23.0121.01000
Sixty-eighth
Legislative Assembly SENATE BILL NO. 2125
of North Dakota
Introduced by
Senators Mathern, Erbele, Hogan
Representatives Dobervich, Kasper, Swiontek
1 A BILL for an Act to amend and reenact sections 23-06.5-06 and 23-06.5-17 of the North
2 Dakota Century Code, relating to health care directive acceptance of appointment as agent.
3 BE IT ENACTED BY THE LEGISLATIVE ASSEMBLY OF NORTH DAKOTA:
4 SECTION 1. AMENDMENT. Section 23-06.5-06 of the North Dakota Century Code is
5 amended and reenacted as follows:
6 23-06.5-06. Acceptance of appointment - Withdrawal as agent.
7 To be effective, the agent must accept the appointment in writing. Subject to the right of the
8 agent to withdraw, the acceptancehealth care directive creates authority for the agent to make
9 health care decisions on behalf of the principal at such time as the principal becomes
10 incapacitated. Until the principal becomes incapacitated, the agent may withdraw by giving
11 notice to the principal. After the principal becomes incapacitated, the agent may withdraw by
12 giving notice to the attending physician. The attending physician shall cause the withdrawal to
13 be recorded in the principal's medical record.
14 SECTION 2. AMENDMENT. Section 23-06.5-17 of the North Dakota Century Code is
15 amended and reenacted as follows:
16 23-06.5-17. Optional health care directive form.
17 The following is an optional form of a health care directive and is not a required form:
18 HEALTH CARE DIRECTIVE
19 I_________________________________, understand this document allows me to do ONE
20 OR ALL of the following:
21 PART I: Name another personindividual (called the health care agent) to make health care
22 decisions for me if I am unable to make and communicate health care decisions for myself. My
23 health care agent must make health care decisions for me based on the instructions I provide in
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1 this document (Part II), if any, the wishes I have made known to him or her, or my agent must
2 act in my best interest if I have not made my health care wishes known.
3 AND/OR
4 PART II: Give health care instructions to guide others making health care decisions for me.
5 If I have named a health care agent, these instructions are to be used by the agent. These
6 instructions may also be used by my health care providers, others assisting with my health care,
7 and my family, in the event I cannot make and communicate decisions for myself.
8 AND/OR
9 PART III: Allows me to make an organ and tissue donation upon my death by signing a
10 document of anatomical gift.
11 PART I: APPOINTMENT OF HEALTH CARE AGENT
12 THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS
13 FOR ME IF I AM UNABLE TO MAKE AND COMMUNICATE
14 HEALTH CARE DECISIONS FOR MYSELF
15 (I know I can change my agent or alternate agent at any time
16 and I know I do not have to appoint an agent or an alternate agent)
17 NOTE: If you appoint an agent, you should discuss this health care directive with your agent
18 and give your agent a copy. If you do not wish to appoint an agent, you may leave Part I blank
19 and go to Part II and/or Part III. None of the following may be designated as your agent: your
20 treating health care provider, a nonrelative employee of your treating health care provider, an
21 operator of a long-term care facility, or a nonrelative employee of a long-term care facility.
22 When I am unable to make and communicate health care decisions for myself, I trust and
23 appoint______________________________ to make health care decisions for me. This
24 personindividual is called my health care agent.
25 Relationship of my health care agent to me: _________________________________
26 Telephone number of my health care agent: _________________________________
27 Address of my health care agent: __________________________________________
28 (OPTIONAL) APPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If my
29 health care agent is not reasonably available, I trust and appoint _____________________
30 to be my health care agent instead.
31 Relationship of my alternate health care agent to me: ________________________
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1 Telephone number of my alternate health care agent: ________________________
2 Address of my alternate health care agent: _________________________________
3 THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO DO
4 IF I AM UNABLE TO MAKE AND COMMUNICATE HEALTH CARE DECISIONS
5 FOR MYSELF
6 (I know I can change these choices)
7 My health care agent is automatically given the powers listed below in (A) through (D). My
8 health care agent must follow my health care instructions in this document or any other
9 instructions I have given to my agent. If I have not given health care instructions, then my agent
10 must act in my best interest.
11 Whenever I am unable to make and communicate health care decisions for myself, my
12 health care agent has the power to:
13 (A) Make any health care decision for me. This includes the power to give, refuse, or
14 withdraw consent to any care, treatment, service, or procedures. This includes deciding whether
15 to stop or not start health care that is keeping me or might keep me alive and deciding about
16 mental health treatment.
17 (B) Choose my health care providers.
18 (C) Choose where I live and receive care and support when those choices relate to my
19 health care needs.
20 (D) Review my medical records and have the same rights that I would have to give my
21 medical records to other people.
22 If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR
23 if I want to LIMIT any power in (A) through (D), I MUST say that here:
24 _____________________________________________________________________
25 _____________________________________________________________________
26 _____________________________________________________________________
27 My health care agent is NOT automatically given the powers listed below in (1) and (2). If I
28 WANT my agent to have any of the powers in (1) and (2), I must INITIAL the line in front of the
29 power; then my agent WILL HAVE that power.
30 ____(1) To decide whether to donate any parts of my body, including organs, tissues, and
31 eyes, when I die.
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1 ____(2) To decide what will happen with my body when I die (burial, cremation).
2 If I want to say anything more about my health care agent's powers or limits on the powers,
3 I can say it here:
4 _____________________________________________________________________
5 _____________________________________________________________________
6 _____________________________________________________________________
7 PART II: HEALTH CARE INSTRUCTIONS
8 NOTE: Complete this Part II if you wish to give health care instructions. If you appointed an
9 agent in Part I, completing this Part II is optional but would be very helpful to your agent.
10 However, if you chose not to appoint an agent in Part I, you MUST complete, at a minimum,
11 Part II (B) if you wish to make a valid health care directive.
12 These are instructions for my health care when I am unable to make and communicate
13 health care decisions for myself. These instructions must be followed (so long as they address
14 my needs).
15 (A) THESE ARE MY BELIEFS AND VALUES ABOUT MY HEALTH CARE
16 (I know I can change these choices or leave any of them blank)
17 I want you to know these things about me to help you make decisions about my health care:
18 My goals for my health care:
19 _____________________________________________________________________
20 _____________________________________________________________________
21 _____________________________________________________________________
22 My fears about my health care:
23 _____________________________________________________________________
24 _____________________________________________________________________
25 _____________________________________________________________________
26 My spiritual or religious beliefs and traditions:
27 _____________________________________________________________________
28 _____________________________________________________________________
29 _____________________________________________________________________
30 My beliefs about when life would be no longer worth living:
31 _____________________________________________________________________
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1 _____________________________________________________________________
2 _____________________________________________________________________
3 My thoughts about how my medical condition might affect my family:
4 _____________________________________________________________________
5 _____________________________________________________________________
6 _____________________________________________________________________
7 (B) THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE
8 (I know I can change these choices or leave any of them blank)
9 Many medical treatments may be used to try to improve my medical condition or to prolong
10 my life. Examples include artificial breathing by a machine connected to a tube in the lungs,
11 artificial feeding or fluids through tubes, attempts to start a stopped heart, surgeries, dialysis,
12 antibiotics, and blood transfusions. Most medical treatments can be tried for a while and then
13 stopped if they do not help.
14 I have these views about my health care in these situations:
15 (Note: You can discuss general feelings, specific treatments, or leave any of them blank).
16 If I had a reasonable chance of recovery and were temporarily unable to make and
17 communicate health care decisions for myself, I would want:
18 _____________________________________________________________________
19 _____________________________________________________________________
20 _____________________________________________________________________
21 If I were dying and unable to make and communicate health care decisions for myself, I
22 would want:
23 _____________________________________________________________________
24 _____________________________________________________________________
25 _____________________________________________________________________
26 If I were permanently unconscious and unable to make and communicate health care
27 decisions for myself, I would want:
28 _____________________________________________________________________
29 _____________________________________________________________________
30 _____________________________________________________________________
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1 If I were completely dependent on others for my care and unable to make and communicate
2 health care decisions for myself, I would want:
3 _____________________________________________________________________
4 _____________________________________________________________________
5 _____________________________________________________________________
6 In all circumstances, my health care providers will try to keep me comfortable and reduce
7 my pain. This is how I feel about pain relief if it would affect my alertness or if it could shorten
8 my life:
9 _____________________________________________________________________
10 _____________________________________________________________________
11 _____________________________________________________________________
12 There are other things that I want or do not want for my health care, if possible:
13 Who I would like to be my health care provider:
14 _____________________________________________________________________
15 _____________________________________________________________________
16 _____________________________________________________________________
17 Where I would like to live to receive health care:
18 _____________________________________________________________________
19 _____________________________________________________________________
20 _____________________________________________________________________
21 Where I would like to die and other wishes I have about dying:
22 _____________________________________________________________________
23 _____________________________________________________________________
24 _____________________________________________________________________
25 My wishes about what happens to my body when I die (cremation, burial, whole body
26 donation):
27 _____________________________________________________________________
28 _____________________________________________________________________
29 _____________________________________________________________________
30 Any other things:
31 _____________________________________________________________________
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1 _____________________________________________________________________
2 _____________________________________________________________________
3 PART III: MAKING AN ANATOMICAL GIFT
4 (A) I WANT TO BE AN ORGAN DONOR
5 [ ] I would like to be an organ donor at the time of my death. I have told my family my
6 decision and ask my family to honor my wishes. I wish to donate the following (initial one
7 statement):
8 [ ] Any needed organs and tissue.
9 [ ] Only the following organs and tissue:___________________________
10 (B) I DO NOT WANT TO BE AN ORGAN DONOR
11 [ ] I do not want to be an organ donor at the time of my death. I have told my family my decision
12 and ask my family to honor my wishes.
13 PART IV: MAKING THE DOCUMENT LEGAL
14 PRIOREARLIER DESIGNATIONS REVOKED. I revoke any priorearlier health care directive.
15 DATE AND SIGNATURE OF PRINCIPAL
16 (YOU MUST DATE AND SIGN THIS HEALTH CARE DIRECTIVE)
17 I sign my name to this Health Care Directive Form on_____________ at
18 (date)
19 _______________________________________
20 (city)
21 ________________________________________
22 (state)
23 ________________________________________________
24 (you sign here)
25 (THIS HEALTH CARE DIRECTIVE WILL NOT BE VALID UNLESS IT IS NOTARIZED OR
26 SIGNED BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR
27 ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES
28 TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE
29 SAME TIME YOU DATE AND SIGN THIS HEALTH CARE DIRECTIVE.)
30 NOTARY PUBLIC OR STATEMENT OF WITNESSES
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1 This document must be (1) notarized or (2) witnessed by two qualified adult witnesses. The
2 personindividual notarizing this document may be an employee of a health care or long-term
3 care provider providing your care. At least one witness to the execution of the document
4 mustmay not be a health care or long-term care provider providing you with direct care or an
5 employee of the health care or long-term care provider providing you with direct care. None of
6 the following may be used as a notary or witness:
7 1. A personAn individual you designate as your agent or alternate agent;
8 2. Your spouse;
9 3. A personAn individual related to you by blood, marriage, or adoption;
10 4. A personAn individual entitled to inherit any part of your estate upon your death; or
11 5. A personAn individual who has, at the time of executing this document, any claim
12 against your estate.
13 Option 1: Notary Public
14 State of _________________
15 County of ________________
16 In my presence on __________ (date), ________________ (name of declarant) acknowledged
17 the declarant's signature on this document or acknowledged that the declarant directed the
18 personindividual signing this document to sign on the declarant's behalf.
19 _________________________
20 (Signature of Notary Public)
21 My commission expires __________________________, 20__.
22 Option 2: Two Witnesses
23 Witness One:
24 (1) In my presence on _________ (date), _____________________ (name of
25 declarant) acknowledged the decla