Advance Directives

In Nebraska, adults who are capable of making health care decisions generally have the right to
say yes or no to medical treatment. They also have the right to prepare a document known as an
Advance Directive. This document tells what medical treatment the individual would want in
the event he/she is unable to communicate that decision due to illness or injury. Every health
care provider is expected to honor that decision. This means an individual can sign a legally
binding document, which identifies exactly what a health care provider is to do if the individuals
is in the terminal or vegetative state from which there is no hope of recovery.

There are two common types of Advance Directives:

A Living Will states the kind of medical care the individual wants or does not if he/she
becomes unable to make his/her decisions.
A Power of Attorney names someone else to make those decisions if he/she becomes
unable to make his/her own decisions.

An advance directive generally takes effect only after the individual is unable to make decisions.
As long as the individual is able to make personal decisions, the healthcare provider will rely on
the individual, not the Advance Directive. The document can be changed or canceled at any
time. An Advance Directive is not required for admission to this facility. The facility does,
however, requiest to be informd of any directives that exist. Please check one of the following

o I do have an Advance Directive. A copy is filed with: ____________________________

o I do not have an Advance Directive and would like more information about them.
o I do not have an Advance Directive and don not want one at this time.

Related Issues

What would you want us to do in the event that the staff find you without a heartbeat and/or not
breathing?

o I want the facility staff to being CPR and call 911

o I want the facility staff NOT to begin CPR (DNR form must be filled out)

Resident Name: ___________________________________________________________

Resident Signature: ________________________________________________________

Family or Responsible Party: _______________________________ Date: ____________

Facility Representative: ____________________________________ Date : ____________

Review Dates: ______________________________________________________________