MINNESOTA STATUTE § 145C
HEALTH CARE DIRECTIVE
OF
_________________________________________________________________________________________________
(Your Name)
I, _______________________________________________________________________, understand this document allows me to do
ONE OR BOTH of the following:
Part I: 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, the wishes I have made known to
him or her, or must act in my best interest 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 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 of my health care agent: ___________________________________________________________________________
Address 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 alternate health care agent to me: ____________________________________________________________________
Telephone number of my alternate health care agent:_________________________________________________________________
Address of my alternate health care agent: _____________________________________________________________________________
________________________________________________________________________________________________________________________________
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. I f 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 not start health care that is keeping me or might keep me alive, and deciding about intrusive
mental health treatment.
(B) Choose my health care providers .
(C) Choose where I live and receive care and support when those choices relate to my health care
needs.
(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 II: Health Care Instructions
NOTE: Complete this Part II if you wish to give health care instructions. I f yo u appointed an
agent i n Part I, completing 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 11 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 (I know I can change these choices or leave any of
them blank)
I want you to know these things about me to help you make decisions about my health care:
1. My goals for my health care:____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2. My fears about my health care:__________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. My spiritual or religious beliefs and traditions:______________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. My beliefs about when life would be no longer worth living:___________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. My thoughts about how my medical condition might affect my family:__________________________
_________________________________________________________________________________
_________________________________________________________________________________
6. (For a woman of childbearing age) My thoughts about how my health care should be handled in the event
I am pregnant: _______________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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 include artificial breathing by a machine connected to a tube in the
lungs, artificial feeding or fluids through tubes, 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 discuss general feelings, specific treatments, or leave any of them blank)
1. If I had a reasonable chance of recovery, and were temporarily unable to decide or speak for
myself, I would want:_____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2. If I were dying and unable to decide or speak for myself, I would want: _____________________
________________________________________________________________________________
________________________________________________________________________________
3. If I were permanently unconscious and unable to decide or speak for myself, I would want:
_____________________________________________________________________________
_____________________________________________________________________________
4. If I were completely dependent on others for my care and unable to decide or speak for myself, I
would want:__________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
5. 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:
1. Who I would like to be my doctor:_________________________________________________
_____________________________________________________________________________
2. Where I would like to live to receive health care: _____________________________________
_____________________________________________________________________________
3. Where I would like to die and other wishes I have about dying:__________________________
_____________________________________________________________________________
_____________________________________________________________________________
4. My wishes about donating parts of my body when I die:________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. My wishes about what happens to my body when I die (cremation, burial):_________________
_____________________________________________________________________________
_____________________________________________________________________________
6. Any other things:____________________________________________________________________________________
_______________________________________________________________________________________________________
Part III: Making The Document Legal
This document must be signed by me. It also must be verified either by a notary public (Option 1) OR
witnessed by two witnesses (Option 2). It must be dated when it is verified or witnessed .
Iam thinking clearly, I agree with everything that is written in this document, and I have made
this document willingly.
_______________________________________________________
My signature
If I cannot sign my name, I can ask someone
to sign this document for me.
Date signed: Date of birth : _______________________
Address: ___________________________________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________ ________________________________________________________
Signature of person who I asked to Printed name of person who I asked to
sign this document for me sign this document for me
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 .
Subscribed and sworn to before me this
_______ day of _____________, _______.
___________________________________
Notary Public
Option 2: Two Witnesses
Two witness 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 health care agent in this document.
(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 (i), I must initial this box: [ ]
I certify that the information in (i) through (iv) is true and correct.
________________________________________________________
(Signature of Witness One)
Address:________________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
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 health care agent in this document.
(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 (i), I must initial this box: [ ]
I certify that the information in (i) through (iv) is true and correct.
________________________________________________________
(Signature of Witness Two)
Address:________________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
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.
