECLARANT] (“Declarant”)
Date of Birth: [MM/DD/YYYY]
Address: [STREET, CITY, WV ZIP]
Effective Date: The later of (a) the date signed below, or (b) the date accepted by the Agent in Section 3.1.
Governing Law: This Advance Directive (“Directive”) is made pursuant to, and shall be construed in accordance with, the West Virginia Health Care Decisions Act, W. Va. Code § 16-30-1 et seq.
Recitals: Declarant, being of sound mind and at least eighteen (18) years of age, desires to ensure that health-care decisions made on Declarant’s behalf conform to Declarant’s wishes and West Virginia law.
2. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings set forth below.
“Advance Directive” or “Directive” means this written instrument expressing Declarant’s instructions and preferences, and appointing an Agent, regarding health-care decisions.
“Agent” or “Health Care Agent” means the individual appointed in Section 3.1 to make health-care decisions for Declarant when Declarant lacks decision-making capacity.
“Good Faith” means honesty in fact in the conduct of the transaction concerned.
“Life-Prolonging Treatment” means any medical intervention that would serve only to artificially delay death in a terminal condition or permanent vegetative state.
“Permanent Vegetative State” has the meaning assigned in W. Va. Code § 16-30-3.
“Qualified Adult Witness” means a competent adult who is not (a) related to Declarant by blood or marriage, (b) entitled to any portion of Declarant’s estate, (c) financially responsible for Declarant’s medical care, or (d) currently serving as Declarant’s attending physician or employer thereof.
“Terminal Condition” means an incurable or irreversible condition that, without the administration of Life-Prolonging Treatment, will, in the opinion of the attending physician, result in death within a relatively short time.
3. OPERATIVE PROVISIONS
3.1 Appointment of Health Care Agent
a. Primary Agent: [FULL NAME], residing at [ADDRESS], telephone [PHONE].
b. Alternate Agent(s):
1. [FULL NAME], [ADDRESS], [PHONE].
2. [FULL NAME], [ADDRESS], [PHONE].
c. Authority Granted: Subject to Section 3.2, the Agent may make any health-care decision Declarant could make if able, including but not limited to consent, refusal, or withdrawal of treatment, hiring and discharge of health-care providers, and admission to or discharge from health-care facilities.
d. Activation: Agent’s authority becomes effective upon certification in writing by the attending physician that Declarant lacks decision-making capacity.
[// GUIDANCE: The statute does not require acceptance by Agent, but a signed acceptance strengthens enforceability.]
3.2 Treatment Instructions (Living Will)
If I (Declarant) am determined to be in a Terminal Condition or Permanent Vegetative State and am unable to participate in decisions regarding my medical care, my directions are as follows (check one):
☐ Option A – WITHHOLD/WITHDRAW Life-Prolonging Treatment.
I direct that Life-Prolonging Treatment not be initiated or, if already initiated, be withdrawn, except for comfort care and pain relief.
☐ Option B – CONTINUE Life-Prolonging Treatment.
I direct that Life-Prolonging Treatment be provided in order to sustain my life as long as medically feasible.
Pain Relief: Regardless of the option selected above, I direct that adequate medication be administered to relieve pain or distress, even if such medication may hasten death.
Artificial Nutrition & Hydration (check one):
☐ I DO NOT want artificial nutrition/hydration.
☐ I DO want artificial nutrition/hydration.
3.3 Anatomical Gifts
Upon my death (check one):
☐ I donate any needed organs/tissues for transplantation, therapy, research, or education.
☐ I donate only the following: [SPECIFY].
☐ I make NO anatomical gift.
[// GUIDANCE: West Virginia participates in the Uniform Anatomical Gift Act; include registry information if known.]
3.4 Pregnancy Directive
If I am pregnant at the time this Directive would otherwise take effect, I intend the following (check one):
☐ This Directive SHALL NOT be implemented while I am pregnant, and all life-sustaining measures shall be provided.
☐ This Directive SHALL be implemented even if I am pregnant, in accordance with my selections above, to the fullest extent permitted by law.
3.5 Revocation & Amendment
a. Revocation by Declarant: This Directive may be revoked at any time by:
1. A signed and dated written instrument;
2. Physical destruction or cancellation of this Directive by Declarant or at Declarant’s direction; or
3. An oral expression of intent to revoke, made by Declarant in the presence of a health-care provider or witness.
b. Automatic Revocation: Appointment of a spouse as Agent is automatically revoked upon divorce or legal separation, unless reaffirmed in writing thereafter.
c. Amendment: Declarant may amend this Directive by executing a new Directive or by written modification executed with the formalities of this instrument.
4. REPRESENTATIONS & WARRANTIES
4.1 Declarant represents that:
a. Declarant is of sound mind and not acting under duress, fraud, or undue influence;
b. Declarant has reviewed this Directive, understands its contents, and voluntarily executes it.
4.2 Each Agent, by signing the acceptance below, represents that:
a. Agent is at least eighteen (18) years old and not disqualified under W. Va. Code § 16-30-3;
b. Agent accepts the appointment and agrees to act in Good Faith and in accordance with Declarant’s known wishes and best interests.
4.3 Witnesses represent that they qualify as Qualified Adult Witnesses and witnessed Declarant’s signing of this Directive.
5. COVENANTS & RESTRICTIONS OF HEALTH CARE AGENT
a. Act consistently with Declarant’s expressed instructions and moral/ religious beliefs.
b. Consult available medical information and consider benefits, burdens, and alternatives.
c. Maintain records of significant health-care decisions made on Declarant’s behalf.
d. Refrain from authorizing non-therapeutic research or experimental treatment absent Declarant’s explicit consent.
6. DEFAULT & REMEDIES
a. If an Agent is unwilling or unable to act, authority passes to the next-named Alternate Agent.
b. Any health-care provider or interested person may petition the Circuit Court of the county in which Declarant is located for review of an Agent’s decision alleged to violate this Directive or the statutory standard of Good Faith.
7. RISK ALLOCATION
7.1 Provider Protection: A health-care provider acting in Good Faith reliance on this Directive or on the decision of an Agent shall be immune from civil and criminal liability to the fullest extent permitted by W. Va. Code § 16-30-11.
7.2 Limitation of Liability: No Agent shall incur civil or criminal liability for Good Faith health-care decisions made pursuant to this Directive.
8. DISPUTE RESOLUTION
Any dispute arising under or relating to this Directive shall be governed by the laws of the State of West Virginia. Jurisdiction and venue shall lie exclusively in the courts of the county where Declarant is receiving treatment at the time the dispute arises.
[// GUIDANCE: Arbitration and jury-trial waivers are intentionally omitted; health-care disputes of this nature are typically addressed in court.]
9. GENERAL PROVISIONS
9.1 Amendment & Waiver: Any amendment must comply with Section 3.5. No waiver of any provision shall be effective unless in writing.
9.2 Severability: If any provision is held invalid, the remaining provisions shall remain in full force and effect.
9.3 Integration: This Directive constitutes the entire statement of Declarant’s health-care instructions and supersedes all prior directives.
9.4 Copies: A photocopy or electronically transmitted copy of this Directive shall have the same effect as the original.
9.5 HIPAA Authorization: Declarant authorizes any Agent to obtain, disclose, and release all protected health information as necessary to carry out the purposes of this Directive.
10. EXECUTION BLOCK
10.1 SIGNATURE OF DECLARANT
I, [FULL LEGAL NAME], the Declarant, sign my name to this Advance Directive on the date below and declare that I am of sound mind and executing this Directive voluntarily.
(Signature of Declarant)
Date: _______
10.2 WITNESS ATTESTATION
We declare that the Declarant is personally known to us, appears to be of sound mind, signed or acknowledged this Advance Directive in our presence, and is not executing under duress, fraud, or undue influence. We further declare that we are Qualified Adult Witnesses as defined herein.
Witness #1:
Signature: ____
Printed Name: __
Address: ___
Date: ______
Witness #2:
Signature: ____
Printed Name: __
Address: ___
Date: ______
10.3 AGENT ACCEPTANCE
I accept the appointment as Health Care Agent and agree to act in Good Faith and consistent with Declarant’s wishes.
Primary Agent: _____ Date: _
Alternate Agent #1: ___ Date: __
Alternate Agent #2: ____ Date: _____
10.4 NOTARIZATION (Optional but Recommended)
State of West Virginia
County of ___, to-wit:
Subscribed, sworn to, and acknowledged before me by [DECLARANT NAME] this _ day of ___, 20____.
Notary Public
My commission expires: ______
[// GUIDANCE:
1. Provide copies to all Agents, attending physicians, and the hospital medical records department.
2. Upload to the West Virginia e-Directive Registry if desired.
3. Review and update at least every three (3) years or upon major life changes.]