WYOMING ADVANCE HEALTH CARE DIRECTIVE
(Living Will & Durable Power of Attorney for Health Care)
TABLE OF CONTENTS
I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block (Signature, Witness & Notary)
I. DOCUMENT HEADER
THIS ADVANCE HEALTH CARE DIRECTIVE (this “Directive”) is made and entered into as of [EFFECTIVE DATE], by [PRINCIPAL FULL LEGAL NAME], date of birth [MM/DD/YYYY], residing at [ADDRESS] (“Principal”).
RECITALS
A. Principal is of sound mind and desires to ensure that Principal’s health-care wishes are followed should Principal lose decisional capacity.
B. This Directive is executed pursuant to, and intended to comply in all respects with, the Wyoming Health Care Decisions Act, Wyo. Stat. Ann. §§ 35-22-401 et seq. (the “Act”).
C. Consideration is the mutual promises herein.
II. DEFINITIONS
For purposes of this Directive, the following terms have the meanings set forth below (alphabetical order):
- “Act” – The Wyoming Health Care Decisions Act, Wyo. Stat. Ann. §§ 35-22-401 et seq.
- “Agent” – The person designated in Section III to make Health-Care Decisions for Principal.
- “Health-Care Decision” – Any decision regarding health-care services, treatment, procedures, or placement.
- “Incapacity” – A determination, made in accordance with the Act, that Principal lacks the ability to understand or communicate an informed health-care decision.
- “Life-Sustaining Treatment” – Medical interventions that serve only to prolong the process of dying when death is imminent or when Principal is in a Persistent Vegetative State.
- “Persistent Vegetative State” – A permanent and irreversible condition of unconsciousness with no reasonable expectation of recovery, as determined by two licensed physicians, one of whom is Principal’s Primary Physician.
- “Primary Physician” – The physician who has primary responsibility for Principal’s health care.
[// GUIDANCE: Add, delete, or modify definitions to match client terminology.]
III. OPERATIVE PROVISIONS
3.01 Appointment of Agent
Principal hereby appoints [PRIMARY AGENT FULL NAME], whose current address is [ADDRESS] and phone [PHONE], as Principal’s true and lawful Agent for purposes of making any and all Health-Care Decisions when Principal is determined to have Incapacity.
3.02 Alternate Agent(s)
If the Primary Agent is unavailable, unwilling, or unable to act, Principal appoints in the order named:
a. [FIRST ALTERNATE AGENT NAME]
b. [SECOND ALTERNATE AGENT NAME]
3.03 Grant of Authority
Subject to Section 3.04, Agent is authorized to:
1. Give or withhold consent to medical, surgical, psychiatric, nursing, hospice, or other health-care treatments or procedures, including Life-Sustaining Treatment;
2. Make anatomical gift determinations under Section 3.06;
3. Access confidential medical information pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”); and
4. Take all other actions permitted under the Act that Principal could take if capable.
3.04 Special Instructions and Limitations
- End-of-Life Care:
a. If I am in a terminal condition or Persistent Vegetative State, [choose one: “I DO NOT want” / “I DO want”] Life-Sustaining Treatment.
b. Artificial Nutrition/Hydration: [choose one: “Withhold” / “Provide” / “No limitation”]. - Pain Management: I direct that adequate medication be provided to relieve pain, even if such medication may hasten death.
- Pregnancy Exception (if applicable): [insert limitation or “none”].
- Additional Instructions: [CUSTOM TEXT OR “None”].
[// GUIDANCE: Wyoming permits any written limitations. Tailor carefully.]
3.05 HIPAA Authorization
Pursuant to 45 C.F.R. § 164.508, Principal authorizes each Covered Entity to disclose to Agent any and all Protected Health Information necessary for Agent to carry out duties.
3.06 Anatomical Gifts (Optional)
Principal [choose one: “does” / “does not”] wish to make an anatomical gift under the Wyoming Uniform Anatomical Gift Act. If “does,” specify organs/tissues and purposes: [DETAILS].
3.07 Nomination of Guardian
If a court decides that a guardian should be appointed, Principal nominates Agent, in the order set forth above, to serve as guardian of Principal’s person.
IV. REPRESENTATIONS & WARRANTIES
4.01 Principal represents that:
a. Principal is at least eighteen (18) years of age and of sound mind;
b. This Directive is executed voluntarily, without coercion or undue influence.
4.02 Each Agent by signing in Section X represents:
a. Agent is willing and qualified to act;
b. Agent will act in good faith and in accordance with Principal’s known wishes, the Act, and this Directive.
4.03 Survival. The representations and warranties herein survive Principal’s Incapacity.
V. COVENANTS & RESTRICTIONS
5.01 Agent shall:
a. Act in Principal’s best interest and, when known, in accordance with Principal’s prior expressed wishes;
b. Consult, to the extent practicable, with Principal’s Primary Physician and family;
c. Keep reasonably detailed records of significant decisions.
5.02 Agent shall not delegate authority except as specifically authorized by the Act.
VI. DEFAULT & REMEDIES
6.01 Removal of Agent. Any interested person may petition the district court of competent jurisdiction to remove an Agent who materially breaches duties or acts contrary to the Principal’s best interest.
6.02 Injunctive Relief. In the event a health-care provider fails to honor this Directive, Agent or any person designated by the Act may seek injunctive relief to compel compliance.
6.03 Attorneys’ Fees. The prevailing party in any such action shall be entitled to reasonable attorneys’ fees and costs.
[// GUIDANCE: Although litigation is rare, these clauses reinforce enforceability.]
VII. RISK ALLOCATION
7.01 Indemnification of Provider. To the fullest extent permitted by law, Principal agrees that any health-care provider, acting in good faith reliance on this Directive, shall be indemnified and held harmless from civil or criminal liability arising from such reliance.
7.02 Limitation of Liability – Good Faith Standard. No Agent or provider acting in good-faith compliance with this Directive shall incur liability, consistent with Wyo. Stat. Ann. § 35-22-407.
VIII. DISPUTE RESOLUTION
8.01 Governing Law. This Directive shall be governed by and construed in accordance with the laws of the State of Wyoming.
8.02 Forum Selection, Arbitration & Jury Waiver. [Not applicable per Metadata.]
IX. GENERAL PROVISIONS
9.01 Amendment & Revocation. Principal may revoke or amend this Directive at any time and in any manner allowed under Wyo. Stat. Ann. § 35-22-406, including by:
a. A signed and dated writing;
b. Physical cancellation or destruction of this Directive;
c. An oral or other expression of intent to revoke, witnessed by a person over eighteen (18).
9.02 Severability. If any provision is held invalid, the remaining provisions shall continue in full force and effect.
9.03 Reliance. Third parties may rely upon photocopies or electronically transmitted copies of this Directive.
9.04 Integration. This Directive contains the entire statement of Principal’s instructions and supersedes all prior inconsistent writings.
9.05 Electronic Signatures & Counterparts. This Directive may be executed in multiple counterparts and by electronic signature, each of which shall be deemed an original.
X. EXECUTION BLOCK
A. Principal Signature
I, [PRINCIPAL FULL LEGAL NAME], sign my name to this Directive at [CITY, WY] on [DATE].
Principal Signature
B. Agent Acceptance
I accept my appointment and agree to serve according to this Directive and Wyoming law.
Primary Agent: _____ Date: _
First Alternate: _____ Date: _
Second Alternate: _______ Date: ____
C. Witness Attestation (Wyo. Stat. Ann. § 35-22-403(b)(ii))
We declare that (1) the Principal is personally known to us, appeared to be of sound mind, and signed this Directive voluntarily; (2) we are at least eighteen (18) years old; (3) we are not the Agent, health-care provider, or an employee of a health-care facility in which the Principal is a patient; and (4) at least one of us is not related to the Principal by blood, marriage, or adoption and not entitled to any portion of the Principal’s estate.
Witness #1: ______ Date: _
Printed Name & Address: _________
Witness #2: ______ Date: _
Printed Name & Address: _________
D. Notary Acknowledgment (Optional – satisfies witnessing requirement)
State of Wyoming )
County of ___ ) ss.
On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument, and acknowledged that (s)he executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Notary Public
My Commission Expires: _______
[// GUIDANCE:
1. Provide clients with explanatory memo summarizing Wyoming statutory framework and best practices for storage and periodic review.
2. Encourage clients to distribute executed copies to primary physician, hospital, and all Agents.
3. Advise annual review to ensure continued accuracy of contact information and wishes.]