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PDF Word ODT

PDF Word ODT

An advance directive allows an individual (principal) to create a health care treatment plan and to choose an agent to make medical decisions on their behalf. The document can only be used if the principal is no longer able to make decisions for themselves (e.g. Dementia, Alzheimer’s disease, etc.).

By State

• Alabama
• Alaska
• Arizona
• Arkansas
• California
• Colorado
• Connecticut
• Delaware
• Florida
• Georgia
• Hawaii
• Idaho
• Illinois
• Indiana
• Iowa
• Kansas
• Kentucky
• Louisiana
• Maine
• Maryland
• Massachusetts
• Michigan
• Minnesota
• Mississippi
• Missouri
• Montana
• Nebraska
• Nevada
• New Hampshire
• New Jersey
• New Mexico
• New York
• North Carolina
• North Dakota
• Ohio
• Oklahoma
• Oregon
• Pennsylvania
• Rhode Island
• South Carolina
• South Dakota
• Tennessee
• Texas
• Utah
• Vermont
• Virginia
• Washington
• Washington D.C.
• West Virginia
• Wisconsin
• Wyoming

What is an Advance Directive?

An advance directive allows a patient to not only choose someone to make health care decisions on their behalf but also to outline their end-of-life treatment options. It replaces what used to be 2 separate documents; medical power of attorney and a living will. Both forms have been combined to create an advance directive to create an easier process for patients and medical staff.

What is included?

• Medical Power of Attorney;
• Living Will;
• Physician Orders for Life-Sustaining Treatment (POLST); and
• Do Not Resusitate Order (DNR).

What if the Principal is incapacitated?

If the principal (the patient) is incapacitated then the family will be required to obtain guardianship rights from the local court. In most circumstances, a hospital will allow the spouse or family member to act as the agent by default although this depends on local and state laws.

Advance Directive vs Other Estate Forms

How to Get an Advance Directive (5 steps)

• Step 1 – Select an Agent
• Step 2 – Decide the Powers
• Step 3 – Choose End-of-Life Options
• Step 4 – Sign
• Step 5 – Register

Step 1 – Select an Agent

This is often referred to as the medical power of attorney portion that requires the principal to select an agent to represent their health care decisions. The agent may ONLY act if the principal cannot make decisions for themselves due to being incapacitated. The agent should understand the wishes of the principal and always keep their best interests in mind when making decisions.

• 2nd Agent – The principal is able to select a 2nd agent to help in case the original agent is not able to perform. Although, decision-making powers cannot be shared.

Step 2 – Decide the Powers

The principal will have to decide how much power to give the agent.

This mainly consists of:

• Electing to have the powers begin immediately or upon the principal’s incapacitation;
• Deciding to prolong the principal’s life as long as possible (even if there is no possible cure); and
• Selecting any post-death responsibilities (ordering an autopsy, where the remains are kept, etc.).

Any other powers should be mentioned to the agent verbally.

Step 3 – Choose End-of-Life Options

This is for the living will portion that allows the principal to select their plans if they should become in a vegetative state or uncurable situation. Under such an event, the principal can choose to stop any life support assistance such as halting breathing machines, food, or water intravenously (through an IV).

Do Not Resuscitate (DNR) – Used to inform medical personnel to not perform CPR or other life-saving procedures should an individual’s heart stop or if they are not breathing.

Step 4 – Sign

Depending on the signing laws in your State, an advance directive must be signed with a notary public, two (2) witnesses, or both. If given the choice, it’s recommended to have the document notarized.

A notary can be found online (Notarize.com), at a local bank, or using a notary service.

Step 5 – Register

It’s best to store an advance directive in an easily accessible place in the event of an emergency. It’s common to record it with a State Registry or a National Organization. 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

Where to Register

An advance directive may be registered in either the principal’s State of residence or in a national registry (see below).

State Registries (not every State has a registry)

• Alaska (AS 13.52.177) – Donor Registry
• Arizona (ARS § 36-32-7) – Registration Form
• California (§ 4800 – § 4806) – Registration Form
• Idaho (§ 39-4515) – Registration Form
• Louisiana (RS 40:1151.2) – Instructions
• Montana (§ 50-9-501) – Registration Form
• Nevada – Registration Form
• North Carolina – Registration Form
• Vermont – Registration Form
• Virginia (§ 54.1-2983) – Online Registration
• West Virginia – Registration Form

National Registries

• JoinCake – 100% free
• U.S. Registry – $59.95/5 years ($25 for additional 5 years)
• Everplans – $75/yr

Sample

Download: Adobe PDF, MS Word, OpenDocument

How to Write

Download: Adobe PDF, MS Word, OpenDocument

Part 1. Medical Power Of Attorney

(1) Power Of Attorney Status. This form potentially serves two distinct functions however, if the Principal or Declarant behind it only requires one of these functions then such a preference must be verified. As the Principal or Declarant using this paperwork, indicate if you intend to use the first part to issue a medical power of attorney or if you intend to leave this area unattended by choice. Mark one of the checkboxes presented to demonstrate your intent with this appointment.

(2) Principal Name. The Private Party who has decided to name an Agent as a Representative of his or her medical preferences is often referred to as the Principal (also, Health Care Principal or Declarant). As the Principal, you must claim this role with a report of your full name.

(3) Principal Address. Your mailing address will aid in identifying you to Medical Providers. Ideally, your address will be the same mailing address dispensed to your Medical or Health Care Providers (i.e. Physicians, Hospitals, Insurance Companies).

(4) Medical Attorney-in-Fact. The full name of the Party you intend to name as your Medical or Health Care Attorney-in-Fact should be declared in this role. This Party, also commonly referred to as your Agent, will be sought by Medical Personnel who seek answers regarding your medical preferences if you are incapacitated or cannot communicate in any manner (i.e. speaking, signing, blinking).

(5) Attorney-in-Fact Address.

(6) Attorney-in-Fact Phone Number. As mentioned, your Agent may need to be contacted by attending Physicians. At times, this may be in response to a medical emergency where you are found unable to communicate or unconscious. If this document is used to contact your Agent (or Medical Attorney-in-Fact), then it should clearly display the current cell phone number of your Agent. If he or she does not have a cell phone number, then present the telephone number needed to reach him or her immediately. You may dispense more than one phone number so long as they are labeled by type (i.e. home, work, field office, etc.).

(7) Alternate Agent Name. There may be times when your Medical Attorney-in-Fact is unable to act effectively or be reached in a timely manner. Since this can be caused by any number of unforeseeable events ranging from the Agent being incapacitated to the Attorney-in-Fact’s power being revoked, many consider this a difficult contingency to prepare for, however, setting up a reserve Agent in advance can provide you with continuous representation. Your Alternate Agent can be thought of as an Attorney-in-Fact held in reserve and who only becomes eligible to act on your behalf when this role becomes empty. To set such a precaution in motion, name the Party that should be considered your Alternate Agent to this role.

(8) Alternate Agent Address.

(9) Alternate Agent Phone.

Part II. Living Will

(10) Living Will Status. The second part of this document is designed to allow you to put your medical directives or preferences in writing. This part can be completed and executed with or without naming an Attorney-in-Fact in the previous section(s) or it can be left intentionally blank. In either case, the decision to issue a living will or to refrain from such a declaration must be shown by submitting an “X” or checkmark to the checkbox statement defining this status then verifying this selection with your initials.

A. Principal 

(11) Principal Name. The Declarant behind this paperwork will set his or her decisions on which medical procedures carry his or her approval and which do not. To use this document to issue your medical directive, you must identify yourself as the Principal (also known as the Declarant).

(12) Principal Address. 

B. Life Support

Quality Of Life

Select Every Applicable Statement With Your Initials And A Checkmark

(13) Chronic Coma Or Persistent Vegetative State. If a medical event severely limits or removes your ability to remain conscious (i.e. you are unconscious, semi-conscious, or incognizant) for an extended period of time and no Medical Attorney-in-Fact (appointed by you) can be found then you will be left prone to the laws of the State and the policies of the treating Medical Provider regarding treatment. If you wish to interrupt these treatment goals, then you must inform the attending Physician using this document. A list allows you to mark off which conditions you would find intolerable with your initials. For instance, if you want to inform attending Medical Personnel that you consider any treatment resulting or causing you to live while in a long-term coma or persistently unconscious as unacceptable, then you must checkmark the first statement and produce your initials of approval to the left.

(14) No Longer Able To Communicate. To inform Physicians that treatments that leave you unable to communicate, even with simple gestures, would result in an intolerable quality of life for you, select and initial the second directive..

(15) No Longer Able To Recognize Loved Ones. Some treatments may have a profoundly detrimental effect on your cognitive abilities regarding the recognition of your loved ones. That is, while you may be cognizant of your surroundings, you may not have the ability to recognize friends and family. Initial the third statement to inform Physicians that any treatment that prevents you from recognizing your loved ones (for the rest of your life) is unacceptable.

(16) Total Dependence For Daily Care. If you do not desire medical treatment goals that result in a total dependence on others for common day-to-day tasks (i.e., not having the motor coordination or awareness to brush your teeth), then check and initial the fourth statement.

(17) Other Principal Concern. While this list of conditions that impact your quality of life will address some of the more common or general concerns, you may have concerns regarding more specific or additional life-long scenarios that would be an unacceptable way to live. You may list them all as the final statement, check the corresponding box, then deliver initials of approval to include them in this directive. If more room is required, then continue in a well-titled attachment that you report as the final description in this list.

Intravenous Food And Water

(18) Nutrition And Hydration. Naturally, if your ability to remain conscious, maintain bodily functions, or are suffering an end-of-life event resulting in both these conditions, then Medical Staff may need to seek your consent to assisted feedings (i.e. food and water) as a way to maintain your body’s nutrition and fluid levels. You can either pre-approve artificial feedings (by tube or intravenously) or state your refusal of artificial feedings when you are incapacitated by selecting the correct statement and producing your initials as confirmation.

C. Certain Life-Sustaining Treatment

Select One Or More Statements As Your Declaration(s)

(19) Cardiopulmonary Resuscitation (CPR). Now that you have set your definitions to the quality of life you expect maintained after a given treatment, it will be time to address the treatments that are commonly applied as a result of a life-threatening medical event. Cardiopulmonary Resuscitation, colloquially known as CPR, is used when your heart and/or lungs cease performing. Such organ failure can result in death or permanent systemwide damage quickly however this procedure (CPR) can be considered invasive and intolerable by many. To inform Medical Responders accessing this document that you do not wish CPR employed under any circumstances, place a check (or an “X”) in the first checkbox then display your initials.

(20) Ventilation (Breathing Machine). When you cannot breathe for an extended period of time, Medical Personnel will seek to extend your life by helping your body deliver the necessary oxygen to your brain and other systems. One manner of treatment to deliver oxygen is a breathing machine which will connect to your air pipe or lungs directly by tube. To deny this treatment, mark the third checkbox and produce your initials to prove your refusal.

(21) Feeding Tube. Medical Personnel may need to insert feeding tubes to keep your nutrition (and fluid) levels to an acceptable level for survival. However, you can refuse to consent to this procedure by selecting the fourth statement of this section and initialing the left-hand area.

(22) Dialysis. Vital organs such as your kidneys may cease functioning while you are unable to communicate. Oftentimes, attending Medical Personnel (I.e., Physicians, Nurses) will seek your consent to maintain your kidney functions intravenously using a dialysis machine. If you do not wish to consent to the use of dialysis should it be needed to prolong your life, then find this item on the list provided, select the corresponding checkbox, and produce your initials.

(23) Principal Directive. Other medical treatments that you as the Principal or Declarant intend to refuse may be included in this list. You may list or discuss them in the final item however keep in mind that you must still mark the checkbox on display and deliver your initials. If an attachment is needed to fully address the medical treatments that must be refused, make sure to title it accordingly then document its title as the approved refusal.

D. End Of Life Wishes

(24) Principal Preferences. If an end-of-life event occurs, those around you may need to be informed through your living will what your preferences involve. If you have instructions regarding hospice care, specific spiritual rituals/beliefs, or funeral arrangements that should be made a priority or at least taken into strong consideration then furnish them to the content of this paperwork. If additional room is needed for this task, dispense your instructions to a separate sheet of paper that is cited accordingly, then make sure it is physically attached.

Part 3. Principal Execution

Proven Principal Signing

(25) Signature Date. The calendar date when you sign this completed directive must be documented.

(26) Witnessed Or Notarized Signing. Sign your name according to the guidelines of your state. This may require that you coordinate your schedule with one or more Witnesses, the Agent, or the Notary Public. If you are not aware of your State’s requirements, then it is strongly recommended that you consult with a professional before signing your name.

(27) Principal Name. Print your name.

Witness/Notary Acknowledgment

Witnesses

(28) Witness 1. The first Witness to take control of this document after you sign it will read the confirmation statement beneath your signature. This Party must sign his or her name, dispense the current date, then deliver his or her printed name directly below the confirmation statement.

(29) Witness 2. The second Party acting as Witness to your signing will also need to review the confirmation statement underneath your signature so that Witness 2 may also declare confirmation accurate by presenting his or her signature, signature date, and printed name.

Notary Acknowledgment

(30) Notary Public. If this document is to be notarized at the time you sign it then make sure the Notary Public obtained has the proper credentials in the State where you issue this directive. Follow the directions of the Notary Public when you sign this form so that the appropriate notarization process may be completed.