KANSAS ADVANCE HEALTH CARE DIRECTIVE

(Living Will & Optional Health-Care Instructions)

[// GUIDANCE: This template complies with the Kansas Natural Death Act, Kan. Stat. Ann. § 65-28,101 et seq., and related Kansas health-care decision–making statutes current through the 2023 legislative session. Replace all bracketed items with client-specific data, remove guidance comments before execution, and review for consistency with any subsequently enacted amendments.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

1.1 Title.
 KANSAS ADVANCE HEALTH CARE DIRECTIVE (hereinafter, this “Directive”).

1.2 Declarant.
 Name: [DECLARANT FULL LEGAL NAME]
 Address: [STREET | CITY | STATE | ZIP]
 Date of Birth: [MM/DD/YYYY]

1.3 Effective Date.
 This Directive becomes effective upon the Declarant’s incapacity to make informed health-care decisions, as determined pursuant to Kan. Stat. Ann. § 65-28,103(c), and remains in effect until revoked in accordance with Section 5.2.

1.4 Governing Law.
 All matters arising under or related to this Directive shall be governed by and construed in accordance with the laws of the State of Kansas, without regard to conflict-of-laws principles.

1.5 Recitals.
 A. Declarant is an adult of sound mind and desires to control health-care decisions if unable to communicate.
 B. This Directive is executed pursuant to the Kansas Natural Death Act, Kan. Stat. Ann. § 65-28,101 et seq.
 C. Declarant intends that health-care providers act in accordance with the instructions herein and that providers acting in good faith shall be protected from liability to the fullest extent permitted by law.

2. DEFINITIONS

For purposes of this Directive, the following terms shall have the meanings set forth below:

2.1 “Adult” means an individual 18 years of age or older.
2.2 “Attending Physician” means the physician who has primary responsibility for the Declarant’s treatment and care.
2.3 “Declarant” has the meaning given in Section 1.2.
2.4 “Directive” means this Kansas Advance Health Care Directive, as amended from time to time.
2.5 “Health-Care Provider” means any person or facility licensed, certified, or otherwise authorized by law to provide medical care in Kansas.
2.6 “Life-Sustaining Procedure” means any medical procedure or intervention that when administered will serve only to prolong the process of dying, including mechanical ventilation, renal dialysis, and artificially-provided nutrition and hydration, except as otherwise expressly stated herein.
2.7 “Persistent Vegetative State” means a condition in which brain function is severely and irreversibly impaired, leaving the Declarant unaware of self or surroundings and unable to interact with others.
2.8 “Surrogate” means the person authorized under Section 3.6 to implement this Directive when the Declarant is incapacitated.
2.9 “Terminal Condition” means an incurable or irreversible condition that, in the opinion of the Attending Physician, will result in death within a relatively short time regardless of the application of Life-Sustaining Procedures.

[// GUIDANCE: Insert additional defined terms as needed and list alphabetically.]

3. OPERATIVE PROVISIONS

3.1 General Directive.
 If at any time I (the Declarant) am diagnosed with a Terminal Condition or am in a Persistent Vegetative State and lack capacity to make informed decisions, I direct that Life-Sustaining Procedures be [WITHHELD / WITHDRAWN] so that I may be permitted to die naturally, except as otherwise specifically provided below.

3.2 Artificial Nutrition & Hydration.
 ☐ I DO want artificially-provided nutrition and hydration.
 ☐ I DO NOT want artificially-provided nutrition and hydration if they only prolong the dying process.
 [INITIAL ONE OPTION]

3.3 Pain Relief & Comfort Care.
 I direct that medication or medical procedures necessary for my comfort and to alleviate pain be provided at all times, even if such measures may hasten death.

3.4 Pregnancy Exception (Required Under Kansas Law).
 If I am known to be pregnant, this Directive shall have no effect during the course of my pregnancy if Life-Sustaining Procedures would enable my fetus to be carried to live birth, unless otherwise permitted under Kansas law at the time of treatment.

3.5 Do-Not-Resuscitate (DNR) Order.
 ☐ I request a DNR order consistent with Kansas regulations and ask my Health-Care Providers to enter such order into my medical record.
 ☐ I do NOT request a standing DNR order at this time.
 [INITIAL ONE OPTION]

3.6 Appointment of Surrogate (Optional but Recommended).
 Name: [PRIMARY SURROGATE NAME]
 Relationship: [RELATIONSHIP]
 Address & Phone: [CONTACT INFORMATION]
 Successor Surrogate (if the above is unavailable):
 Name: [SECONDARY SURROGATE NAME]
 Relationship & Contact: [RELATIONSHIP / CONTACT]

3.7 Access to Medical Records.
 My Surrogate is authorized to receive and disclose my protected health information to the extent necessary to implement this Directive, pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and implementing regulations, 45 C.F.R. §§ 164.502 & 164.508.

3.8 Special Instructions.
 [INSERT ANY ADDITIONAL LIMITATIONS OR PRIORITIES, e.g., religious beliefs, organ donation, experimental treatments.]

4. REPRESENTATIONS & WARRANTIES

4.1 Capacity.
 Declarant represents that, at the time of execution, Declarant is of sound mind and not under duress.

4.2 Voluntariness.
 This Directive is executed voluntarily and after full consideration of its consequences.

4.3 Consistency With Insurance & Contracts.
 Declarant warrants that no provision of this Directive conflicts with any existing contract of insurance, annuity, or other agreement to which Declarant is a party. To the extent of any conflict, this Directive shall control Declarant’s health-care decisions.

4.4 Disclosure to Surrogate.
 Declarant has informed the Surrogate(s) named herein of the existence and substance of this Directive.

5. COVENANTS & RESTRICTIONS

5.1 Notification Responsibility.
 Declarant covenants to provide copies of this Directive to the Attending Physician, Health-Care Provider(s), Surrogate(s), and close family members.

5.2 Revocation.
 Declarant may revoke this Directive at any time and in any manner—including written revocation, physical destruction, oral statement of intent to revoke, or execution of a subsequent Directive—in accordance with Kan. Stat. Ann. § 65-28,104. Upon revocation, Declarant shall notify the Attending Physician and Surrogate(s) as soon as practicable.

5.3 Amendments.
 Any amendment must (a) be in writing, (b) clearly identify itself as an amendment to this Directive, (c) be executed with the same formalities as this Directive, and (d) be promptly communicated to the parties identified in Section 5.1.

6. DEFAULT & REMEDIES

6.1 Failure to Honor Directive.
 If any Health-Care Provider fails or refuses to honor this Directive, the Surrogate or any interested person may:
 (a) Request immediate transfer of the Declarant to a willing provider; and/or
 (b) Petition a court of competent jurisdiction for injunctive or declaratory relief to enforce the terms of this Directive.

6.2 Attorney Fees.
 A prevailing party in any action to enforce this Directive shall be entitled to reasonable attorney fees and costs incurred.

6.3 Escalating Remedies.
 Nothing in this Section limits any other remedies available under Kansas law.

7. RISK ALLOCATION

7.1 Provider Protection & Indemnification.
 A Health-Care Provider acting in good faith reliance on this Directive, or on any direction from an authorized Surrogate, shall not be criminally or civilly liable and shall be indemnified by the Declarant’s estate to the fullest extent permitted by Kan. Stat. Ann. § 65-28,107.

7.2 Limitation of Liability.
 No person shall be liable for honoring or failing to honor this Directive in good faith, provided that such person acted in accordance with generally accepted medical standards.

7.3 Insurance.
 [OPTIONAL] Declarant’s estate shall maintain, or cause to be maintained, liability insurance customary for risk mitigation in end-of-life health-care decisions.

8. DISPUTE RESOLUTION

8.1 Governing Law.
 See Section 1.4.

8.2 Forum Selection.
 Any action arising under this Directive shall be brought exclusively in the District Court of [COUNTY], Kansas.

8.3 Alternative Dispute Resolution.
 The parties may voluntarily submit any dispute to mediation, but no party is required to do so as a condition precedent to seeking judicial relief.

8.4 Jury Waiver.
 Not applicable.

8.5 Injunctive Relief.
 Nothing herein shall preclude any party from seeking immediate injunctive relief as contemplated in Section 6.1.

9. GENERAL PROVISIONS

9.1 Entire Agreement.
 This Directive constitutes the entire expression of Declarant’s wishes regarding the subject matter hereof and supersedes all prior directives.

9.2 Severability.
 If any provision of this Directive is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

9.3 Successors & Assigns.
 The rights and obligations herein shall inure to the benefit of, and be binding upon, Declarant’s heirs, executors, administrators, and personal representatives.

9.4 Counterparts; Electronic Signatures.
 This Directive may be executed in counterparts and by electronic signature with the same effect as an original.

10. EXECUTION BLOCK

[// GUIDANCE: Kansas allows EITHER two qualified witnesses OR a notary acknowledgment—choose one method only.]

10.1 Declarant Signature

I, [DECLARANT NAME], sign my name to this Kansas Advance Health Care Directive on this ___ day of ____, 20__, at [CITY], Kansas.

[DECLARANT SIGNATURE]

10.2 WITNESS ATTESTATION (Two Witnesses Required if Not Notarized)

We declare that the Declarant is personally known to us, appeared to be of sound mind, and signed or acknowledged this Directive in our presence without duress. We are at least 18 years old, not related to the Declarant by blood or marriage, not entitled to any portion of the Declarant’s estate, and not financially responsible for the Declarant’s medical care.

Witness #1
Name: _____
Address: _____
Signature: _____
Date: _______

Witness #2
Name: _____
Address: _____
Signature: _____
Date: _______

—OR—

10.3 NOTARY ACKNOWLEDGMENT

State of Kansas )
County of __ ) ss.

On this ___ day of ____, 20__, before me, the undersigned, a Notary Public in and for said county and state, personally appeared [DECLARANT NAME], known to me (or satisfactorily proven) to be the individual whose name is subscribed to the foregoing Directive, and acknowledged that he/she executed the same for the purposes therein contained.

IN WITNESS WHEREOF, I hereunto set my hand and official seal.

Notary Public
My Commission Expires: ___

[// GUIDANCE: After execution, provide copies to the Declarant’s primary physician, health-care facility, surrogate(s), and close family. Consider registering the Directive with any statewide electronic registry if available.]