Montana Living Will Form

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Montana Living Will

Montana Living Will

The Montana living will is a form that helps in your effort to manage your end of life treatments if you should become in a mental state where you cannot think for yourself.

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DECLARATION OF LIVING WILL APPOINTMENT

If I should have an incurable and irreversible condition that, without the

administration of life-sustaining treatment, will, in the opinion of my attending physician

or my attending advanced practice registered nurse, cause my death within a relatively

short time and I am no longer able to make decisions regarding my medical treatment, I

appoint _______________________________________, or if he or she is not reasonably

available or is unwilling to serve I appoint ________________________________ in the

alternative, to make decisions on my behalf regarding withholding or withdrawal of

treatment that only prolongs the process of dying and is not necessary for my comfort or

to alleviate pain, pursuant to the Montana Rights of the Terminally 111 Act. If the

individual(s) I have appointed are not reasonably available or are unwilling to serve, I

direct my attending physician or my attending advanced practice registered nurse,

pursuant to the Montana Rights of the Terminally Ill Act, to withhold or withdraw

treatment that only prolongs the process of dying and is not necessary for my comfort or

to alleviate pain.

Signed this____ day of _________________, 20___.

___________________________________

Signature

___________________________________

Printed name

___________________________________

Address

The declarant voluntarily signed this document in my presence.

_______________________________ ______________________________

Witness Name Address

_______________________________ ______________________________

Witness Name Address

Chapter IV – 4

DECLARATION OF LIVING WILL

If I should have an incurable or irreversible condition that, without the

administration of life-sustaining treatment, will, in the opinion of my attending physician

or my attending advanced practice registered nurse, cause my death within a relatively

short time and I am no longer able to make decisions regarding my medical treatment, I

direct my attending physician or my attending advanced practice registered nurse,

pursuant to the Montana Rights of the Terminally III Act, to withhold or withdraw

treatment that only prolongs the process of dying and is not necessary to my comfort or to

alleviate pain.

Signed this_____ day of ___________________,20____.

______

Signature

_____ ____

Printed name

______________________________

Address

The declarant voluntarily signed this document in my presence:

_______________________________ ______________________________

Witness Address

_______________________________ ______________________________

Witness Address

Chapter IV – 5

REVOCATION OF DECLARATION

OF LIVING WILL

I, ____________________ hereby revoke my Declaration (Living Will) regarding

withholding or withdrawal of life-sustaining treatment in the event I am in a terminal

condition which will result in my death in a short period of time.

This revocation is effective immediately and must be communicated to my

attending physician and other health care providers as soon as possible.

Dated this _________ day of ___________________________, 20___.

__________________________________

(Signature)

Chapter IV – 6

RIGHTS OF THE TERMINALLY ILL ACT

Excerpts from Montana Codes Annotated

Title 50, Chapter 9

50-9-102. Definitions. As used in this chapter, the following definitions apply:

(1) “Advanced practice registered nurse” means an individual who is licensed under

Title 37, Chapter 8, to practice professional nursing in this state and who has fulfilled the

requirements of the Board of Nursing pursuant to 37-8-202 and 37-8-409

(3) “Attending physician” means the physician selected by or assigned to the patient,

who has primary responsibility for the treatment and care of the patient.

(4) “Board” means the Montana state board of medical examiners.

(5) “Declaration” means a document executed in accordance with the requirements of

50-9-103.

(7) “Emergency medical services personnel” means paid or volunteer firefighters, law

enforcement officers, first responders, emergency medical technicians, or other

emergency services personnel acting within the ordinary course of their professions.

(8) “Health care provider” means a person who is licensed, certified, or otherwise

authorized by the laws of this state to administer health care in the ordinary course of

business or practice of a profession.

(9) “Life-sustaining treatment” means any medical procedure or intervention

that, when administered to a qualified patient, serves only to prolong the dying

process.

(13) “Qualified patient” means a patient 18 years of age or older who has executed a

declaration in accordance with this chapter and who has been determined by the attending

physician to be in a terminal condition

(16) “Terminal condition” means an incurable or irreversible condition that, without the

administration of life-sustaining treatment will, in the opinion of the attending physician

or attending advanced practice registered nurse, result in death within a relatively short

time.

50-9-103. Declaration relating to use of life-sustaining treatment -designee. (1) An

individual of sound mind and 18 or more years of age may execute at any time a

declaration governing the withholding or withdrawal of life-sustaining treatment. The

declarant may designate another individual of sound mind and 18 of age or older to make

decisions governing the withholding or withdrawal of life-sustaining treatment. The

declaration must be signed by the declarant or another at the declarant’s direction and

must

be witnessed by two individuals. A health care provider may presume, in the absence of

actual notice to the contrary, that the declaration complies with this chapter and is valid.

(2) A declaration directing a physician or advanced practice registered nurse to withhold

or withdraw life-sustaining treatment may but need not be in the following form:

DECLARATION

If I should have an incurable or irreversible condition that, without the administration of

life-sustaining treatment, will, in the opinion of my attending physician or my attending

advanced practice registered nurse, cause my death within a relatively short time and I

am no longer able to make decisions regarding my medical treatment, I direct my

attending physician or my attending advanced practice registered nurse, pursuant to the

Montana Rights of the Terminally Ill Act, to withhold or withdraw treatment that only

prolongs the process of dying and is not necessary to my comfort or to alleviate pain.

Signed this _________ day of _________________, _________.

Signature _______________________________________________________

City, County, and State of Residence ___________________________________

The declarant voluntarily signed this document in my presence.

Witness __________________________

Address __________________________

Witness __________________________

Address __________________________

(3) A declaration that designates another individual to make decisions governing the

withholding or withdrawal of life-sustaining treatment may but need not be in the

following form:

Chapter IV – 8

DECLARATION

If I should have an incurable and irreversible condition that, without the

administration of life-sustaining treatment, will, in the opinion of my attending

physician or my attending advanced practice registered nurse, cause my death

within a relatively short time and I am no longer able to make decisions regarding

my medical treatment, I appoint _______________________or, if that person is

not reasonably available or is unwilling to serve, ____________________, to make

decisions on my behalf regarding withholding or withdrawal of treatment that only

prolongs the process of dying and is not necessary for my comfort or to alleviate

pain, pursuant to the Montana Rights of the Terminally Ill Act.

If the individual I have appointed is not reasonably available or is unwilling to

serve, I direct my attending physician or my attending advanced practice registered

nurse, pursuant to the Montana Rights of the Terminally Ill Act, to withhold or

withdraw treatment that only prolongs the process of dying and is not necessary for

my comfort or to alleviate pain.

Signed this _________ day of _________________, ________.

Signature _________________________________________________

City, County, and State of Residence ___________________________

The declarant voluntarily signed this document in my presence.

Witness __________________________

Address __________________________

Witness __________________________

Address __________________________

Name and address of designee.

Name ____________________________

Address __________________________

Chapter IV – 9

(4) If the designation of an attorney-in-fact pursuant to 72-5-501 and 72-5-502 or

the judicial appointment of an individual contains written authorization to make

decisions regarding the withholding or withdrawal of life-sustaining treatment, that

designation or appointment constitutes, for the purposes of this part, a declaration

designating another individual to act for the declarant pursuant to subsection (1).

(5) A health care provider who is furnished a copy of the declaration shall make

it a part of the declarant’s medical record and, if unwilling to comply with the

declaration, shall advise the declarant and any individual designated to act for the

declarant promptly.

50-9-104. Revocation of declaration.

(1) A declarant may revoke a declaration at any time and in any manner, without

regard to mental or physical condition. A revocation is effective upon its

communication to the attending physician, attending advanced practice registered

nurse, or other health care provider by the declarant or a witness to the revocation.

A health care provider or emergency medical services personnel witnessing a

revocation shall act upon the revocation and shall communicate the revocation to

the attending physician or the attending advanced practice registered nurse at the

earliest opportunity. A revocation communicated to a person other than the

attending physician, attending advanced practice registered nurse, emergency

medical services personnel, or a health care provider is not effective unless the

attending physician or the attending advanced practice registered nurse is informed

of it before the qualified patient is in need of life-sustaining treatment.

(2) The attending physician, attending advanced practice registered nurse, or

other health care provider shall make the revocation a part of the declarant’s

medical record.

50-9-105. When declaration operative.

(1) A declaration becomes operative when:

(a) it is communicated to the attending physician or the attending advanced

practice registered nurse; and

(b) the declarant is determined by the attending physician or the attending

advanced practice registered nurse to be in a terminal condition and no longer able

to make decisions regarding administration of life-sustaining treatment.

(2) Except as provided in 72-17-216, when the declaration becomes operative, the

attending physician or attending advanced practice registered nurse and other health

care providers shall act in accordance with its provisions and with the instructions of

a designee under 50-9-103(1) or comply with the transfer requirements of 50-9-203.

Chapter IV – 10

50-9-106. Consent by others to withholding or withdrawal of treatment.

(1) If a written consent to the withholding or withdrawal of the treatment,

witnessed by two individuals, is given to the attending physician or the attending

advanced practice registered nurse, the physician or attending advanced practice

registered nurse may withhold or withdraw life-sustaining treatment from an

individual who:

(a) has been determined by the attending physician or attending advanced

practice registered nurse to be in a terminal condition and no longer able to make

decisions regarding the administration of life-sustaining treatment; and

(b) has no effective declaration.

(2) The authority to consent or to withhold consent under subsection (1) may be

exercised by the following individuals, in order of priority:

(a) the spouse of the individual;

(b) an adult child of the individual or, if there is more than one adult

child, a majority of the adult children who are reasonably available

for consultation;

(c) the parents of the individual;

(d) an adult sibling of the individual or, if there is more than one adult

sibling, a majority of the adult siblings who are reasonably available

for consultation; or

(e) the nearest other adult relative of the individual by blood or

adoption who is reasonably available for consultation.

(3) A full guardian may consent or withhold consent under subsection (1) as

provided in 72-5-321.

(4) If a class entitled to decide whether to consent is not reasonably available for

consultation and competent to decide or if it declines to decide, the next class is

authorized to decide. However, an equal division in a class does not authorize the

next class to decide.

(5) A decision to grant or withhold consent must be made in good faith. A

consent is not valid if it conflicts with the expressed intention of the individual.

(6) A decision of the attending physician or attending advanced practice

registered nurse acting in good faith that a consent is valid or invalid is conclusive.

(7) Life-sustaining treatment cannot be withheld or withdrawn pursuant to this

section from an individual known to the attending physician or the attending

advanced practice registered nurse to be pregnant so long as it is probable that the

fetus will develop to the point of live birth with continued application of lifesustaining

treatment.

Chapter IV – 11

50-9-107. When health care provider may presume validity of declaration. In

the absence of knowledge to the contrary, a health care provider may assume that a

declaration complies with this chapter and is valid.

50-9-108. Effect of previous declaration. An instrument executed before

October 1, 1991, that substantially complies with 50-9-103(1) is effective under

this chapter.

50-9-109. Reserved.

50-9-110. Authority to adopt rules. The department may adopt rules to

implement this chapter.

50-9-111. Recognition of declarations executed in other states. A declaration

executed in a manner substantially similar to 50-9-103 in another state and in

compliance with the law of that state is effective for purposes of this chapter.

PART 2

Effect on Health Care — Rights and Duties

50-9-201. Recording determination of terminal condition and content of

declaration. Upon determining that a declarant is in a terminal condition, the

attending physician or attending advanced practice registered nurse who knows of

a declaration shall record that determination and the terms of the declaration in the

declarant’s medical record.

50-9-202. Treatment of qualified patients.

(1) A qualified patient may make decisions regarding life-sustaining treatment so

long as the patient is able to do so.

(2) This chapter does not affect the responsibility of the attending physician,

attending advanced practice registered nurse or other health care provider to

provide treatment, including nutrition and hydration, for a patient’s comfort care or

alleviation of pain.

(3) Life-sustaining treatment cannot be withheld or withdrawn pursuant to a

declaration from an individual known to the attending physician or attending

advanced practice registered nurse to be pregnant so long as it is probable that the

fetus will develop to the point of live birth with continued application of lifesustaining

treatment.

50-9-203 Transfer of patients. An attending physician, attending advanced

practice registered nurse, or other health care provider who is unwilling to comply

with this chapter shall take all reasonable steps as promptly as practicable to

transfer care of the declarant to another physician, advanced practice registered

nurse, or health care provider who is willing to do so. If the policies of a health

care facility preclude compliance with the declaration of a qualified patient under

this chapter, that facility shall take all reasonable steps to transfer the patient to a

facility in which the provisions of this chapter can be carried out.

50-9-204. Immunities.

(1) In the absence of actual notice of the revocation of a declaration, the

following, while acting in accordance with the requirements of this chapter, are not

subject to civil or criminal liability or guilty of unprofessional conduct:

(a) a physician or advanced practice registered nurse who causes the

withholding or withdrawal of life-sustaining treatment from a qualified patient;

Chapter IV – 13

(b) a person who participates in the withholding or withdrawal of lifesustaining

treatment under the direction or with the authorization of a

physician or advanced practice registered nurse;

(c) emergency medical services personnel who cause or participate in the

withholding or withdrawal of life-sustaining treatment under the direction of or

with the authorization of a physician or advanced practice registered nurse or who

on receipt of reliable documentation follow a living will protocol;

(d) emergency medical services personnel who proceed to provide lifesustaining

treatment to a qualified patient pursuant to a revocation communicated

to them; and

(e) a health care facility in which withholding or withdrawal occurs.

(2) A health care provider whose action under this chapter is in accord with

reasonable medical standards is not subject to civil or criminal liability or

discipline for unprofessional conduct with respect to that decision.

(3) A .health care provider whose decision about the validity of consent under

50-9-106 is made in good faith is not subject to criminal or civil liability or

discipline for unprofessional conduct with respect to that decision.

(4) An individual designated pursuant to 50-9-103(l) or an individual authorized

to consent pursuant to 50-9-106, whose decision is made or consent is given in

good faith pursuant to this chapter, is not subject to criminal or civil liability or

discipline for unprofessional conduct with respect to that decision.

50-9-205. Effect on insurance — patient’s decision.

(1) Death resulting from the withholding or withdrawal of life-sustaining

treatment in accordance with this chapter does not constitute, for any purpose, a

suicide or homicide.

(2) The making of a declaration pursuant to 50-9-103 does not affect the sale,

procurement, or issuance of any policy of life insurance or annuity, nor does it

affect, impair, or modify the terms of an existing policy of life insurance. A policy

of life insurance is not legally impaired or invalidated by the withholding or

withdrawal of life-sustaining treatment from an insured, notwithstanding any term

of the policy to the contrary.

(3) A person may not prohibit or require the execution of a declaration as a

condition for being insured for or receiving health care services.

(4) This chapter does not create a presumption concerning the intention of an

individual who has revoked or has not executed a declaration with respect to the

Chapter IV – 14

use, withholding, or withdrawal of life-sustaining treatment in the event of a

terminal condition.

(5) This chapter does not affect the right of a patient to make decisions

regarding use of life-sustaining treatment, so long as the patient is able to do so, or

impair or supersede a right or responsibility that any person has to affect the

withholding or withdrawal of medical care.

(6) This chapter does not require a health care provider to take action contrary to

reasonable medical standards.

(7) This chapter does not condone, authorize, or approve mercy killing or

euthanasia.

Chapter IV – 15

DO NOT RESUSCITATE — NOTIFICATION

Part 1 General

50-10-101. Definitions. As used in this part, unless the context clearly requires

otherwise, the following definitions apply:

(1) “Advanced practice registered nurse” means an individual who is licensed

under Title 37, Chapter 8, to practice professional nursing in this state and who has

fulfilled the requirements of the board of nursing pursuant to 37-8-202 and 37-8-

409

(2) “Attending advanced practice registered nurse” means the advanced practice

registered nurse who is selected by or assigned to the patient and who has primary

responsibility for the treatment and care of the patient.

(3) “Attending physician” has the meaning provided in 50-9-102.

(4) “Board” means the state board of medical examiners.

(5) “Department” means the department of public health and human services

provided for in 2-15-2201.

(6) “DNR identification” means a standardized identification card, form,

necklace, or bracelet of uniform size and design, approved by the department,

which signifies that the possessor is a qualified patient, as defined in 50-9-102, or

that the possessor’s attending physician or attending advanced practice registered

nurse has issued a do not resuscitate order for the possessor and has documented

the grounds for the order in the possessor’s medical file.

(7) “Do not resuscitate order” means a directive from a licensed physician or

advanced practice registered nurse that emergency life-sustaining procedures

should not be administered to a particular person.

(8) “Do not resuscitate protocol” means a standardized method of procedure,

approved by the board and adopted in the rules of the department, for the

withholding of emergency life-sustaining procedures by physicians, advanced

practice registered nurses, and emergency medical services personnel.

(9) “Emergency medical services personnel” has the meaning provided in

50-9-102.

(11) “Life-sustaining procedure” means cardiopulmonary resuscitation or a

component of cardiopulmonary resuscitation.

(10) “Physician” means a person licensed under Title 37, chapter 3, to Practice

medicine in this state.

Chapter IV – 16

50-10-102. Immunities.

(1) The following are not subject to civil or criminal liability and are not guilty

of unprofessional conduct upon discovery of DNR identification upon a person:

(a) a physician or advanced practice registered nurse who causes the

withholding or withdrawal of life-sustaining procedures from that person;

(b) a person who participates in the withholding or withdrawal of lifesustaining

procedures under the direction or with the authorization of a

physician or advanced practice registered nurse;

(c) emergency medical services personnel who cause or participate in the

withholding or withdrawal of life-sustaining procedures from that person;

(d) a health care facility in which withholding or withdrawal of lifesustaining

procedures from that person occurs;

(e) physicians, advanced practice registered nurses, persons under the

direction or authorization of a physician or advanced practice registered

nurse, emergency medical services personnel, or health care facilities that

provide life-sustaining procedures pursuant to an oral or written request

communicated to them by a person who possesses DNR identification.

(2) The provisions of subsections (1)(a) through (1)(d) apply when a lifesustaining

procedure is withheld or withdrawn in accordance with the do not

resuscitate protocol.

(3) Emergency medical services personnel who follow a do not resuscitate order

from a licensed physician or an advanced practice registered nurse are not subject

to civil or criminal liability and are not guilty of unprofessional conduct.

50-10-103. Adherence to do not resuscitate protocol — transfer of patients.

(1) Except as provided in 72-17-216, emergency medical services personnel,

other than physicians or advanced practice registered nurses, shall comply with the

do not resuscitate protocol when presented with either do not resuscitate

identification, an oral do not resuscitate order issued directly by a physician or an

advanced practice registered nurse, or a written do not resuscitate order entered on

a form prescribed by the department.

(2) An attending physician, an attending advanced practice registered nurse, or a

health care facility unwilling or unable to comply with the do not resuscitate

protocol shall take all reasonable steps to transfer a person possessing DNR

identification to another physician or advanced practice registered nurse or to a

health care facility in which the do not resuscitate protocol will be followed

Chapter IV – 17

50-10-104. Effect on insurance — patient’s decision.

(1) Death resulting from the withholding or withdrawal of emergency lifesustaining

procedures pursuant to the do not resuscitate protocol and in accordance

with this part is not, for any purpose, a suicide or homicide.

(2) The possession of DNR identification pursuant to this part, does not affect in

any manner the sale, procurement, or issuance of any policy of life insurance, nor

does it modify the terms of an existing policy of life insurance. A policy of life

insurance is not legally impaired or invalidated in any manner by the withholding

or withdrawal of emergency life-sustaining procedures from an insured person

possessing DNR identification, notwithstanding any term of the policy to the

contrary.

(3) A physician, advanced practice registered nurse, advanced practice registered

nurse, health care facility, or other health care provider and a health care service

plan, insurer issuing disability insurance, self-insured employee welfare benefit

plan, or nonprofit hospital plan may not require a person to possess DNR

identification as a condition for being insured for or receiving health care services.

(4) This part does not create a presumption concerning the intention of an

individual who does not possess DNR identification with respect to the use,

withholding, or withdrawal of life-sustaining procedures.

(5) This part does not increase or decrease the right of a patient to make

decisions regarding use of life-sustaining procedures if the patient is able to do so,

nor does this part impair or supersede any right or responsibility that a person has

to effect the withholding or withdrawal of medical care in any lawful manner. In

that respect the provisions of this part are cumulative.

(7) This part does not authorize or approve mercy killing.

50-10-107. DNR form to be readily available. The department shall ensure that

the DNR identification form approved by the department is readily available at no

cost or at a nominal charge.

Chapter IV – 18

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