Form VA Form 10-0137 VA Form 10-0137 VA Advance Directive: Durable Power of Attorney for Heal

OMB Approval Number 2900-0556
Estimated Burden Avg: 30 minutes

VA ADVANCE DIRECTIVE:
DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
This advance directive form is an official document where you can write down your preferences
about your medical care. If some day you become unable to make health care decisions for
yourself, this advance directive can help guide the people who will make decisions for you. You can
use this form to name specific people to make health care decisions for you and/or to describe your
preferences about how you want to be treated. When you complete this form, it is important that
you also talk to your doctor, your family, or others who may be involved in decisions about your
care, to make sure they understand what you meant when you filled out this form. A health care
professional can help you with this form and can answer any questions you might have.
PART I: PERSONAL INFORMATION
SOCIAL SECURITY NUMBER

NAME (Last, First, Middle)

STREET ADDRESS

CITY, STATE AND ZIP CODE

HOME PHONE WITH AREA CODE

WORK PHONE WITH AREA CODE

MOBILE PHONE WITH AREA CODE

Privacy Act Information and Paperwork Reduction Act Notice
The information requested on this form is solicited under the authority of 38.C.F.R. §17.32. It is being collected to document your
preferences about your medical care in the event you are no longer able to express these preferences. The information you provide
may be disclosed outside the VA as permitted by law; possible disclosures include those described in the "routine uses" identified in
the VA system of records 24VA19, Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act
of 1974. This is also available in the Compilation of Privacy Act Issuances via online GPO access at
http://www.access.gpo.gov/su_docs/aces/. Completion of this form is voluntary; however, without this information VA health care
providers may have less information about your preferences. Failure to furnish the information will have no adverse effect on any
other benefits which you may be entitled to receive. The Paperwork Reduction Act of 1995 requires us to notify you that this
information collection is in accordance with the clearance requirements of section 3507 of this Act. The public reporting burden for
this collection of information is estimated to average 30 minutes, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. No person
will be penalized for failing to furnish this information if it does not display a currently valid OMB control number.

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

PART II: DURABLE POWER OF ATTORNEY FOR HEALTH CARE
This section of the advance directive form is called a Durable Power of Attorney for Health Care. This
section of the form allows you to appoint a specific person to make health care decisions for you in case you
become unable to make decisions for yourself. This person will be called your Health Care Agent. Your
Health Care Agent should be someone you trust, who knows you well, and is familiar with your values and
beliefs. Your Health Care Agent will have the authority to make all health care decisions for you, including
decisions to admit you to and discharge you from any hospital or other health care institution. Your Health
Care Agent can also decide to start or stop any type of clinical treatment, and can access your personal
health information, including information from your medical records. NOTE: Information about whether
you have been tested for HIV or treated for AIDS, sickle cell anemia, substance abuse or alcoholism
cannot be shared with your Health Care Agent unless you give special written consent. Ask your
VA health care provider for the special form you must sign (VA Form 3288) if you wish to give
permission for VA to share this information with your Health Care Agent.
A - HEALTH CARE AGENT

Initial the box next to your choice. Choose only one.
Initials

I do not wish to designate a Health Care Agent at this time.
(Skip this section and go to Part III, page 4.)

Initials

I appoint the person named below to make decisions about my health care if there ever comes a
time when I cannot make those decisions.

Name (Last, First, Middle)
Street Address
Home Phone with Area Code

Relationship
City, State and Zip Code
Work Phone with Area Code

Mobile Phone with Area Code

B - ALTERNATE HEALTH CARE AGENT

Complete this section if you want to appoint a second person to make health care decisions for you in case
the first person you appointed is unavailable.
Initials

If the person named above cannot or will not make decisions for me, I appoint the person named
below to act as my Health Care Agent.

Name (Last, First, Middle)
Street Address
Home Phone with Area Code

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Relationship
City, State and Zip Code
Work Phone with Area Code

Mobile Phone with Area Code

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

PART II: DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Cont'd)
C - OTHER CONTACTS

Complete this section if you want to request that your Health Care Agent consider the views of specific
people in making your health care decisions (for example, a family member who is not designated as a
Health Care Agent, your close friend or spiritual advisor).
Initials

I ask that my Health Care Agent make reasonable attempts to include the views of the people
named below in making my health care decisions if there is time.

Name (Last, First, Middle)

Street Address

Home Phone with Area Code

Relationship

City, State and Zip Code

Work Phone with Area Code

Name (Last, First, Middle)

Street Address

Home Phone with Area Code

Relationship

City, State and Zip Code

Work Phone with Area Code

Name (Last, First, Middle)

Street Address

Home Phone with Area Code

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Mobile Phone with Area Code

Mobile Phone with Area Code

Relationship

City, State and Zip Code

Work Phone with Area Code

Mobile Phone with Area Code

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

PART III: LIVING WILL

This section of the advance directive form is called a Living Will. This section of the form allows you
to write down how you want to be treated in case you become unable to make decisions for yourself.
Its purpose is to inform the people who will be making decisions about your care.
A - HOW STRICTLY YOU WANT YOUR PREFERENCES FOLLOWED

Initial the box next to the statement that reflects how strictly you want your preferences to be followed.
Choose only one.
Initials

Initials

I want my preferences, expressed below, to serve as a general guide. I understand that in
some situations the person making decisions for me may decide something different from
the preferences I express below if they think it is in my best interest.
I want my preferences, expressed below, to be followed strictly, even if the person who is
making decisions for me thinks this is not in my best interest.
B - GENERAL PREFERENCES ABOUT LIFE-SUSTAINING TREATMENTS

Life-sustaining treatments are used to try to keep you alive when you are so sick that you would
probably die without them. These treatments can include cardiopulmonary resuscitation (CPR),
mechanical ventilation (breathing machine), artificial fluid and nutrition (feeding tubes), dialysis
(kidney machine), etc.
Initial the box next to your choice. Choose only one.
Initials

Initials

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I would always want life-sustaining treatments started and continued regardless of my
situation or how sick I am.
In some situations, I would want to be allowed to die naturally and not have life-sustaining
treatments.

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

PART III: LIVING WILL (Cont'd)
C - SPECIFIC PREFERENCES ABOUT LIFE-SUSTAINING TREATMENTS

This section is optional. It gives you a place to indicate your preferences about life-sustaining
treatments in particular situations. If you wish to provide this information, after each statement on
the left, initial the box that best answers the question, “In this situation, would you want to have
life-sustaining treatments?” Choose only one box for each statement.
Yes. I would want to
have life-sustaining
treatments.
If I am unconscious, in a
coma, or in a persistent
vegetative state and
there is little or no chance
of recovery

It would depend on
the circumstances.

No. I would not want to
have life-sustaining
treatments; I would want
to be allowed to die
naturally.

Initials

Initials

Initials

Initials

Initials

Initials

Initials

Initials

Initials

If I am confined to bed
and need a breathing
machine for the rest of
my life

Initials

Initials

Initials

If I have pain or other
severe symptoms that
cannot be relieved

Initials

Initials

Initials

Initials

Initials

Initials

If I have permanent
severe brain damage
(for example, severe
dementia) that makes me
unable to recognize my
family or friends
If I have a permanent
condition that makes me
completely dependent on
others for my daily needs
(for example, eating,
bathing, toileting)

If I have a condition that
will cause me to die very
soon, even with lifesustaining treatments
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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

PART III: LIVING WILL (Cont'd)
D - ADDITIONAL COMMENTS

Use this space to write any other preferences about your health care that are important to you and
that are not described elsewhere in this document. This may include general preferences about
how you would like to be cared for or specific requests. For example, you might have clear
opinions about whether you would want a particular treatment (for example, a feeding tube or
blood transfusions). You might want to comment on treatment of pain, or whether you would want
life-sustaining treatments on a trial basis. Or you might want to write about your preferences
regarding treatment of mental illness.

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

PART IV: SIGNATURES
A - YOUR SIGNATURE
By my signature below, I certify that this form accurately describes my preferences.

Signature

Date
B - WITNESSES' SIGNATURES

Two people must witness your signature. VA employees of the Chaplain Service, Psychology
Service, Social Work Service, or nonclinical employees (e.g., Medical Administration Service,
Voluntary Service or Environmental Management Service) may serve as witnesses. Other
individuals employed by your VA facility may not sign as witnesses to the advance directive unless
they are family members.
Witness #1:
I personally witnessed the signing of this advance directive. I am not appointed as Health Care Agent in this advance
directive. I am not financially responsible for the care of the person making this advance directive. To the best of my
knowledge, I am not named in the person's will.
SIGNATURE

Date

Name (Printed or Typed)

Street Address

City, State and Zip Code

Witness #2:
I personally witnessed the signing of this advance directive. I am not appointed as Health Care Agent in this advance
directive. I am not financially responsible for the care of the person making this advance directive. To the best of my
knowledge, I am not named in the person's will.
SIGNATURE

Date

Name (Printed or Typed)

Street Address

City, State and Zip Code

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

PART V: SIGNATURE AND SEAL OF NOTARY PUBLIC (Optional)

This VA Advance Directive form does not have to be notarized to be valid in VA facilities. However,
you may need to have this document notarized for it to be recognized outside the VA health care
setting. Space for a Notary's signature and seal is included below.
On this

day of

, in the year of

, personally appeared before me
,

known by me to be the person who completed this document and acknowledged it as their free act
and deed. IN WITNESS WHEREOF, I have set my hand and affixed my official seal in the County
of
, State of
, on the date written above.
Notary Public

Commission Expires

.

[SEAL]

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