TENNESSEE - Advance Directive

2023. Reproduction and distribution by an organization or organized group without the written

permission of the National Hospice and Palliative Care Organization is expressly forbidden.

TENNESSEE

Advance Directive

Planning for Important Healthcare Decisions

Courtesy of CaringInfo

www.caringinfo.org

800-658-8898

CaringInfo, a program of the National Hospice and Palliative Care Organization (NHPCO), is a

national consumer engagement initiative to improve care and the experience of caregiving

during serious illness and at the end of life. As part of that effort, CaringInfo provides detailed

guidance for completing advance directive forms in all 50 states, the District of Columbia, and

Puerto Rico.

This package includes:

• Instructions for preparing your advance directive. Please read all the instructions.

• Your state-specific advance directive forms, which are the pages with the gray

instruction bar on the left side.

BEFORE YOU BEGIN

Check to be sure that you have the materials for each state in which you may receive

healthcare. Because documents are state-specific, having a state-specific document for each

state where you may spend significant time can be beneficial. A new advance directive is not

necessary for ordinary travel into other states. The advance directives in this package will be

legally binding only if the person completing them is a competent adult who is 18 years of age

or older, or an emancipated minor.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so you will

have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide you

through the process.

3. Talk with your family, friends, and physicians about your advance directive. Be sure the

person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy, scan, or take a photo of the form and

give it to the person you have appointed to make decisions on your behalf, your family,

friends, healthcare providers, and/or faith leaders so that the form is available in the event

of an emergency.

5. You may also want to save a copy of your form in your electronic healthcare record, or an

online personal health records application, program, or service that allows you to share your

medical documents with your physicians, family, and others who you want to take an active

role in your advance care planning.

INTRODUCTION TO YOUR TENNESSEE ADVANCE HEALTH CARE DIRECTIVE

This packet contains a legal document, known as a Tennessee Advance Directive, that

protects your right to refuse medical treatment you do not want, or to request treatment you do

want, in the event you lose the ability to make decisions yourself. This document is based on

forms created by the Tennessee Department of Health.

Page one includes an Appointment of Health Care Agent. This lets you name someone,

called an agent, to make decisions about your medical care — including decisions about life

support — if you can no longer speak for yourself. An agent can speak for you any time you are

unable to make your own medical decisions, not only at the end of life.

Pages two and three contain an Individual Instruction that lets you provide your wishes

regarding medical care in the event that you can no longer speak for yourself. In addition to

health care decisions, the individual instruction portion of the form also allows you to give

instructions regarding your other advance planning concerns, such as your burial wishes.

Finally, the individual instruction portion of the form allows you to make a declaration of your

wishes regarding organ donation.

You must fill out either page four or page five for the document to be effective.

How do I make my Tennessee Advance Health Care Directive legal?

You must sign your advance directive. Your signature must either be notarized or witnessed by

two competent adults. Either option is available with this form.

If you have your signature witnessed, the witnesses cannot be the person you name as your

agent. In addition, at least one of your witnesses must be a person 1) who is not related to you

by blood, marriage, or adoption; and 2) who will not inherit any part of your estate.

Whom should I appoint as my agent?

Your agent is the person you appoint to make decisions about your healthcare if you become

unable to make those decisions yourself. Your agent may be a family member or a close friend

whom you trust to make serious decisions. The person you name as your agent should clearly

understand your wishes and be willing to accept the responsibility of making healthcare

decisions for you.

You can appoint a second person as your alternate agent. The alternate will step in if the first

person you name as an agent is unable, unwilling, or unavailable to act for you.

Should I add personal instructions to my advance directive?

Yes! One of the most important reasons to execute an advance directive is to have your voice

heard. When you name an agent and clearly communicate to them what you want and don’t

want, they are in the strongest position to advocate for you. Because the future is

unpredictable, be careful that you do not unintentionally restrict your agent’s power to act in

your best interest. Be especially careful with the words “always” and “never.” In any event, be

sure to talk with your agent and others about your future healthcare and describe what you

consider to be an acceptable “quality of life.”

When does my agent’s authority become effective?

Your advance directive goes into effect when your designated physician determines that you are

no longer able to understand the significant benefits, risks, and alternatives to proposed

healthcare and to make and communicate a healthcare decision.

You retain the primary authority for your healthcare decisions as long as you are able to make

your wishes known.

Agent Limitations

Your agent will be bound by the current laws of

Tennessee

as they regard pregnancy and

termination of pregnancies.

What if I change my mind?

You may revoke all or part of your advance directive, except for the designation of an agent, at

any time you have capacity and in any manner that communicates an intent to revoke. This

could include tearing, burning, or otherwise destroying the document or simply stating orally

that you intend to revoke your advance directive.

You may revoke the designation of your agent only by a signed writing or by personally

informing your supervising health care provider. If your spouse is your agent, a decree of

annulment, divorce, dissolution of marriage, or legal separation automatically revokes his or her

power, unless you specify otherwise in your advance directive.

You can also draft a new advance directive. An advance directive that conflicts with an earlier

advance directive revokes the earlier directive to the extent of the conflict.

Mental Health Issues

These forms do not

expressly

address mental illness, although you can state your wishes and

grant authority to your agent regarding mental health issues. The National Resource Center on

Psychiatric Advance Directives maintains a website (https://nrc-pad.org/) with links to each

state’s psychiatric advance directive forms. If you would like to make more detailed advance

care plans regarding mental illness, you could talk to your physician and an attorney about a

durable power of attorney tailored to your needs.

What other important facts should I know?

Be aware that your advance directive will not be effective in the event of a medical emergency,

except to identify your agent. Ambulance and hospital emergency department personnel are

required to provide cardiopulmonary resuscitation (CPR) unless you have a separate physician’s

order, which are typically called “prehospital medical care directives” or “do not resuscitate

orders.” DNR forms may be obtained from your state health department or department of aging

(https://www.hhs.gov/aging/state-resources/index.html). Another form of orders regarding CPR

and other treatments are state-specific POLST (portable orders for life sustaining treatment)

(https://polst.org/form-patients/). Both a POLST and a DNR form MUST be signed by a

healthcare provider and MUST be presented to the emergency responders when they arrive.

These directives instruct ambulance and hospital emergency personnel not to attempt CPR (or

to stop it if it has begun) if your heart or breathing should stop.

TENNESSEE ADVANCE DIRECTIVE

PAGE 1 OF 5

APPOINTMENT OF HEALTH CARE AGENT

I, , give my agent named below

permission to make health care decisions for me if I cannot make decisions for

myself. If my agent is unavailable or is unable or unwilling to serve, the alternate

named below will take the agent’s place.

Agent:

Name:

Relation:

Address:

Phone #:

Alternate Agent:

Name:

Relation:

Address:

Phone #:

Other Instructions or Limitations for my Agent:

INSERT YOUR NAME

ADD YOUR AGENT’S

NAME, PHONE

NUMBER, RELATION

TO YOU, AND

ADDRESS

ADD YOUR

ALTERNATE

AGENT’S NAME,

PHONE NUMBER,

RELATION TO YOU,

AND ADDRESS

ADD ANY

LIMITATIONS OR

INSTRUCTIONS YOU

HAVE FOR YOUR

AGENT

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TENNESSEE ADVANCE DIRECTIVE

PAGE 2 OF 5

INDIVIDUAL INSTRUCTION

I, , hereby give these individual

instructions on how I want to be treated by my doctors and other health care

providers when I can no longer make those treatment decisions myself.

I want my doctors to help me maintain an acceptable quality of life including

adequate pain management. I do not consider the following conditions to be an

acceptable quality of life:

Permanent Unconscious Condition: I become totally unaware of people

or surroundings with little chance of ever waking up from the coma.

Permanent Confusion: I become unable to remember, understand, or

make decisions. I do not recognize loved ones or cannot have a clear

conversation with them.

Dependent in all Activities of Daily Living: I am no longer able to talk

clearly or move by myself. I depend on others for feeding, bathing,

dressing, and walking. Rehabilitation or any other restorative treatment will

not help.

nd-Stage Illnesses: I have an il

lness that has reached its final stages in

spite of full treatment. Examples: Widespread cancer that does not respond

anymore to treatment; chronic and/or damaged heart and lungs, where

oxygen is needed most of the time and activities are limited due to a feeling

of suffocation.

If my condition is irreversible – that is, it will not improve – I direct that medically

appropriate treatment be provided as indicated below. If I mark “No” below, I

authorize the withholding or withdrawal of such care:

Yes No

CPR (Cardiopulmonary Resuscitation): To make the heart beat

again and restore breathing after it has stopped. Usually this

involves electric shock, chest compressions, and breathing

assistance.

Yes No

Life Support / Other Artificial Support: Continuous use of

breathing machine, IV fluids, medications, and other equipment that

helps the lungs, heart, kidneys, and other organs to continue to

work.

Yes No

Treatment of New Conditions: Use of surgery, blood

transfusions, or antibiotics that will deal with a new condition but will

not help the primary illness.

Yes No

Artificially Provided Nourishment and Fluids: Use of tubes to

deliver food and water to patient’s stomach or use of IV fluids into a

vein which would include artificially delivered nutrition and hydration.

INSERT YOUR NAME

QUALITY OF LIFE

STATEMENT

CHECK THE BOXES

FOR CONDITIONS

THAT YOU DO NOT

CONSIDER AN

ACCEPTABLE

QUALITY OF LIFE

YOU CAN CHECK AS

MANY OF THESE

ITEMS AS YOU

WANT, OR ADD

ADDITIONAL

CONDITIONS IN

THE “OTHER

INSTRUCTIONS” ON

THE NEXT PAGE

TREATMENT

INSTRUCTIONS

CHECK THE “YES”

BOXES IF YOU

WANT TO RECEIVE

THE TREATMENT

CHECK THE “NO”

BOXES IF YOU DO

NOT WANT TO

RECEIVE THE

TREATMENT

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Palliative Care

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TENNESSEE ADVANCE DIRECTIVE

PAGE 3 OF 5

OTHER INSTRUCTIONS

ther Instructions (Optional)

Organ Donation (Optional)

pon my death, I DO NOT wish to make an anatomical gift

Upon my death, I wish to make the following anatomical gift (please mark one):

Any organ/tissue My entire body Only the following organs/tissues:

ADD OTHER

INSTRUCTIONS, IF

ANY, REGARDING

YOUR ADVANCE

CARE PLANS

THESE

INSTRUCTIONS CAN

FURTHER ADDRESS

YOUR HEALTH CARE

PLANS, SUCH AS

YOUR WISHES

REGARDING

HOSPICE

TREATMENT, BUT

CAN ALSO ADDRESS

OTHER ADVANCE

PLANNING ISSUES,

SUCH AS YOUR

BURIAL WISHES

ATTACH

ADDITIONAL PAGES

IF NEEDED

CHECK THE

APPROPRIATE

BOXES

IF YOU WANT TO

LIMIT YOUR

ANATOMICAL GIFT,

INDICATE THE

LIMITATION HERE.

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Palliative Care

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2023 Revised.

TENNESSEE ADVANCE DIRECTIVE

PAGE 4 OF 5

SIGNATURE

You

r signature must either be witnessed by two competent adults (Option A, below)

or notarized (Option B, below). If witnessed, neither witness may be the person you

appointed as your agent, and at least one of the witnesses must be someone who is

not related to you by blood, marriage, or adoption or entitled to any part of your

estate.

OPTION A:

SIGN WITH WITNESSES

Pri

ncipal’s name (please print or type)

Signature of Principal Date

(must be at least 18 or emancipated minor)

I am a competent adult and have not been named as the Principal’s agent. I

witnessed the Principal’s signature on this form.

Sig

nature of witness number 1 Date

I am a competent adult and have not been named as the Principal’s agent. I am

not related to the Principal by blood, marriage, or adoption and I am not entitled

to any portion of the Principal’s estate upon his or her death under any existing will

or codicil or by operation of law. I witnessed the Principal’s signature on this form.

Sig

nature of witness number 2 Date

PRINT YOUR NAME

SIGN AND DATE

YOUR ADVANCE

DIRECTIVE

SIGNATURE OF

WITNESS 1

SIGNATURE OF

WITNESS 2

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Palliative Care

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2023 Revised.

TENNESSEE ADVANCE DIRECTIVE

PAGE 5 OF 5

OPTION B:

SIGN BEFORE A NOTARY

Principal’s name (please print or type)

Signature of Principal Date

STATE OF TENNESSEE

COUNTY OF

I am a Notary Public in and for the State and County named above. The person

who signed this instrument is personally known to me (or proved to me on the

basis of satisfactory evidence) to be the person whose name is shown above as

the “Principal.” The Principal personally appeared before me and signed above or

acknowledged the signature above as his or her own. I declare under penalty of

perjury that the Principal appears to be of sound mind and under no duress, fraud,

or undue influence.

My commission expires:

Signature of Notary Public

Courtesy of CaringInfo

www.caringinfo.org

PRINT YOUR NAME

SIGN AND DATE

YOUR ADVANCE

DIRECTIVE

HAVE YOUR

SIGNATURE

NOTARIZED

Hospice and

Palliative Care

Organization

2023 Revised.