(Minnesota Health Care Directive) : Wakiiladayda Daryeelkayga Caafimaadka

Minnesota - Xulashada Qaabka
Go’aan ka gaarida Dayeelka nolosha iyo dawenta

ee qofka xoriyad loo siiyey
(Minnesota Health Care Directive)
• Macluumaadkani wuxuu bedelayaa nooc kata oo ku saabsan wakiilasho daryeele caafimaad oo la
sameeyey kan ka hor. (This document replaces any health care directive made before this one.)
• Dukumentigaan ma quseyo daaweynta electroconvulsive ama daaweynada dhimirka ee loogu talagalay
dadka maskaxda ka jiran. (This document doesn’t apply to electroconvulsive therapy or neuroleptic medications for mental
illness.)
• Waxaan siin doonaa qoraal koobi ah Wakiilkayga daryeelka caafimaad iyo kooxda daryeelka
caafimaadkayga markii la dhammeystiro. (I will give copies to my health care agents and health care teams when
completed.)
• Waxaan samaysan doonaa daryeele cusub daryeelkayga caafimaad haddii ay wax iska bedelaan
qorshahayga fog, doorshadayda, ama Hab raacayga guud. (I will make a new health care directive if my agents, goals,
preferences, or instructions change.)
Magaca (full name):____________________________ Taariikhda Dhalasheyda (date of birth):_____________

Ciwaanka (address): __________________________________________ Guriga # (home) ________________
Telefoonka gacanta # (cell) __________________________ Shaqada # (work) ________________________
Wakiiladayda Daryeelkayga Caafimaadka

(My health care agents)
Wakiilka daryeelka caafimaadka waa codkeyga haddii aan aniga sameyn Karin go’aamada nafteyda. Waxaan
aaminsanahay inuu noqdo qarankeyga, si aan u raaco tilmaamaha, iyo si sameynta go’aamada ku
saleysan waxa aan u baahanahay. Wakiiladeyda ugu yaraan 18 sano jir. Haddii aan doorto bixiyaha daryeelka
caafimaadkeyga inuu wakil iga noqdo, waxaan siinaya sababa hoos.
(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.)
Wakiilka Daryeelka Caafimaadka (Health care agent)
Magaca (full name) ______________________________________________________________________
Wawaxa aan isku nahay (Relationship to me)_________________________________________________
Ciwaanka (address) __________________________________ Guriga # (home) _____________________
Telefoonka gacanta # (cell) ________________________ Shaqada # (work) _______________________
Qofka kale ee Koowaad ee Wakiilka Daryeelka Caafimaadka—Haddii wakiilkeyga caafimaadka uusan

rabin, awoodin, surtagal aheyn in la helo.
(First alternate health care agent—if my health care agent isn’t willing, able, or reasonably available.)
Magaca (full name) ______________________________________________________________________
524357so Rev 4/21 MINNESOTA HEALTH CARE DIRECTIVE - SOMALI Page 1 of 4
Advance Directives and Living Will ORIGINAL: Person PHOTOCOPY: Medical Record
Magaca (Name)__________________________________ Taariikhda (Date) _________________
Qofka kale ee Labaad ee Wakiilka Daryeelka Caafimaadka—Haddii wakiilkeyga caafimaadka uusan rabin,
awoodin, surtagal aheyn in la helo. (Second alternate health care agent—if my first alternate agent isn’t willing, able, or
reasonably available.)
Magaca (full name) ______________________________________________________________________
Sababta aan u Doortay Wakiilada daryeelka Caafimaadkaan (Why I chose these health care agents):
__________________________________________________________________________________________________
Wakiilada Daryeelka Caafimaadka: Awoodaha iyo Xaaladdaha Gaarka ah

(Health Care Agents: Powers and Special Situations)
Haddii aan awoodin inaan sameyo go’aamadeyda daryeelka caafimaadka, wakiilka daryeelka caafimaadka ayaa
awoodda: isticmaali kara diiwaanada caafimaadkeyga, go’aamiyo markii aan bilaabayo iyo marka aan joojinayo
daaweynta, iyo doorashada kooxda daryeelka caafimaadkeya iyo goobta daryeelka.
(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.)
Waxaan sidoo kale rabaa wakiilka daryeelka caafimaadkeyga inuu (I also want my health care agent to):
Samey go’aamada ku saabsan sii wadista uurka haddii aan sameyn karin.
(Make decisions about continuing a pregnancy if I can’t make them myself.)
Samey go’aamada ku saabsan daryeelka jirka kadib dhimashada (baarisa, duugta, gubida). (Make decisions
about the care of my body after death—autopsy, burial, cremation).
Doorkayga Daryeelkeyga Mustaqbalka Haddii aan Gabi ahaan Miir Daboolmo

(My Future Care Preferences if I’m Permanently Unconscious)
Miir daboolmida Joogtada ah waxaa keeni kara shiil, istrook, iyo xanuunada kale. Kooxdeyda daryeelka
caafimaadka waxaa ugu yeeri karaan Xaaladd miyir daboolid joogto ah. Tani waxay ka dhigan tahay inay
maskaxda ay six xun u dhawancan tahay qof ma iska warqabo ama kuwa kale, ma fahimi karo ama ma hadli
karo, iyo kooxda daryeelkeyga caafimaadka waxay rumeysanyihiin in uu qofka uu soo kabaneynin.
(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.)
Farsamada iyo daaweynta macmalka ah ayaa ka dhigi karaa qofka inuu noolaado marka uu jirka shaqeyneynin.
Tusaale ahaan: hawada (mashiinka neefta) marka ay sababada shaqeynaynin, wadno soo celinta (CPR) si lag
isku dayo inuu dib dib u shaqeyo marka uu joojiyo garaacida, ku quudinta tuubyada macmalka ah, cabitaanada
xidida laga qaato, iyo kilyo dhaqimada markii ay kilayaha shaqada joojiyaan.
(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.)
Haddii aan si joogto ah u miir beelo (if I’m permanently unconscious):

Waxaan rabaa qaar ama dhammaan daaweynta taageerida-nolosha haddii aan si joogto ah u miir
daboolmo. Wakiilka daryeelka caafimaadkeyga waa inuu la shaqeyaa kooxdeyda daryeelka caafimaadka
si loo go’aamada ku saleysan daaweynta hadafyada iyo heerarka.
(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.)
AMA (OR)
Ma rabo daaweynta taageerida-nolosha haddii aan si joogto ah miir daboolmo. Xooga saar inaad ii
qanciso aniga iyo ii ogolow dhismada dabiiciga ah.
(I don’t want life-sustaining treatments if I’m permanently unconscious. Focus on making me comfortable and allow natural
death.)
AMA (OR)
Hadda ma sameyn karo wax ku saabsan daawoyinka taageerida-nolosha haddii aan si joogto ah miir
daboolmo. Wakiilka daryeelkeyga caafimaadka waa in uu la shaqeya kooxda daryeelka caafimaadka si
looga go’aamiyo haddii aan isticmaalayo daawooyinka taageerida-nolosha iyo haddii kale ee ku saleysan
hadafyadeyda iyo heerarka.
(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.)
Ku deeqid Xubninta
(Organ Donation)
Waxaan rabaa inaan ku deeqo indhaheyga, xuubka iyo/ama xunaha, haddii aan awoodo. Wakiilka
daryeelka caafimaakeyga waxaa laga yabaa inu bilaabo iyo sii wado daaweynta baahan yahay ilaa ku
deeqida laga dhammeystiro.
(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.)
Ma rabo inaan ku deeqo indhaheyga, xuubka iyo/ama xubnaha.
(I don’t want to donate my eyes, tissues and/or organs.)
Tilmaamaha Dheeraadka ah
(Additional instructions):
Waxan ku lifaaqay #______ bogga(yada) ee tilmaamaha dukumentigan.
(I have attached #______ page(s) of additional instructions to this document.)

Ka dhigida Dukumentigaan Sharci

(Making this document legal)
1. Saxiixa iyo taariikhda (sign and date):
__________________________________________________ _____________________________
Saxiixeyga (My signature) Taariikhda la Sixiiay (Date signed)
2. Saxiixagaaga ma la xaqiijiyay ama 2 marqaati ma saxiixday. (Have your signature notarized OR verified by
2 witnesses)
MINNESOTA NOTARY PUBLIC NOTARY SEAL BELOW
(NOOTAAYADA DADWEYNAHA EE MINNESOTA): (SHABADA NOOTAAYADA HOOSE)
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.
Gobolka ___________________________(magaca gobolka)

Waxaan xaadir ahaa taariikhda ________ (taariikhda la cadeyey)
__________________________________(qofka kor saxiixay)
oganashaha saxiixdooda ee dukumentigan. Ma iihi wakiilka daryeelka
caafimaadka dukumentigam.
Signature of Notary (Saxiixa Nooteeyada) ___________________________________________________
AMA (OR)
CADEYNTA MARQAATIGA: Ugu yaraan waxaan jiraa 18 sano. Ma iihi wakiilka daryeelka
caafimaadka ee ku magacaban dukumentigan. Hal marqaati oo kaliya wuxuu la shaqeyn kraa nidaamka
daryeelka caafimaadka ee qof taariikhdaan.
(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.)
Saxiixa Marqaatiga #1 (Witness # 1 Signature) _______________________________________________

Taariikhda la Saxiixay (Date Signed)_____________________________
Qor Magaca (Printed Name) ____________________________________________________
Saxiixa # Marqaatiga #2 (Witness # 2 Signature) _____________________________________________

Taariikhda la Saxiixay (Date Signed)_____________________________
Qor Magaca (Printed Name) ____________________________________________________


(Minnesota Health Care Directive) : Wakiiladayda Daryeelkayga Caafimaadka

Uploaded by

Copyright:

Available Formats

(Minnesota Health Care Directive) : Wakiiladayda Daryeelkayga Caafimaadka

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

(Minnesota Health Care Directive) : Wakiiladayda Daryeelkayga Caafimaadka

Uploaded by

Copyright:

Available Formats

Minnesota - Xulashada Qaabka

Go’aan ka gaarida Dayeelka nolosha iyo dawenta

Magaca (full name):________________ Taariikhda Dhalasheyda (date of birth):_

Wakiiladayda Daryeelkayga Caafimaadka

Qofka kale ee Koowaad ee Wakiilka Daryeelka Caafimaadka—Haddii wakiilkeyga caafimaadka uusan

Wakiilada Daryeelka Caafimaadka: Awoodaha iyo Xaaladdaha Gaarka ah

Doorkayga Daryeelkeyga Mustaqbalka Haddii aan Gabi ahaan Miir Daboolmo

Haddii aan si joogto ah u miir beelo (if I’m permanently unconscious):

524357so Rev 4/21 MINNESOTA HEALTH CARE DIRECTIVE - SOMALI Page 3 of 4

Ka dhigida Dukumentigaan Sharci

County of _________________________________(county name)

Gobolka ___________________________(magaca gobolka)

Signature of Notary (Saxiixa Nooteeyada) ___________________________________________________

Saxiixa Marqaatiga #1 (Witness # 1 Signature) _______________________________________________

Saxiixa # Marqaatiga #2 (Witness # 2 Signature) _____________________________________________

524357so Rev 4/21 MINNESOTA HEALTH CARE DIRECTIVE - SOMALI Page 4 of 4

You might also like