202A.430 Form of advance directive for mental health treatment. An advance directive for mental health treatment shall be in substantially the following form: "Advance directive for mental health treatment I, ___________, willfully and voluntarily execute this advance directive for mental health treatment. I want the instructions in this advance directive to be followed as described below. Designated surrogate ___I am naming a surrogate to see that my instructions for mental health treatment are carried out. ___I am not naming a surrogate to see that my instructions for mental health treatment are carried out. I designate ____________ to act as my surrogate. If this person withdraws or is unwilling to act on my behalf, or if I revoke that person's authority to act as my surrogate, I designate ____________ to act as my alternate surrogate. If I do not designate a surrogate, if my surrogate and alternate surrogate withdraw or are unwilling to act on my behalf, or if I revoke their authority to act, then the health care provider and health care facility may proceed to render treatment in accordance with my instructions as described here and in accordance with standards for mental and physical health care. The person acting as my surrogate is authorized to act in accordance with the content of this advance directive and may override the advance directive if, and only if, there is substantial medical evidence that failing to do so would result in harm to me. If my instructions and preferences are not stated in the advance directive, the surrogate may act in good faith in making treatment decisions in the manner in which the surrogate believes I would act. Psychotropic medication provisions I may indicate below any refusals of treatment with specific psychotropic medications, not to include an entire class of medications, due to factors that may include but are not limited to lack of efficacy, known drug sensitivity, or experience of adverse reaction: I specifically do not consent and do not authorize my surrogate to consent to the administration of the following medications or their respective brand-name or generic equivalents for the reasons given: Specific psychotropic medication Reason for refusal ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ I may list below any specific psychotropic medications that I would be willing to have administered to me if additional medications become necessary: Specific psychotropic medications ____________________________ ____________________________ ____________________________ ____________________________ Electroconvulsive therapy provisions Below are my instructions regarding electroconvulsive therapy (ECT): ____I consent to electroconvulsive therapy (ECT) if it is deemed clinically appropriate to treat my condition. ____I do not consent to electroconvulsive therapy (ECT). Preferred procedures for emergency interventions I may state preferences for procedures for emergency interventions to be used when necessary for my protection or the protection of others. I understand that I am requesting consideration of my preferences for procedures for emergency interventions but that my surrogate, my health care provider, and the health care facility where I am a patient are not subject to civil liability for not abiding by these preferences. I understand that in the case of possible harm to myself or others, my health care provider or the health care facility may need to use procedures that override my stated preferences. If during an admission or while a patient in a health care facility, it is determined that I am engaging in behavior that requires emergency intervention, my preferences regarding the procedures to be used during an emergency intervention and the order that I prefer the interventions to be used are as follows: Intervention Order of preference Reason for this preference Seclusion___________________________________________________________ Physical restraints____________________________________________________ Seclusion and physical restraint combined_____________________________________________________ Medication by injection_________________________________________________ Medication in pill form_________________________________________________ Liquid medication_____________________________________________________ Other:_______________________________________________________________ Signed this ____ day of _________, 20__ Signature of grantor:_________________________ Address of grantor:_____________________________________________________ _____________________________________________________________________ In my presence, the grantor voluntarily dated and signed this writing or directed it to be dated and signed. I am not the grantor's current health care provider, a relative of the current health care provider, or an owner, operator, employee or relative of an owner or operator of a health facility in which the grantor is a client or resident. Signatures of witnesses: _________________________________________________ _____________________________________________________________________ Surrogate contact information (if designated): Name:_______________________________ Address:______________________________ _____________________________________ Telephone:_____________________________ Signed this ____ day of _________, 20__ Signature of surrogate:____________________ Alternate surrogate contact information (if designated): Name:_______________________________ Address:______________________________ _____________________________________ Telephone_____________________________ Signed this ____ day of _________, 20__ Signature of alternate surrogate:______________________" Effective: June 24, 2003 History: Created 2003 Ky. Acts ch. 190, sec. 6, effective June 24, 2003.