1. Estate Planning »
  2. Advance Directive

Advance Directive Form

An advance directive is a document that allows a person (principal) to select someone else (agent) to make health care decisions on their behalf and select their end-of-life medical treatment preferences. Advance directives combine a medical power of attorney and a living will.

The signing requirements, in most states, involve the principal executing the form in the presence of a notary public or two (2) witnesses for it to be effective.

By State

What is an Advance Directive?

An advance directive includes 4 parts covering a patient’s designation to select a health care proxy and to make personal decisions about their treatment and body. It is requested by medical staff if a patient cannot speak for themselves to make important medical decisions.

4 Parts

  1. Medical Power of Attorney
  2. Living Will
  3. Donation of Organs
  4. Primary Care Physician

1. Medical Power of Attorney

A medical power of attorney is a designation given to grant someone else health care powers if a patient cannot speak for themselves. The agent selected is commonly a spouse or close family member that understands the patient’s medical preferences.

Depending on the state, a medical power of attorney must be signed by the patient and two (2) witnesses or a notary public (or both). It is not filed with any government agency. Therefore, the agent must present the medical power of attorney each time when acting on behalf of the patient.

2. Living Will

A living will outlines a patient’s medical preferences and instructions for medical staff if they cannot speak for themselves. This allows the patient to decide whether they would prefer to have feeding tubes and ventilation machines connected to prolong their life (even if there is no possibility of being healthy again).

3. Donation of Organs

The donation of organs section allows a patient to give all or only specific organs to the hospital after death. The patient can choose to have the organs be for the use of:

  • Transplant;
  • Therapy;
  • Research; and
  • Education.

4. Primary Physician

A primary physician may be entered to allow medical staff a resource to call and get more information about a patient’s condition. The name of the physician, including their phone number, is recommended.

Sample

ADVANCE HEALTH-CARE DIRECTIVE

PART 1. POWER OF ATTORNEY FOR HEALTH CARE

1. DESIGNATION OF AGENT: I designate the following individual as my agent to make healthcare decisions for me:

Agent’s Name: [NAME]
Agent’s Address: [ADDRESS]
Cell Phone: [PHONE]

2. AGENT’S AUTHORITY: My agent is authorized to make all health-care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here: [ENTER ANY EXCEPTIONS]

3. WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority becomes effective when my primary physician determines that I am unable to make my own health-care decisions unless I mark the following box.

If I mark this box ☐, my agent’s authority to make health-care decisions for me takes effect immediately.

4. AGENT’S OBLIGATION: My agent shall make health-care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health-care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

5. NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not willing, able, or reasonably available to act as guardian, I nominate the alternate agents whom I have named, in the order designated.

PART 2. INSTRUCTIONS FOR HEALTH CARE

6. END-OF-LIFE DECISIONS: I direct that my healthcare providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:

☐ – (a) Choice NOT To Prolong Life. I do not want my life to be prolonged if (i) I have an incurable and irreversible condition that will result in my death within a relatively short time, (ii) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (iii) the likely risks and burdens of treatment would outweigh the expected benefits, OR

☐ – (b) Choice To Prolong Life. I want my life to be prolonged as long as possible within the limits of generally accepted health-care standards.

7. ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutrition and hydration must be provided, withheld, or withdrawn in accordance with the choice I have made in paragraph (6) unless I mark the following box. If I mark this box ☐, artificial nutrition and hydration must be provided regardless of my condition and regardless of the choice I have made in paragraph (6).

8. RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for the alleviation of pain or discomfort be provided at all times, even if it hastens my death: [DESCRIBE TREATMENT PREFERENCES]

9. OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that: [DESCRIBE SPECIAL WISHES]

PART 3. DONATION OF ORGANS AT DEATH (OPTIONAL)

10. UPON MY DEATH: (mark applicable box)

☐ – (a) I give any needed organs, tissues, or parts, OR
☐ – (b) I give the following organs, tissues, or parts only: [LIST ORGANS]
☐ – (c) My gift is for the following purposes (strike any of the following you do not want)

    • (i) Transplant
    • (ii) Therapy
    • (iii) Research
    • (iv) Education

PART 4. PRIMARY PHYSICIAN (OPTIONAL)

11. PHYSICIAN DESIGNATION: I designate the following physician as my primary physician:

Physician’s Name: [NAME]
Agent’s Address: [ADDRESS]
Cell Phone: [PHONE]

12. SIGNATURES: Sign and date the form here:

Principal’s Signature: __________________ Date: [DAY] day of [MONTH], 20[XX]
Print Name: ___________________________________________________________
Address:  _____________________________________________________________