State of Tennessee

Advance Directive for Health Care

Made pursuant to the Tennessee Health Care Decisions Act, Tenn. Code Ann. §§ 68-11-1801 et seq.

I, , hereby give these advance instructions on how I want to be treated by my doctors and other health care providers when I can no longer make those treatment decisions myself.

Date of birth: Address:

What Matters Most to You Your values, in your own words — to guide the people making decisions for you.

What brings meaning to your daily life?

If you were very sick, what would be most important to you?

Are there situations where continuing life-sustaining treatment wouldn't be worthwhile?

Part 1 — Health Care Agent The person I want to make health care decisions for me when I cannot.

I want the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my agent must follow my instructions in this directive.

Agent

Name: Relationship:

Phone: Address:

Alternate Agent

If the person named above is unable or unwilling to make health care decisions for me, I appoint the following person as alternate.

Name: Relationship:

Phone: Address:

My agent is also my personal representative for purposes of federal and state privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. §§ 160–164.

When effective (select one)

I give my agent permission to make health care decisions for me at any time, even if I have capacity to make decisions for myself.

I do not give such permission — this directive applies only when I no longer have capacity.

Have you discussed this role with your agent?

YesNo

Part 2 — Care Preference Statement What I want my agent and doctors to know about my care.

If I am so sick or badly hurt that I cannot make decisions for myself, this is what I want my agent and doctors to know about my care preferences:

Option 1 — Try everything to extend life.Using life-support like CPR, breathing machines, and dialysis for as long as possible, even if recovery is unlikely.

Option 2 — Focus on comfort.Choosing pain relief and time with loved ones instead of life-extending treatments.

Option 3 — Try treatments with limits.Pursuing recovery if a meaningful quality of life is possible, otherwise focusing on comfort.

Why did you choose this approach?

Part 3 — Additional Instructions Anything else you want your agent and doctors to know (optional).

Other instructions, such as hospice care, burial arrangements, or anything else:

Signature

Your signature must be witnessed by two competent adults.

Signature of patient

Date

Witness Attestation

Neither witness may be the person appointed as agent or alternate agent, and at least one witness must be someone who is not related to the patient by blood, marriage, or adoption and would not be entitled to any part of the patient's estate.

Witness 1 — printed name

Witness 1 — signature

Witness 2 — printed name

Witness 2 — signature

Revocation Pursuant to Tenn. Code Ann. § 68-11-1804, a designation of an agent may be revoked by a signed writing or by personally informing the supervising health care provider. All other provisions of this advance directive may be revoked at any time and in any manner that communicates an intent to revoke. Copies A copy of this directive has the same force and effect as the original. You should provide a copy to your physician(s), keep a copy in your personal files where it is accessible to others, tell your closest relatives and friends what is in the document, and provide a copy to the person(s) you named as your health care agent. Presumption of Validity A health care provider or institution may presume, in the absence of actual knowledge to the contrary, that this advance directive is valid and that the instructions herein reflect the current wishes of the principal.

Shown for preview only. Rosemary will walk you through the official version on your call.