202A.430 Form of advance directive for mental health treatment.
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An advance directive for mental health treatment shall be in substantially the following form:
"Advance directive for mental health treatment I, ___________, willfully and voluntarily execute this advance directive for mental health treatment. I want the instructions in this advance directive to be followed as described below.
Designated surrogate ___I am naming a surrogate to see that my instructions for mental health treatment are
carried out. ___I am not naming a surrogate to see that my instructions for mental health treatment are
carried out. I designate ____________ to act as my surrogate. If this person withdraws or is unwilling
to act on my behalf, or if I revoke that person's authority to act as my surrogate, I
designate ____________ to act as my alternate surrogate. If I do not designate a surrogate, if my surrogate and alternate surrogate withdraw or are
unwilling to act on my behalf, or if I revoke their authority to act, then the health
care provider and health care facility may proceed to render treatment in accordance
with my instructions as described here and in accordance with standards for mental
and physical health care. The person acting as my surrogate is authorized to act in accordance with the content of
this advance directive and may override the advance directive if, and only if, there is
substantial medical evidence that failing to do so would result in harm to me. If my
instructions and preferences are not stated in the advance directive, the surrogate
may act in good faith in making treatment decisions in the manner in which the
surrogate believes I would act.
Psychotropic medication provisions I may indicate below any refusals of treatment with specific psychotropic medications,
not to include an entire class of medications, due to factors that may include but are
not limited to lack of efficacy, known drug sensitivity, or experience of adverse
reaction: I specifically do not consent and do not authorize my surrogate to consent to the
administration of the following medications or their respective brand-name or
generic equivalents for the reasons given: Specific psychotropic medication Reason for refusal ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
I may list below any specific psychotropic medications that I would be willing to have administered to me if additional medications become necessary: Specific psychotropic medications ____________________________ ____________________________ ____________________________ ____________________________
Electroconvulsive therapy provisions Below are my instructions regarding electroconvulsive therapy (ECT): ____I consent to electroconvulsive therapy
(ECT)if it is deemed clinically appropriate to treat my condition. ____I do not consent to electroconvulsive therapy (ECT).
Preferred procedures for emergency interventions I may state preferences for procedures for emergency interventions to be used when
necessary for my protection or the protection of others. I understand that I am
requesting consideration of my preferences for procedures for emergency
interventions but that my surrogate, my health care provider, and the health care
facility where I am a patient are not subject to civil liability for not abiding by these
preferences. I understand that in the case of possible harm to myself or others, my
health care provider or the health care facility may need to use procedures that
override my stated preferences. If during an admission or while a patient in a health
care facility, it is determined that I am engaging in behavior that requires emergency
intervention, my preferences regarding the procedures to be used during an
emergency intervention and the order that I prefer the interventions to be used are as
follows: Intervention Order of preference Reason for this preference Seclusion___________________________________________________________ Physical restraints____________________________________________________ Seclusion and physical restraint combined_____________________________________________________ Medication by injection_________________________________________________ Medication in pill form_________________________________________________ Liquid medication_____________________________________________________ Other:_______________________________________________________________ Signed this ____ day of _________, 20__ Signature of grantor:_________________________ Address of grantor:_____________________________________________________ _____________________________________________________________________
In my presence, the grantor voluntarily dated and signed this writing or directed it to be dated and signed. I am not the grantor's current health care provider, a relative of the current health care provider, or an owner, operator, employee or relative of an owner or operator of a health facility in which the grantor is a client or resident. Signatures of witnesses: _________________________________________________ _____________________________________________________________________ Surrogate contact information (if designated):
Name:_______________________________ Address:______________________________ _____________________________________ Telephone:_____________________________ Signed this ____ day of _________, 20__ Signature of surrogate:____________________ Alternate surrogate contact information (if designated): Name:_______________________________ Address:______________________________ _____________________________________ Telephone_____________________________ Signed this ____ day of _________, 20__ Signature of alternate surrogate:______________________"