Minnesota Catholic Health Care Directive

Minnesota

Catholic Health Care Directive

Revised edition approved by the Catholic Bishops of Minnesota

September 21, 2011

Resurrection of the body is a foundational belief in the Roman Catholic Church.

Catholics declare this belief publicly every Sunday as part of the Liturgy of the Word and the

Eucharist.

Death, the final experience of every living person on earth, is a reality. Questions and concerns about

death may be frightful, intimidating, and even avoided.

Who will speak for me when I cannot speak for myself? How can I make sure the decisions made

about my health care are morally right? These are questions being asked with increasing frequency.

People often avoid questions like these until faced with having to make a decision. Many of us believe

that only the sick or dying need to think about such matters. However, these are questions we all must

ask and be able to answer—whether we are young or old, sick or healthy. There could come a time in

any person’s life when he or she may not be able to communicate his or her wishes.

For the past several decades, the increase of life-prolonging technologies, pharmaceuticals, early

diagnoses of disease, detection of potential life-threatening conditions, and successful rehabilitation of

traumatic injuries have contributed to addressing the end of life issues.

Various social trends have added motivation toward advance planning in medical decisions as the end

of life approaches. These include the compassionate caring and supportive environment of hospice;

advances in palliative care; greater emphasis on self-determination and informed conscience in moral

decision-making; discussions about reform in our health care system; and media coverage of difficult

cases.

To assist Catholics of the state who wish to have an advance directive, the Minnesota Catholic Confer-

ence, comprised of the Minnesota Catholic Bishops, has prepared a Catholic Health Care Directive

that meets the state’s legal requirements and reflects the Church’s teaching and the recommendations

of Church, health care, and community leaders. The Conference has also prepared a Guide to answer

some basic questions about the law, Church teaching, and completing a health care directive.

MINNESOTA CATHOLIC HEALTH CARE DIRECTIVE

I, ______________________________, understand this document allows me to do ONE OR BOTH of the following:

PART I (RECOMMENDED): Name another person (called the health care agent) to make health care decisions for

me if I am unable to decide or speak for myself. My health care agent must make health care decisions for me

based on the instructions I provide in this document (Part II), if any, and the wishes I have made known to him or

her. He or she must act in my best interest consistent with the principles of Catholic teaching if I have not made my

health care wishes known.

AND/OR

PART II: Give health care instructions to guide others making health care decisions for me. If I have named a

health care agent, these instructions are to be used by the agent. These instructions may also be used by my health

care providers, others assisting with my health care, and my family, in the event I cannot make decisions for myself.

PART I: APPOINTMENT OF HEALTH CARE AGENT:

THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS FOR ME IF I AM UNABLE

TO DECIDE OR SPEAK FOR MYSELF

(I know I can change my agent or alternate agent at any time and I know I do not have to appoint an agent or an alternate agent.)

NOTE: If you appoint an agent, you should discuss this health care directive with your agent and give your agent a

copy. If you do not wish to appoint an agent, you may leave Part I blank and go to Part II.

When I am unable to decide or speak for myself, I trust and appoint _____________________________________

to make health care decisions for me. This person is called my health care agent.

Relationship of my health care agent to me: ________________________________________________________

Telephone number(s) of my health care agent: _____________________________________________________

Address and email of my health care agent: _______________________________________________________

___________________________________________________________________________________________

(OPTIONAL) APPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If my health care agent is not reasonably

available, I trust and appoint ________________________________________ to be my health care agent instead.

Relationship of my alternate health care agent to me: _________________________________________________

Telephone number(s) of my alternate health care agent: _______________________________________________

Address and email of my alternate health care agent: _________________________________________________

____________________________________________________________________________________________

PART II: HEALTH CARE INSTRUCTIONS

NOTE: Complete this Part II if you wish to give health care instructions. If you appointed an agent in Part I, com-

pleting this Part II is optional but would be very helpful to your agent. However, if you chose not to appoint an agent

in Part I, you MUST complete some or all of this Part II if you wish to make a valid health care directive.

These are instructions for my health care when I am unable to decide or speak for myself. These instructions must

be followed (so long as they address my needs).

THESE ARE MY BELIEFS AND VALUES ABOUT MY HEALTH CARE

My Wishes

This is what I want my health care agent—or if I have no health care agent, whoever will make decisions regarding my care—

to do if I am unable to make and communicate health care decisions for myself. Most of what I state here is general in nature

since I cannot anticipate all the possible circumstances of a future illness. If I have not given specific instructions, then my

agent must decide consistent with my wishes and beliefs.

As a Catholic, I believe that God created me for eternal life in union with Him. I understand that my life is a precious gift from

God and that this truth should inform all decisions with regards to my health care. I have a duty to preserve my life and to use it

for God’s glory. Suicide, euthanasia, and acts that intentionally and directly would cause my death by deed or omission, are

never morally acceptable. However, I also know that death, being conquered by Christ, need not be resisted by any and every

means and that I may refuse any medical treatment that is excessively burdensome or would only prolong my imminent death.

Those caring for me should avoid doing anything that is contrary to the moral teaching of the Catholic Church

. I ask that deci-

sions be thus made respectful of, and according to, the following principles:

 Medical treatments may be withdrawn or avoided if they do not offer a reasonable hope of benefit to me or are excessively

burdensome.

 There should be a presumption in favor of providing me with nutrition and hydration if they are of benefit to me. In princi-

ple, there is an obligation to provide food and water (employing medically assisted nutrition and hydration for those who

cannot take food orally) to all patients, including those in chronic and presumably irreversible conditions. Medically assist-

ed nutrition and hydration, however, become morally optional when they cannot reasonably be expected to prolong life,

when they would be excessively burdensome for the patient, or when they would cause significant physical discomfort.

 In accord with the teachings of the Church, I have no moral objection to the use of medication or procedures necessary for

my comfort, even if they may indirectly and unintentionally shorten my life.

 If my death is imminent, I direct that treatment that will maintain only a precarious and burdensome prolongation of my life

should be withdrawn or avoided, unless those responsible for my care judge at that time that there are special and signifi-

cant reasons why I should continue to receive such treatment.

 If I fall terminally ill, I ask that I be told of this so that I might prepare myself for death, and I ask that efforts be made that I

be attended by a Catholic priest and receive the Sacraments of Reconciliation, Anointing, and Eucharist as viaticum.

“My Wishes” in the section above completes my health care directive. □ Yes _________(initials)

□ No, in addition to the “My Wishes” section, above, I would like you to know these further things about me

to help you make decisions about my health care:

Believing none of the following directives conflicts with the teachings of my Catholic faith or the directives listed above, I add

the following directives:

(Please attach extra sheets if needed.)

My goals for my health care: ___________________________________________________________________

My fears about my health care: _________________________________________________________________

My beliefs about when medical interventions to prolong my life are no longer of benefit to me: _______________

__________________________________________________________________________________________

My thoughts about how my medical condition might affect my family: ___________________________________

____________________________________________________________________________________________________

Making an Anatomical Gift (Optional)

So long as it is consistent with Catholic moral teaching, I would like to be an organ donor at the

time of my death. I wish to donate the following (initial one statement):

[ ] Any needed organs and tissue.

[ ] Only the following organs and tissue: _____________________________________________

THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE

(I know I can change these choices or leave any of them blank.)

Many medical treatments may be used to try to improve my medical condition or to prolong my life. Examples in-

clude artificial breathing by a machine connected to a tube in the lungs, attempts to start a stopped heart, surgeries,

dialysis, antibiotics, and blood transfusions. Most medical treatments can be tried for a while and then stopped if

they do not help.

I have these views about my health care in these situations:

(Note: You can describe general feelings, specific treatments, or leave any of them blank, but each should be discussed thoroughly by patients

and health care agents.)

If I had a reasonable chance of recovery, and were temporarily unable to decide or speak for myself, I would want:

___________________________________________________________________________________________

If I were dying and unable to decide or speak for myself, I would want: ___________________________________

___________________________________________________________________________________________

If I were permanently unconscious and unable to decide or speak for myself, I would want: ___________________

___________________________________________________________________________________________

If I were completely dependent on others for my care and unable to decide or speak for myself, I would

want: ______________________________________________________________________________________

In all circumstances, my doctors will try to keep me comfortable and reduce my pain. This is how I feel about pain

relief if it would affect my alertness or if it could shorten my life: _________________________________________

___________________________________________________________________________________________

There are other things that I want or do not want for my health care, if possible:

Who I would like to have as my doctor: ____________________________________________________________

Where I would like to live to receive health care: ___________________________________________________

Where I would like to die, and other wishes I have about dying: _________________________________________

___________________________________________________________________________________________

My wishes about what happens to my body when I die (cremation, burial): _______________________________

Any other things: _____________________________________________________________________________

___________________________________________________________________________________________

REMINDER: Keep this document with your personal papers in a safe place (not in a

safe deposit box). Give signed copies to your doctors, family, close friends, health

care agent, and alternate health care agent. Make sure your doctor is willing to follow

your wishes. This document should be part of your medical record at your physician's

office and at the hospital, home care agency, hospice, or nursing facility where you

receive your care.

THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO

DO IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF

(I know I can change these choices.)

My health care agent is automatically given the powers listed below in (A) through (D). My health care agent must

follow my health care instructions in this document or any other instructions I have given to my agent. If I have not

given health care instructions, then my agent must act in my best interest.

Whenever I am unable to decide or speak for myself, my health care agent has the power to:

(A) Make any health care decision for me. This includes the power to give, refuse, or withdraw consent to any care,

treatment, service, or procedures. This includes deciding whether to stop or to forgo health care that is keeping me

or might keep me alive, and deciding about intrusive mental health treatment.

(B) Choose my health care providers.

(D) Review my medical records and have the same rights that I would have to give my medical records to other

people.

If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR if I want to LIMIT any

power in (A) through (D), I MUST say that here: ___________________________________________________

__________________________________________________________________________________________

My health care agent is NOT automatically given the powers listed below in (1) and (2). If I WANT my agent to

have any of the powers in (1) and (2), I must INITIAL the line in front of the power; then my agent WILL HAVE that

power.

____ (1) To decide whether to donate any parts of my body, including organs, tissues, and eyes, when I die.

____ (2) To decide what will happen with my body when I die (burial, cremation).

If I want to say anything more about my health care agent's powers or limits on the powers, I can say it here:

__________________________________________________________________________________________

PART III: MAKING THE DOCUMENT LEGAL

This document must be signed by me. It also must either be verified by a notary public (Option 1) OR witnessed by

two witnesses (Option 2). It must be dated when it is verified or witnessed.

I am thinking clearly, I agree with everything that is written in this document, and I have made this document

willingly.

_______________________________________________ ____________

My signature Date signed

Date of birth: _______________ Address: _____________________________________

_____________________________________

If I cannot sign my name, I can ask someone to sign this document for me.

______________________________________________________

Signature of the person I asked to sign this document for me

______________________________________________________

Printed name of the person I asked to sign this document for me

This health care directive will not be valid unless it is notarized or signed by two qualified witnesses who are present when you

sign or acknowledge your signature. If you have attached any additional pages to this form, you must date and sign each of the

additional pages at the same time you date and sign this health care directive.

If notarized: The person notarizing this document may be an employee of a health care or long-term care provider giving you

care. If witnessed: At least one witness to the execution of the document must not be a health care or long-term care provider

giving you direct care or an employee of the health care or long-term care provider giving you direct care.

None of the following may be used as a notary or witness:

1. A person you designate as your agent or alternate agent;

2. Your spouse;

3. A person related to you by blood, marriage, or adoption;

4. A person entitled to inherit any part of your estate upon your death; or

5. A person who has, at the time of executing this document, any claim against your estate.

Option 1: Notary Public

In my presence on ______________ (date), ____________________________________(name) acknowledged

his/her signature on this document or acknowledged that he/she authorized the person signing this document to

sign on his/her behalf. I am not named as a health care agent or alternate health care agent in this document.

___________________________________________

(Signature of Notary) (Notary Stamp)

Option 2: Two Witnesses

Two witnesses must sign. Only one of the two witnesses can be a health care provider or an employee of a health

care provider giving direct care to me on the day I sign this document.

Witness One:

(i) In my presence on _____________(date), ___________________________________ (name) acknowledged

his/her signature on this document or acknowledged that he/she authorized the person signing this document to

sign on his/her behalf.

(ii) I am at least 18 years of age.

(iii) I am not named as a health care agent or an alternate.

(iv) If I am a health care provider or an employee of a health care provider giving direct care to the person listed

above in (A), I must initial this box [ ].

I certify that the information in (i) through (iv) is true and correct.

_________________________________________

(Signature of Witness One)

Witness Two:

(i) In my presence on ____________(date), ____________________________________ (name) acknowledged

his/her signature on this document or acknowledged that he/she authorized the person signing this document to

sign on his/her behalf.

(ii) I am at least 18 years of age.

(iii) I am not named as a health care agent or an alternate.

(iv) If I am a health care provider or an employee of a health care provider giving direct care to the person listed

above in (A), I must initial this box [ ].

I certify that the information in (i) through (iv) is true and correct.

_________________________________________

(Signature of Witness Two)

REMINDER: Keep this document with your personal

papers in a safe place (not in a safe deposit box). Give

signed copies to your doctors, family, close friends,

health care agent, and alternate health care

agent. Make sure your doctor is willing to follow your

wishes. This document should be part of your medical

record at your physician's office and at the hospital,

home care agency, hospice, or nursing facility where

you receive your care.