Kuv Cov Neeg Sawv Cev Saib Xyuas Mob Nkeeg. (My Health Care Agents)

Transcription

1 Rau cov neeg uas muaj mob tsis txawj zoo/mob hnyav (MN Health Care Directive for Patients with a Chronic/Serious Illness) Daim ntawv no hloov rau txhua daim ntawv sau txog kev saib xyuas mob nkeeg uas sau ua ntej daim no. (This document replaces any health care directive made before this one.) Daim ntawv no tsis siv rau kev kho mob nrog hluav taws xob (electroconvulsive) los sis kho mob hlwb (neuroleptic) rau kev puas hlwb. (This document doesn t apply to electroconvulsive therapy or neuroleptic medications for mental illness.) Kuv yuav muab ib co ntawv theej rau kuv cov chaw saib xyuas mob nkeeg thiab pawg kws saib xyuas mob nkeeg thaum ua tiav. (I will give copies to my health care agents and health care teams when completed.) Kuv yuav sau ib daim ntawv tshiab hais txog kev saib xyuas mob nkeeg yog kuv cov chaw kho mob, cov hom phiaj, kev nyiam, los sis cov lus qhia txawv txav. (I will make a new health care directive if my agents, goals, preferences, or instructions change.) Kuv Lub Npe thiab Xeem (Name) Kuv Lub Hnub Yug (date of birth): Kuv Qhov Chaw Nyob (Address) Xovtooj ntawm tes # (Cell #) Hauv Tsev # (Home #) Chaw ua haujlwm # (Work #) Kuv Cov Neeg Sawv Cev Saib Xyuas Mob Nkeeg (My Health Care Agents) Kuv tus neeg sawv cev saib xyuas mob nkeeg yog tus ua hauj lwm tam rau kuv tau yog kuv tus kheej tsis tuaj yeem txiav txim siab txog kev kho mob rau kuv tau lawm. Kuv ntseeg tias kuv tus neeg sawv cev yuav yog kuv tus kws qhia, yuav ua raws li kuv cov lus qhia, thiab yuav txiav txim siab raws li yam kuv xav tau. Kuv cov neeg sawv cev yuav tsum muaj hnub nyoog tsawg kawg yog 18 xyoo. Yog kuv xaiv kuv tus kws kho mob yog tug neeg sawv cev tam, Kuv muaj lub lawj thawj (reason) raws li hauv qab no. (My health care agent is my voice if I can t make health care decisions for myself. I trust my agent to be my advocate, to follow my instructions, and to make decisions based on what I would want. My agents are at least 18 years old. If I chose my health care provider to be an agent, I have given my reason below.) Tus Neeg Sawv Cev Saib Xyuas Mob Nkeeg (Health Care Agent) Lub Npe (Name) Kev txheeb ze rau kuv (Relationship to me) Chaw nyob (Address) Xovtooj ntawm tes # (Cell #) Chaw ua haujlwm # (Work #) Hauv Tsev # (Home #) 1628hg Rev 08/18 MN HEALTH CARE DIRECTIVE: RECOMMENDED FOR ADULTS Page 1 of 7

2 Thawj Txoj Hau Kev Xaiv Tus Neeg Sawv Cev Saib Xyuas Mob Nkeeg Yog kuv tus neeg saib xyuas mob nkeeg tsis txaus siab, tsis tuaj yeem ua tau, los sis tsis khoom. (First alternate health care agent if my health care agent isn t willing, able, or reasonably available.) Lub Npe (Name) Kev txheeb ze rau kuv (Relationship to me) Chaw nyob (Address) Xovtooj ntawm tes # (Cell #) Chaw ua haujlwm # (Work #) Hauv Tsev # (Home #) Tus Neeg Sawv Cev Saib Xyuas Mob Nkeeg Thib Ob Yog kuv thawj tus neeg saib xyuas mob nkeeg tsis txaus siab, tsis tuaj yeem ua tau, los sis tsis khoom. (Second alternate health care agent if my first alternate agent isn t willing, able, or reasonably available.) Lub Npe (Name) Kev txheeb ze rau kuv (Relationship to me) Chaw nyob (Address) Xovtooj ntawm tes # (Cell #) Chaw ua haujlwm # (Work #) Hauv Tsev # (Home #) Vim li cas kuv thiaj li xaiv cov neeg sawv cev saib xyuas mob nkeeg no (Why I chose these health care agents): Cov Neeg Sawv Cev Saib Xyuas Mob Nkeeg: Lub Hwj Chim thiab Thaum Muaj Tej Yam Tshwj Xeeb (Health Care Agents: Powers and Special Situations) Yog kuv tsis tuaj yeem txiav txim siab saib xyuas mob nkeeg rau kuv tus kheej tau, kuv tus neeg sawv cev saib xyuas mob nkeeg tuaj yeem: tau txais kuv cov ntaub ntawv kho mob teev tseg, txiav txim siab thaum yuav pib kho mob thiab tso tseg kho mob, thiab xaiv kuv pawg kws saib xyuas mob nkeeg thiab muab kev saib xyuas rau kuv. (If I m not able to make my own health care decisions, my health care agent can: access my medical records, decide when to start and stop treatments, and choose my health care team and place of care.) Kuv kuj xav kom kuv tus neeg sawv cev saib xyuas mob nkeeg mus ua (I also want my health care agent to): Txiav txim siab txog cev xeeb menyuam zaum txuas mus ntxiv yog kuv tus kheej tsis tuaj yeem txiav txim siab tau. (Make decisions about continuing a pregnancy if I can t make them myself.) Txiav txim siab txog kev saib xyuas kuv lub cev tom qab tag sim neej (kev phais thaum tuag lawm, kev faus, kev hlawv lub cev) (Make decisions about the care of my body after death autopsy, burial, cremation). 1628hg Rev 08/18 MN HEALTH CARE DIRECTIVE: RECOMMENDED FOR ADULTS Page 2 of 7

3 Kuv Cov Hom Phiaj thiab Kev Ntseeg Muaj Nuj Nqi (My Goals and Values) Cov nqe lus teb no yuav raug siv coj los pab txiav txim siab txog kev saib xyuas mob nkeeg yog kuv tus kheej tsis tuaj yeem txiav txim siab tau. (These answers should be used to help make health care decisions if I can t make them myself.) Peb yam uas tsis yog kev kho mob uas kuv xav kom lwm tus neeg paub txog ntawm kuv yog (three non-medical things I want others to know about me): Yam uas rau kuv muaj zog los sis ua rau kuv muaj nyob ntxiv mus tau lub sij hawm nyuaj (what gives me strength or keeps me going in difficult times): Yam kuv txhawj xeeb thiab ntshai txog kuv li kev noj qab haus huv (my worries and fears about my health): Kuv cov hom phiaj yog kuv qhov mob tsis zoo (my goals if my health gets worse): Yam kuv xav kom lwm tus neeg paub txog kuv li kev ntseeg, kev cai dab qhuas, kab lis kev cai, los sis lwm yam kev ntseeg yog (what I want others to know about my spiritual, cultural, religious, or other beliefs): Yam uas ua rau kuv txoj sia muaj nuj nqi thaum ua neeg nyob (things that make my life worth living): Thaum kuv ze qhov yuav tag sim neej, kuv xav tau kev nyob nyab xeeb thiab kev pab los ntawm (when I am nearing death, I would find comfort and support from): Kuv qhov kev xav txog kev tag sim neej zoo yog (my idea of a good death is): 1628hg Rev 08/18 MN HEALTH CARE DIRECTIVE: RECOMMENDED FOR ADULTS Page 3 of 7

4 Kev Kho Pab Txoj Sia Nyob Ruaj Ntseg (Life-Sustaining Treatments) Kev kho mob los ntawm tej yam khoom siv los sis khoom siv cuav tuaj yeem ua rau ib tug tib neeg muaj txoj sia nyob tau thaum lub cev tsis tuaj yeem ua hauj lwm lawm. Piv txwv muaj li: kev ua pa (tshuab pab ua pa) thaum cov ntsws tsis ua hauj lwm, kev pab nias kom lub plawv nres lawm rov ua hauj lwm (CPR) tau, kev tso cua ua pa raws cov thoj yas ua pa, kev tso zaub mov yug lub cev raws txoj thoj yas (IV), thiab kev lim ntshav thaum ob lub raum tsis ua hauj lwm. (Mechanical or artificial treatments may keep a person alive when the body can t function on its own. Examples are: ventilation (breathing machine) when the lungs aren t working, cardiopulmonary resuscitation (CPR) to try to restart a heart that has stopped beating, artificial feeding through tubes, intravenous (IV) fluids, and dialysis when the kidneys aren t working.) Kev Saib Xyuas Kuv Rau Yav Tom Ntej Thaum Kuv Tsis Nco Qab Lawm Li (My future care preferences if I m permanently unconscious) Kev tsis nco qab lawm li tuaj yeem tshwm sim tau los ntawm ib qhov xwm txheej raug teeb meem (accident), mob hlab ntsha tawg, thiab lwm yam mob. Kuv pawg kws saib xyuas mob nkeeg hu qhov no tias nyob rau kis tsis nco qab mus ib txhis. Qhov no txhais tau tias lub hlwb raug mob phem uas ua rau tus neeg no tsis paub nws tus kheej los sis tsis paub lwm tus neeg, tsis nkag siab los sis tsis tuaj yeem tham nrog lwm tus neeg tau, thiab pawg kws saib xyuas mob nkeeg ntseeg tias tus neeg no yuav zoo tsis taus rov los lawm.(permanent unconsciousness can be caused by an accident, a stroke, and other illnesses. My health care team may call this a permanent vegetative state. This means the brain is so badly hurt that the person isn t aware of self or others, can t understand or communicate, and the health care team believes the person won t get better.) Yog tias kuv tsis tsim rov qab (if I m permanently unconscious): Kuv xav kom qee los sis txhua qhov kev kho mob pab txoj sia nyob ruaj ntseg yog tias kuv tsis tsim rov qab los lawm. Kuv tus neeg sawv cev saib xyuas mob nkeeg yuav tsum ua hauj lwm nrog kuv pawg kws saib xyuas mob nkeeg los mus muab kev txiav txim siab hais txog kev kho mob rau kuv raws kuv cov hom phiaj thiab kev ntseeg muaj nuj nqi. (I want some or all possible life-sustaining treatments if I m permanently unconscious. My health care agent should work with my health care team to make decisions about treatments based on my goals and values.) LOS SIS (OR) Kuv tsis xav tau kev kho mob pab txoj sia nyob ruaj ntseg yog tias kuv tsis tsim rov qab los lawm. Npaj ua kom kuv nyob nyab xeeb thiab cia kuv tag txoj sia raws li keeb kwm tuag.(i don t want lifesustaining treatments if I m permanently unconscious. Focus on making me comfortable and allow natural death.) LOS SIS (OR) Kuv tsis tuaj yeem txiav txim siab txog qhov kev kho mob pab txoj sia nyob ruaj ntseg yog tias kuv tsis tsim rov qab los lawm. Kuv tus neeg sawv cev saib xyuas mob nkeeg yuav tsum ua hauj lwm nrog kuv pawg kws saib xyuas mob nkeeg txiav txim siab puas muaj kev kho mob pab txoj sia nyob ruaj ntseg los sis tsis muaj cov kev kho mob raws li kuv cov hom phiaj thiab kev ntseeg muaj nuj nqi. (I can t make a decision now about life-sustaining treatments if I m permanently unconscious. My health care agent should work with my health care team to decide whether or not to use life-sustaining treatments based on my goals and values.) 1628hg Rev 08/18 MN HEALTH CARE DIRECTIVE: RECOMMENDED FOR ADULTS Page 4 of 7

5 Kuv Qhov Kev Ntshaw Kev Saib Xyuas Yav Tom Ntej Thaum Kuv Mob Yuav Tuag Tiag Lawm (My future care preferences if I m terminally ill) Kev mob yuav tuag tiag lawm yog tsis tuaj yeem kho tau lawm thiab yeej yuav tag sim neej rau yav tom ntej sai. Qhov no yog vim los ntawm: cov khoom tseem ceeb hauv lub cev nruab nrog tsis ua hauj lwm (nrog rau plawv nres tsis ua hauj lwm lawm, lub ntsws tsis ua hauj lwm lawm, raum tsis ua hauj lwm lawm, thiab lub siab tsis ua hauj lwm lawm), mob khees xaws (cancer), mob puas hlwb, mob plawv nres los sis mob hlab ntsha tawg, thiab lwm yam mob. (A terminal condition means no cure is possible and death is expected in the near future. This can be caused by: failure of vital organs (including end-stage heart failure, lung failure, kidney failure, and liver failure), advanced cancer, advanced dementia, a massive heart attack or stroke, and other causes.) Yog tias kuv mob yuav tuag tiag (if I m terminally ill): Kuv xav kom qee los sis txhua qhov kev kho mob pab txoj sia nyob ruaj ntseg yog tias kuv mob yuav tuag tiag lawm. Kuv tus neeg sawv cev saib xyuas mob nkeeg yuav tsum ua hauj lwm nrog kuv pawg kws saib xyuas mob nkeeg los mus muab kev txiav txim siab hais txog kev kho mob rau kuv raws kuv cov hom phiaj thiab kev ntseeg muaj nuj nqi. (I want some or all possible life-sustaining treatments if I m terminally ill. My health care agent should work with my health care team to make decisions about treatments based on my goals and values.) LOS SIS Kuv tsis xav kom muaj kev kho mob pab txoj sia nyob ruaj ntseg yog tias kuv mob yuav tuag tiag lawm. Npaj ua kom kuv nyob nyab xeeb thiab cia kuv tag txoj sia raws li keeb kwm tuag. (I don t want life-sustaining treatments if I m terminally ill. Focus on making me comfortable and allow natural death.) LOS SIS Kuv tsis tuaj yeem txiav txim siab rau kev kho mob pab txoj sia nyob ruaj ntseg yog tias kuv mob yuav tuag tiag lawm. Kuv tus neeg sawv cev saib xyuas mob nkeeg yuav tsum ua hauj lwm nrog kuv pawg kws saib xyuas mob nkeeg los mus muab kev txiav txim siab tias yuav muaj kev kho mob pab txoj sia kom nyob ruaj ntseg los tsis muab cov kev kho mob raws li kuv cov hom phiaj thiab kev ntseeg muaj nuj nqi. (I can t make a decision now about life-sustaining treatments if I m terminally ill. My health care agent should work with my health care team to decide whether or not to use life-sustaining treatments based on my goals and values.) Kev Muab Khoom Hauv Nruab Nrog Cev Pub Rau Lwm Tus (Organ Donation) Kuv xav muab kuv ob lub qhov muag, cov npluag nqaij thiab/los sis cov khoom hauv nruab nrog cev pub rau lwm tus, yog kuv tuaj yeem muab tau. Kuv tus neeg sawv cev saib xyuas mob nkeeg yuav pib thiab txuas ntxiv kev kho mob rau kuv tom qab kev muab khoom nruab nrog cev pub rau lwm tus tiav lawm. (I want to donate my eyes, tissues and/or organs, if I can. My health care agent may start and continue any treatments needed until the donation is complete.) Kuv tsis kam muab kuv ob lub qhov muag, cov npluag nqaij thiab/los sis cov khoom hauv nruab nrog cev pub rau lwm tus. (I don t want to donate my eyes, tissues and/or organs.) 1628hg Rev 08/18 MN HEALTH CARE DIRECTIVE: RECOMMENDED FOR ADULTS Page 5 of 7

6 Tom Qab Kuv Tuag (After I Die) Ntawm no yog kuv kev xav tau hais txog yuav ua li cas rau kuv lub cev tom qab kuv tag sim neej lawm (kev phais lub cev thaum tuag, kev faus, kev hlawv los lwm yam ntxiv ) thiab kuv xav kom ua kev hmov tshua li cas (kev tshaj tawm xov xwm ploj tuag, kev ua lub ntees, kev ua kev hmov tshua, los lwm yam ntxiv): (These are my wishes about what to do with my body after I have died (autopsy, burial, cremation, etc.) and how I wish to be remembered (obituary, funeral, memorial service, etc.) Lwm Yam Lus Qhia Ntxiv (Additional instructions) Kuv tau muab # nplooj ntawv tso nrog) cov lus qhia ntxiv rau cov ntaub ntawv no. (I have attached # page(s) of additional instructions to this document.) 1. Kos npe thiab hnub tim (Sign and date): Kev Sau Cov Ntaub Ntawv Raug Cai No (Making this document legal) Kuv kev Kos Npe (My signature) Hnub Tim Kos Npe (Date signed) 2. Kom muaj 2 tug neeg ua pov thawj lees paub koj qhov kos npe LOS SIS tau pom zoo nrog. (Have your signature notarized OR verified by 2 witnesses) MINNESOTA NOTARY PUBLIC (TSOOM FWV MINNESOTA QHOV KEV LEES PAUB) County of (county name) In my presence on the date of (date notarized) (person signing above) acknowledged their signature on this document. I am not named as a healthcare agent in this document. (Cheeb tsam nroog ntawm (lub npe cheeb tsam nroog). Hauv hnub tim kuv hais (hnub lees paub) (tus neeg kos npe saum toj sauv) tau lees paub lawv qhov kev kos npe rau daim ntawv no. Kuv tsis yog tus sau npe yog tus neeg sawv cev saib xyuas mob nkeeg tus sawv cev nyob hauv cov ntaub ntawv no.) NOTARY SEAL BELOW (NTAUS THWJ DAIM NTAWV LEES PAUB HAUV QAB NO) Signature of Notary (Kos Npe ntawm Tus Neeg Lees Paub) 1628hg Rev 08/18 MN HEALTH CARE DIRECTIVE: RECOMMENDED FOR ADULTS Page 6 of 7

7 LOS SIS (OR) COV LUS NTAWM TUS NEEG UA POV THAWJ: Kuv hnub nyoog tsawg kawg yuav tsum muaj 18 xyoo. Kuv tsis yog tus sau npe yog tus neeg sawv cev saib xyuas mob nkeeg nyob hauv cov ntaub ntawv no. Tsuas muaj ib tug neeg ua pov thawj thiaj li yog ib tug neeg ua hauj lwm ntawm feem saib xyuas mob nkeeg uas los muab kev saib xyuas mob nkeeg rau hnub no. (STATEMENT OF WITNESSES: I am at least 18 years old. I am not named as a health care agent in this document. Only one witness can be an employee of the health care system providing care to the person on this date.) Tus Neeg Ua Pov Thawj # 1 Kos Npe (Witness # 1 Signature) Hnub Tim Kos Npe (Date Signed) Sau Npe (Printed Name) Tus Neeg Ua Pov Thawj # 2 Kos Npe (Witness # 2 Signature) Hnub Tim Kos Npe (Date Signed) Sau Npe (Printed Name) 1628hg Rev 08/18 MN HEALTH CARE DIRECTIVE: RECOMMENDED FOR ADULTS Page 7 of 7

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