Advance Directives
As a patient at any University Community Health facility, you have the right to make decisions concerning your medical care, including the right to accept or refuse medical/surgical treatment. University Community Health wants to make it easier for you to express your wishes concerning your health care by filling out documents called Advance Directives. You will receive the same level of care at all University Community Health facilities whether or not you have an Advance Directive.

When you are admitted to a University Community Health hospital you will be asked if you have already completed an Advance Directive. If you have and have it with you, we will put a copy on your medical chart. If you have one and did not bring it with you, you will be asked if you wish to complete another one, unless there is a copy in your medical record from a previous admission.

You are not required to complete an Advance Directive. If you choose not to, simply indicate "no" on the questionnaire form.

Your Rights Under Florida Law
All adult individuals (those over the age of 18) who are competent (mentally able) to make their own decisions have the right to choose to receive or to refuse medical treatment or procedures. To prevent this right from being lost when a person cannot make his or her own decisions, Florida law allows each competent adult to document in advance what his or her wishes would be in certain circumstances using a Living Will and/or Designation of Health Care Surrogate.

Living Will
A Living Will allows you to direct, at a future time when you cannot make your own decisions, whether you want to have life-prolonging procedures given to you or have these procedures withheld or withdrawn if you are in a terminal condition, persistent vegetative state, or an end-stage condition.

Health Care Surrogate
A Health Care Surrogate is a person who is chosen by you, in writing, to make your health care decisions when you cannot. You may also designate an alternate surrogate who will be asked to make your decisions if your primary surrogate is unable or unwilling to perform his or her duties. Your surrogate’s role is to help make sure your wishes are carried out. Your surrogate will have the duty to consult with your health care providers, make decisions and give informed consent for you. A Living Will can make it easier for a surrogate to feel confident in knowing your wishes. Your surrogate should be aware you have chosen him or her, should agree to serve in the role and should be given a copy of all Advance Directives you have. In selecting who would be your surrogate, it is suggested that you choose someone who has shown special care and concern for you, has maintained regular contact with you and is familiar with your personal, religious, moral and/or cultural beliefs.

How to Make Advance Directives
The Living Will and Designation of Health Care Surrogate are legal documents. A form for each of these documents is suggested in Florida law. While you are in one of our hospitals, you may obtain a copy of either of these forms by asking your nurse or physician or by contacting the Case Management Department in the hospital where you are receiving care.

You may also click the links at the end of this page to download and print copies of University Community Health’s Advance Directive forms. Be sure to bring a completed copy of the form(s) with you if you come to the hospital.

You must be an adult (age 18 or older) and of clear mind when completing these forms. You must sign these documents in the presence of two adult witnesses. Only one witness may be your spouse or a blood relative. If you are designating a surrogate, the person you appoint as your health care surrogate or as an alternate surrogate cannot be a witness. If you are not physically able to sign your name, one of the two witnesses may sign your name in the presence of you and the other witness at your direction. These documents do not need to be notarized.

These documents are valid for as long as you do not revoke them, unless the document has an expiration date written on it. However, it is a good idea to look at the documents at least once year or as circumstances change.

Keep the original document and give copies to:

The individual you named as your health care surrogate (if applicable).
To the alternate health care surrogate, if you named one.
Your physician(s) or other primary health care providers.
Any family member you want to know your health care wishes.
Any hospital where you are admitted as a patient.
Nursing home or assisted living facility, if this is where you live.
Your attorney or spiritual advisor, if you wish.

If you are in the hospital and are completing one of these forms, please ask your nurse to make a copy to place in your medical record.

Revoking an Advance Directive
You may revoke (take back) a Living Will or Designation of Health Care Surrogate at any time. You may do this by doing any one of the following: Writing a letter, which you sign and date, stating that you want to revoke the Living Will and/or Designation of Health Care Surrogate. Physically canceling or destroying the original document. Stating verbally that the document is no longer in effect. Completing a later document that is different from the former document. If you decide at any time that you wish to revoke either your Living Will or Designation of Health Care Surrogate while you are in a University Community Health hospital, notify your nurse and the physician treating you as soon as possible. You should also take back and destroy all copies given to others as soon as possible.

Frequently Asked Questions
Is a Living Will the same as a will that disposes of property?
No. A will that disposes of property alone (without mention of health care decisions or designating a surrogate) serves a different purpose and is not the same.

Do I need both a Living Will and a Designation of Health Care Surrogate?
No. You can fill out either or both. However, we recommend that you consider filling out both, as it will give you documentation of your wishes and a person who is chosen by you to help make sure your wishes are carried out.

I have an Advance Directive from another state. Can I use it in Florida?
As long as the form meets Florida requirements, it should be honored in Florida. However, you may wish to complete a form that is specific to Florida in order to avoid any questions.

If I have an Advance Directive, will I automatically be a “No Code” or A “Do Not Resuscitate” when I am in the hospital?
No. If you are able to make your own decisions, you will certainly be asked before a “No Code” or “Do Not Resuscitate” order is written for you. If you are not able to make your own decisions in the future and were in a terminal condition, end stage condition or persistent vegetative state, your wishes as expressed in your Advance Directive and/or by your surrogate would determine whether a “No Code” or “Do Not Resuscitate” order would be considered by your physician.

Definition Of Terms
Terminal means a condition caused by injury, disease, or illness from which there is no reasonable chance of recovery and which, without treatment, can be expected to cause death.

End Stage Condition means an irreversible condition that is caused by injury, disease, or illness which has resulted in progressively severe and permanent deterioration and for which, to a reasonable degree of medical probability, treatment of the irreversible condition would be ineffective.

Persistent Vegetative State means a permanent and irreversible condition of unconsciousness in which there is the absence of voluntary action or intended behavior of any kind; and an inability to communicate or interact purposefully with the environment.

Life-Prolonging Procedure means any medical procedure, treatment, or intervention, including artificial feeding and fluids, that keeps a patient alive by supporting, restoring or taking the place of a vital body function. Examples of life-prolonging procedures are breathing tubes, breathing machines (ventilators), artificial respiration and circulation (CPR), defibrillation (electric shock of the heart) and medicines which are given during resuscitation to restore a normal heart rhythm. Life prolonging procedures do not include medicine or medical procedures that are intended to provide comfort to a patient or to ease pain.

These guidelines are based on current Florida law and are not intended to be legal advice. If you need further guidance or have questions while you are in any University Community Health hospital, please contact the Case Management Department at that facility.

Case Management Departments
University Community Hospital/Pepin Heart Hospital: (813) 615-7268 (outside the hospital) or ext. 57268 (inside the hospital)
University Community Hospital-Carrollwood: (813) 558-8045 (outside the hospital) or ext. 88045 (inside the hospital)
Helen Ellis Memorial Hospital: (727) 942-5188 (outside the hospital) or ext. 5188 (inside the hospital)

Forms
Click below to download a blank copy of University Community Health's Advance Directives. Be sure to bring a completed copy of the form(s) with you if you come to the hospital.

Designation of Health Care Surrogate
Living Will