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Mississippi Advance Directive Form

A Mississippi advance directive is a form that allows someone to choose someone else to decide on their healthcare-related matters. This can be extremely useful for older people and people with a high risk of injury, illness, or mental incapacitation. An advance directive is also known as medical power of attorney.

Signing Requirements (§ 41-41-209) – Two (2) adult witnesses or a notary public. The witnesses must be personally known by the principal.

Statutory Form

PART 1: POWER OF ATTORNEY FOR HEALTH CARE

(1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health-care decisions for me:

[NAME]
[ADDRESS, CITY, STATE, ZIP CODE]
[PHONE NUMBER] [PHONE NUMBER]

(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:

[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

If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out this part of the form. If you do fill out this part of the form, you may strike any wording you do not want.

(6) END-OF-LIFE DECISIONS: I direct that my health-care 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
[◻] (b) Choice To Prolong Life

(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 alleviation of pain or discomfort be provided at all times, even if it hastens my death: [EXCEPTIONS]

PART 3: PRIMARY PHYSICIAN (OPTIONAL)

(10) I designate the following physician as my primary physician:

[NAME]
[ADDRESS, CITY, STATE, ZIP CODE]
[PHONE NUMBER]

(11) EFFECT OF COPY: A copy of this form has the same effect as the original.
(12) SIGNATURES: Sign and date the form here:

_________________________________________ [DAY] day of [MONTH], 20[XX]
(sign your name)

[NAME]
[ADDRESS, CITY, STATE, ZIP CODE]

(13) WITNESSES: This power of attorney will not be valid for making health-care decisions unless it is either (a) signed by two (2) qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature; or (b) acknowledged before a notary public in the state.

Witness
I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code of 1972, that the principal is personally known to me, that the principal signed or acknowledged this power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as agent by this document, and that I am not a health-care provider, nor an employee of a health-care provider or facility. I am not related to the principal by blood, marriage or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

_________________________________________ [DAY] day of [MONTH], 20[XX]
(signature of witness)
[NAME]
[ADDRESS, CITY, STATE, ZIP CODE]

Witness

I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code of 1972, that the principal is personally known to me, that the principal signed or acknowledged this power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as agent by this document, and that I am not a health-care provider, nor an employee of a health-care provider or facility.

_________________________________________ [DAY] day of [MONTH], 20[XX]
(signature of witness)
[NAME]
[ADDRESS, CITY, STATE, ZIP CODE]