KRS 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 i nstructions 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 f actors 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 the ir respective brand -name or

generic equivalents for the reasons given:

Specific psychotropic medication Reason for refusal

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

I may list below any specific psychotropic medicati ons 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 pr eferences 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, o r 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:______________________"