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Advance Directive Form

An advance directive allows a patient to choose end-of-life treatment options and appoint an agent to make medical decisions on their behalf. It only becomes in effect if the patient is no longer able to make decisions for themselves due to incapacity or impairment.
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Four (4) Parts

By State

What if the Principal is ALREADY Incapacitated?

A family member or spouse must obtain guardianship rights if the principal is already incapacitated (i.e., cannot make decisions for themselves due to dementia or mental disability).

This can be obtained from a local court. Usually, a hospital will allow a spouse or close family member to act as the agent by default if no one else is available.

Advance Directive vs. Other Estate Forms

Form Healthcare Agent Decide Treatments Can Prohibit CPR
Advance Directive
Medical Power of Attorney
Living Will
Do Not Resuscitate (DNR)

How to Get an Advance Directive (5 steps)

1. Select an Agent

man interviewing potential medical agent

This is often referred to as the medical power of attorney portion, which requires the principal to select an agent to represent them in their healthcare decisions.

The agent may only act on behalf of the principal in a medical power of attorney if they cannot make decisions for themselves. The agent should understand the wishes of the principal and always keep their best interests in mind when making decisions.

Second (2nd) Agent: The principal is able to select a second agent to help in case the original agent is not able to perform. However, decision-making powers cannot be shared.

2. Decide the Powers

principal deciding on medical powers for agent

The principal will have to decide how much power to give the agent, such as:

  1. Immediate or Springing: Electing to have the powers begin immediately or upon the principal’s incapacitation;
  2. End-of-Life Treatments: Deciding to prolong the patient’s life as long as possible (even if there is no possible cure); and
  3. Post-Death: Selecting any post-death responsibilities (e.g., ordering an autopsy, where the remains are kept, etc.).

Any other powers should be mentioned verbally to the agent.

3. Choose End-of-Life Options

principal researching end-of-life options on computer

For the living will section, this allows the principal to select their end-of-life care option if they should become in an incurable situation.

The principal can choose to stop any life support assistance, such as stopping breathing and feeding machines.

Do Not Resuscitate (DNR) – Used to inform medical personnel NOT to perform CPR or other life-saving procedures in the event that the principal’s heart stops beating or if they are not breathing.

4. Sign

principal signing medical poa document

Depending on the signing laws in your state, an advance directive must be signed with a notary public, two witnesses, or both. If given the choice, it’s recommended to have the document notarized.

Where to Find a Notary: A notary can be found online (Notarize.com), at a local bank, UPS Store, or using FindaNotary.com.

5. Register

man putting advance directive card in wallet

It’s best to store an advance directive in an easily accessible place in the event of an emergency.

Recording it with a state registry or a national organization is recommended.

Wherever the advance directive is stored, the location should be recorded in a Wallet Card and kept on the principal at all times.

Signing Requirements (By State)

A witness cannot be related by blood or marriage to the principal or agent, or be a beneficiary of the principal (in their last will or living trust).

If a notary public is required, they cannot be a witness.

STATE FORM NAME(S) SIGNING LAWS
 Alabama Advance Directive for Health Care Two witnesses § 22-8A-4(c)(4)
 Alaska Advance Health Care Directive Two witnesses or a notary public AS 13.52.010(b)
 Arizona Health Care Power of Attorney, Living Will One witness or a notary public § 36-3221(A)(3), § 36-3262
 Arkansas Durable Power of Attorney for Health Care, Declaration of Living Will Two witnesses or a notary public § 20-6-103(c), § 20-17-202
 California Advance Health Care Directive Two witnesses or a notary public PROB § 4701
 Colorado Medical Durable Power of Attorney, Declaration as to Medical or Surgical Treatment Two witnesses or notary public § 15-18-106(1)
 Connecticut Appointment of Health Care Representative, Declaration to Remove Life Support System Two witnesses § 19a-575a, § 19a-575
 Delaware Advance Health Care Directive Two witnesses § 2503(b)(1)
 Florida Designation of Health Care Surrogate, Living Will Two witnesses § 765.202(1), § 765.302(1)
 Georgia Advance Directive for Health Care Two witnesses

§ 31-32-5(c)(1)

 Hawaii Advance Health Care Directive Form Two witnesses or a notary public § 327E-3(b)(1)(2)
 Idaho Advance Care Planning Document Principal only § 39-4510
 Illinois Living Will Declaration, Durable Power of Attorney for Health Care Two witnesses 755 ILCS 35/3(b), 755 ILCS 45/4-10
 Indiana Living Will Declaration, Health Care Representative Appointment Two witnesses or a notary public IC § 16-36-7-28
 Iowa Declaration Relating to Use of Life-Sustaining Procedures, Durable Power of Attorney for Health Care Decisions Two witnesses and a notary public § 144B.3
 Kansas Living Will Declaration, Durable Power of Attorney for Healthcare Decisions Two witnesses or a notary public § 65-28,103, § 58-632
 Kentucky Advance Directive Two witnesses or a notary public § 311.625(2)
 Louisiana Living Will Declaration, Medical Power of Attorney Two witnesses RS 28:224RS 40:1151.4
 Maine Health Care Advance Directive Form Two witnesses § 5-803(2)
 Maryland Advance Directive Two witnesses § 5-602(c)
 Massachusetts Health Care Proxy, Living Will Directive Two witnesses § 201D-2
 Michigan Durable Power of Attorney for Health Care, Living Will Two witnesses § 700.5506(4)
 Minnesota Health Care Directive Two witnesses or a notary public § 145C.03
 Mississippi Advance Health Care Directive Two witnesses or a notary public § 41-41-209
 Missouri Health Care Directive, Durable Power of Attorney for Health Care Two witnesses and a notary public § 404.705§ 459.015
 Montana Living Will Declaration, Durable Power of Attorney for Health Care Two witnesses § 509103(1)§ 53-21-1304(2)(d)
 Nebraska Living Will Declaration, Power of Attorney for Health Care Two witnesses or a notary public § 30-3404(5)§ 20-404(1)
 Nevada Declaration/Living Will, Durable Power of Attorney for Healthcare Decisions Two witnesses or notary public NRS 162A.790(2)NRS 449A.433(1)
 New Hampshire Advance Directive Two witnesses or a notary public § 137-J:14
 New Jersey Medical Power of Attorney (proxy), Living Will Declaration Two witnesses or a notary public § 26:2H-56
 New Mexico Advance Directive for New Mexico Principal only § 24-7A-2(B)§ 24-7A-4
 New York Health Care Proxy, Living Will Two witnesses PBH § 2981
 North Carolina Health Care Power of Attorney, Advance Directive for a Natural Death (“Living Will”) Two witnesses and a notary public § 90-321§ 32A-16(3)
 North Dakota Health Care Directive Two witnesses or a notary public § 23-06.5-05
 Ohio Living Will Declaration, Health Care Power of Attorney Two witnesses or a notary public § 2133.02(A)(1)§ 1337.12(B)(C)
 Oklahoma Advance Directive for Health Care Two witnesses § 63-3101.4
 Oregon Advance Directive for Health Care Two witnesses or a notary public ORS 127.515(2)(b), ORS 127.527
 Pennsylvania Durable Health Care Power of Attorney, Living Will Two witnesses § 5442, § 5452
 Rhode Island Living Will Declaration, Durable Power of Attorney for Healthcare Two witnesses or notary public § 23-4.11-3, § 23-4.10-2
 South Carolina Health Care Power of Attorney, Living Will Declaration Two witnesses and notary public § 62-5-503, § 62-5-504, § 44-77-40
 South Dakota Durable Power of Attorney for Health Care, Living Will Declaration Two witnesses or a notary public § 59-7-2.1§ 34-12D-2
 Tennessee Advance Directive for Health Care Two witnesses or a notary public § 68-11-1803(b), § 34-6-203(a)(3)
 Texas Directive to Physicians and Family (living will), Durable Power of Attorney for Health Care Two witnesses or a notary public § 166.154, § 166.164
 Utah Advance Health Care Directive One witness § 75-2a-107(c)
 Vermont Advance Directive for Health Care Two witnesses 18 V.S.A. § 9703
 Virginia Advance Medical Directive Two witnesses § 54.1-2983
 Washington Durable Power of Attorney for Health Care, Health Care Directive Two witnesses or a notary public RCW 11.125.050, RCW 70.122.030
Washington D.C. Declaration, Durable Power of Attorney for Health Care Two witnesses § 7-622(a)(4) and § 21–2205(c)
West Virginia Medical Power of Attorney, Living Will Two witnesses and a notary public § 16-30-4(a)
 Wisconsin Declaration to Physicians Living Will, Power of Attorney for Health Care Two witnesses § 155.10(1)(c), § 154.03(1)
 Wyoming Advance Health Care Directive Two witnesses or a notary public § 35-22-403(b)

Where to Register an Advance Directive?

State Registries (Note: Not every state has a registry.)

National Registries

Sample

Download: PDF, MS Word, ODT

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