Advance Directive Form (Medical POA + Living Will)

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Updated November 09, 2022

An advance directive allows an individual (“principal”) to create a healthcare treatment plan and 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 due to impairment.

Signing Requirements – Must be signed in accordance with state law.

By State

What is an Advance Directive?

An advance directive allows a person (“principal”) to choose someone else (“agent”) to make health care decisions on their behalf and to create end-of-life treatment instructions. To complete, the form must be signed in accordance with state law, which often requires two witnesses or a notary public.

Once signed, the agent must present the advance directive to medical at each occurrence it is used.

What is Included? (4 parts)

  1. Medical Power of Attorney – Allows the individual to assign an agent to make their medical decisions.
  2. Living Will – A written record with personal requests for inclusion and exclusion of certain medical treatments.
  3. Physician Orders for Life-Sustaining Treatment (POLST) – Detailed end-of-life options overviewed and recorded by a physician.
  4. Do Not Resuscitate Order (DNR) – A patient can opt in or out of life-sustaining measures, such as CPR.

What if the Principal is Already Incapacitated?

If the principal (the patient) is already incapacitated, the family will be required to obtain guardianship rights from the local court in order to make the patient’s medical decisions. In most circumstances, a hospital will allow the spouse or family member to act as the agent by default (although this may depend on local and state laws).

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)

Step 1 – Select an Agent

man interviewing potential medical agent

This is often referred to as the medical power of attorney portion that requires the principal to select an agent to represent their healthcare 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.

  • Second 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.

Step 2 – Decide the Powers

principal deciding on medical powers for agent

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

principal researching end-of-life options on computer

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 in the event that the principal’s heart stops beating or if they are not breathing.

Step 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.

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

Step 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. 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

A witness cannot be related to the principal, the agent, or be a beneficiary in the principal’s last will and testament. If a notary public is required, they may not act as 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 Living Will and Durable Power of Attorney for Health Care 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 § 16-36-4-8(b)(5), § 16-36-1-7
 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

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

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

National Registries

Sample

Download: Adobe PDF, MS Word, OpenDocument

Advance Directive

PART I. MEDICAL POWER OF ATTORNEY

A medical power of attorney allows you the right to name someone else to make health care decisions on your behalf.

I choose to: (initial and check) (choose one)

[INITIALS] ☐ – Have a medical power of attorney.

[INITIALS] ☐ – Not have a medical power of attorney. Part I of this form is intentionally left blank.

A. PRINCIPAL. I, [NAME], with a mailing address of [ADDRESS], City of [CITY], State of [STATE], Zip Code: [ZIP] hereby designate:

B. AGENT. [NAME], with a mailing address of [ADDRESS], City of [CITY], State of [STATE], Zip Code: [ZIP]. AGENT’S TELEPHONE (CELL): [PHONE]

C. ALTERNATE AGENT. If my Agent is unable or unwilling to serve or make a decision in a timely manner, I select [NAME], with a mailing address of [ADDRESS], City of [CITY], State of [STATE], to act as my alternate agent. ALTERNATE AGENT’S TELEPHONE: [PHONE]

I intend for my Agent to receive any and all of my health records and information as if I were the one requesting such information.


PART II. LIVING WILL

A living will allows a principal to select end-of-life treatment options in the chance of incapacitation with no viable cure.

I choose to: (initial and check) (choose one)

  • [INITIALS] ☐ – Have a living will.
  • [INITIALS] ☐ – Not have a living will. Part II of this form is intentionally left blank.

A. PRINCIPAL. I, [NAME], with a mailing address of [ADDRESS], City of [CITY], County of [COUNTY], State of [STATE], with the last four (4) digits of my social security number (SSN) being [SSN] (“Principal”) desire to advise my doctors and medical providers of my wishes for my health care in the event I am not able to communicate my wishes.

B. LIFE SUPPORT.

I desire that my doctor make a concerted effort to return me to an acceptable quality of life using then available treatments and therapies. However, if my quality of life becomes unacceptable as I have defined below, and my doctors have determined that my condition will not improve (is irreversible), I direct that all treatments that extend my life be withdrawn.

An unacceptable quality of life means (initial and check all that apply):

  • [INITIALS] ☐ – Chronic coma or persistent vegetative state
  • [INITIALS] ☐ – No longer able to communicate my needs
  • [INITIALS] ☐ – No longer able to recognize family or friends
  • [INITIALS] ☐ – Total dependence on others for daily care
  • [INITIALS] ☐ – Other: [DESCRIBE].

(initial and check) (choose one)

  • [INITIALS] ☐ – Even if I have the quality of life described above, I still wish to be treated with food and water by tube or intravenously (IV).
  • [INITIALS] ☐ – If I have the quality of life described above, I do NOT wish to be treated with food and water by tube or intravenously (IV).

C. CERTAIN LIFE-SUSTAINING TREATMENT.

Some people do not wish to have certain life-sustaining treatments under any circumstance, even if recovery is a possibility. Check the treatments below, if any, that you do not wish to have under any circumstances:

(initial and check) (choose one)

  • [INITIALS] ☐ – Cardiopulmonary Resuscitation (CPR)
  • [INITIALS] ☐ – Ventilation (breathing machine)
  • [INITIALS] ☐ – Feeding tube
  • [INITIALS] ☐ – Dialysis
  • [INITIALS] ☐ – Other: [DETAILS].

D. END OF LIFE WISHES. (hospice care, funeral arrangements, etc.):

When I am near death, it is important to me that: [DETAILS]


I have signed this document on this [DAY] day of [MONTH], 20[YEAR].

Principal’s Signature: ___________________________________

Print Name: ___________________________________

WITNESS 1

Signature: ___________________________________ Date: _______________

Print Name: ___________________________________

WITNESS 2

Signature: ___________________________________ Date: _______________

Print Name: ___________________________________