Illinois Advance Directive Form

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An Illinois advance directive is a document that lets a person choose a medical agent to handle health care decisions in the chance they cannot do so for themselves. The agent is instructed to make decisions in accordance with the person’s health care goals and needs listed in the living will declaration portion of the form. After signing with two (2) witnesses the form is authorized for use.

Table of Contents

Laws

Statutes

Signing Requirements (755 ILCS 35/3(b)) – Two (2) witnesses 18 years of age or older.

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Declaration OF Mental Health Treatment

(1) Principal Name. As a potential Illinois Mental Health Patient, you can issue definitive instructions to Health Care Providers using this directive. Identify yourself as the Illinois Principal who is issuing this directive.

(2) Principal Birth Date. Your birth date is required to solidify your identity to future Illinois Mental Health and Medical Professionals referring to this document for instructions.

Pre-Existing Conditions In The Illinois Principal

(3) Mental Health Status. If you have been diagnosed with or are prone to any mental health conditions that would significantly impact your ability to communicate your directions or provide an informed treatment decision, then document each one in the space provided.

Psychotropic Medication

Initial Item 4 Or Initial Item 5 

(4) Consent To Psychotropic Medication. Your consent to psychotropic medications that Illinois Mental Health Care Professionals wish to administer to treat your symptoms will be sought before any such treatment can be applied. You can deliver this consent prematurely through this document by initialing the first statement in this section and supplying a list of medications that you consent to. If you wish to consent to any medication necessary, you may write int he word “All” in the space provided.

(5) Refusal Of Psychotropic Medication. To refuse specific or all psychotropic medications Illinois Health Care Professionals may wish to administer, initial the second statement of this section then, to clarify your decision, provide a list of the refused psychotropic medications, or write in the word “All.”

(6) Conditions Or Limitations. The final area in this section is reserved for any instructions or concerns you wish to convey to Illinois Mental Health Professionals.

Electroconvulsive Treatment

Initial Item 7 Or Initial Item 8

(7) Consent To Electroconvulsive Treatment. The decision to receive electroconvulsive therapy can also be provided through this form by initialing your approval where requested.

(8) Denying Electroconvulsive Treatment. If you have determined that electroconvulsive treatment should not be administered and wish to refuse this treatment, then provide your initials to the second statement.

(9) Conditions Or Limitations. Regardless of whether you have delivered consent or refusal to electroconvulsive therapy, you can expand upon your decision by applying any circumstances, conditions, or trial periods to your decision on electroconvulsive therapy.

Admission To And Retention In Facility

Initial Item 10 Or Item 11

(10) Consent To Admission. At times, your mental health status may prompt attending Illinois Physicians or Mental Health Professionals to seek your consent to admit you to a Facility they believe is equipped to provide better mental health treatment. You may provide consent to this Facility admission using your initials to declare the first statement provided on this subject as your medical preference.

(11) Refusal Of Admission. If you do not wish to be admitted to a Facility to treat a mental health condition, then initial the appropriate statement to solidify this refusal.

(12) Conditions And Limitations. You may apply provisions to your consent to admission or your refusal using the space presented in this section. For instance, you may wish admittance to a Facility for treatment but insist on a discharge after a trial period.

Selection Of Physician

(13) Physician Information. An area devoted to presenting the identity of your preferred Diagnosing Physician and the Institution or Medical Office where he or she operates has been included. In order for Mental Health Professionals to use this document during a crisis or a serious event, two Physicians whose licenses to practice must be recognized by the State of Illinois will be required to diagnose you as incapacitated and unable to make an informed decision. You can determine the identity of one of these Physicians by documenting his or her name and practice.

Additional References Or Instructions

(14) Principal Mental Health Directives. You can provide further information regarding your treatment preferences to Illinois Mental Health Providers. For instance, you may wish a specific family member contacted during a time of crisis or require treatment known as effective but not normally administered.

(15) Illinois Mental Health Treatment Conditions. Additionally, you may impose conditions on when treatment goals should be considered and limitations to any mental health treatment that may be used.

Illinois Attorney-in-Fact For Mental Health Treatment

(16) Mental Health Attorney-in-Fact. A wise precaution to set in place should a mental health crisis require treatment decisions after you have been incapacitated is to authorize a specific Party who can be consulted with on your behalf. To appoint someone to speak to Illinois Mental Health Professional as well as deliver necessary consents or refusals in your name, you must attach his or her name to this role as well as his or her mailing address and telephone number. Make sure this information remains up-to-date and reliable since it may be used to contact your Mental Health Attorney-in-Fact during a mental health crisis.

(17) Successor To Attorney-in-Fact. As mentioned above, Illinois Mental Health Providers may need to gain your consent or refusal of treatments in an expedient manner. If the Party that is appointed as your Mental Health Attorney-in-Fact cannot or will not be able to act in this role when needed, then a Successor Mental Health Attorney-in-Fact can be given the authority to represent you. This Successor Agent will only be able to represent you if the Mental Health Attorney-in-Fact fails in his or her duty and a Successor is specifically given the authority to step into this role. To this end, record the full name, address, and contact telephone number of the Successor Mental Health Attorney-in-Fact you authorize to represent you if necessary.

Illinois Principal Dated Signature

(18) Principal Signature. Your directives and the appointment of your Mental Health Care Attorney-in-Fact can only be effective if you provide a witnessed and dated signature. Sign and date the signature line provided then give this document to the Witness observing you.

Affirmation Of Witnesses

(19) Witness Testimony. The statement verifying that your signature has been observed by qualifying Witnesses must be signed and dated by each Witness. In order for a Witness to act in this role in the State of Illinois, he or she cannot be related to you by blood or marriage, related to anyone working for your Mental Health Care Provider (and Health Care Provider), and may not be professionally involved with the Facility or Office where you receive care.

Acceptance Of Illinois Attorney-in-Fact

(20) Attorney-in-Fact Acceptance. The Mental Health Attorney-in-Fact named to represent you in the State of Illinois should review this document as well as the acceptance statement. If he or she intends to adhere to your wishes and accepts this responsibility, then the Mental Health Attorney-in-Fact should sign his or her name and supply his or her signature date.

(21) Attorney-in-Fact Signature Date And Printed Name.

(22) Successor Attorney-in-Fact Acceptance. An additional line has been placed to receive the Successor Attorney-in-Fact’s signature of acceptance, signature date, and printed name.

Future Revocation

(23) Revoking The Above Document. You have the right to revoke or terminate either or both Mental Health Attorney(s)-in-Fact so long as you are not diagnosed as incapacitated in a way where you cannot make informed decisions. That is, decisions that you would normally make when not in a crisis and diagnosed as incapacitated. Similarly, you may revoke the declarations made by your living will. This requires some basic language where your printed name must be supplied to complete.

(24) Purpose. The purpose of your revocation must be presented. You may indicate the level of your revocation by marking the checkbox declaring your entire directive should no longer be considered valid or by marking the checkbox indicating that only the specific parts that you list from your directive should be revoked.

(25) Dated Signature. When a revocation is issued to terminate a part of or all of the previously issued mental health directive, the Principal will need to sign it. This will prove his or her intention is to nullify, cancel, or terminate the concerned directive.

(26) Physician Confirmation. Your signature to the revocation of power must be produced while fully aware of your decision and the ramifications of dismissing your Illinois Mental Health Care Agent through the revocation. To this end, a Physician should provide testimony to your comprehension of the revocation by signing his or her name. Before doing so, a brief declaration statement must be completed with his or her full name.

(27) Physician Testimonial Signature. The Physician verifying your state of mind as appropriate to issue a revocation must sign his or her name and furnish the calendar date when he or she signed the revocation.

Living Will

(28) Declaration Date. To issue a living will to apply when you are medically incapacitated and near-death, several pieces of information must be submitted. Begin with a record of the formal calendar date of your declaration that you wish life support to be denied or withheld at a time when you are unable to communicate and have been diagnosed with an incurable medical condition that will result in death with or without the administration of life-prolonging.

(29) Declarant Identity. Your full name must be presented for this declaration to be attached to your identity.

(30) Declarant Date Of Birth.

(31) Declarant Signature. When you are ready to execute this document, sign your name then provide your “City, Country, and State of Residence” where requested, Your signature must be performed before two Illinois qualifying Witnesses.

(32) Witness Testimony. Two Witnesses can verify that you signed the living will above by signing their names as proof that the testimony provided is accurate.

IDPH Uniform Practitioner Order For Life-Sustaining Treatment (POLST)

(33) Patient Name. A licensed Physician can work with you to document medical preferences that you indicate should be employed when incapacitated because of a severe medical event and approve your directions as appropriate. Such a directive can then be stored in your medical files for easy access by Illinois Physicians and Responders. The first step in completing this form is to present the full name of the Illinois Patient. It will be assumed that the Illinois Patient this POLST concerns will be filling it out personally with the Physician involved.

(34) Patient Date Of Birth.

(35) Patient Gender.

(36) Patient Address.

Part A. Cardiopulmonary Resuscitation

(37) Illinois CPR Directive. If your heart or your lungs become severely damaged or cease functioning altogether, then you may be found unconscious as a result of this cardiopulmonary failure. Illinois Responders and attending Physicians will seek to resuscitate these organs through mechanical means or with machines. One of the two checkboxes in Part A must be selected to indicate whether the Illinois Patient consents to CPR (cardiopulmonary resuscitation) as the proper response or refuses the resuscitation of his or her cardiopulmonary system when his or her heart and/or lungs fail.

Part B. Medical Interventions

Select Item 38 Or Select Item 39 Or Select Item 40

(38) Full Treatment. If you require medical intervention and/or maintenance to stay alive after you have been diagnosed with a condition that cannot be cured, then this document can be used to indicate the level of medical intervention you are willing to accept from Illinois Health Care Providers. If you would consent to receive full medical treatment to stay alive for as long as possible then select the first definition in Part B by marking the corresponding checkbox.

(39) Selective Treatment. Some medical interventions and life-prolonging treatments can be considered invasive, detrimental, or even burdensome enough to be counter-productive (especially when the level of discomfort becomes intolerable). You can inform Illinois Medical Providers that you consent to medical interventions that will prolong your life so long as they are not invasive. For instance, the use of a mask to breathe with the aid of a machine may be acceptable but the use of a tube inserted into the Patient’s air canal may be considered intolerable. If you wish Illinois Doctors to administer life-prolonging procedures while considering the comfort of the care provided to be as high a priority, then the second statement in Part B should be selected.

(40) Comfort-Focused Treatment. If you wish the Illinois Physicians attending to your medical treatment to focus on comfort rather than prolonging your life, then select the final statement in Part B. This will mean that invasive treatments may not be used even if your life will end shortly without them. 

(41) Optional Additional Orders. You can provide instructions concerning the level of care that you wish Illinois Physicians to administer when suffering a severe and life-threatening medical condition directly to Part B to further define your selection above.

Part C. Medically Administered Nutrition

Select Item 42 Or Item 43 Or Item 44

(42) Long-Term Nutrition Consent. If you are unconscious or severely incapacitated, then the possibility of eating or drinking (even with physical assistance) may result in a choking hazard or simply be ineffective in keeping your body’s nutrition and fluids status at a healthy level. When this happens, Illinois Physicians may wish to administer nutrition and liquids intravenously. To consent to receive your nutrients and water intravenously, initial the appropriate statement in Part C.

(43) Trial Period Of Medically Administered Nutrition. If you wish to consent to artificially delivered nutrition and fluids when you cannot intake them independently but only for a limited amount of time, select the second statement. This selection will require further definition that may be provided later in this section.

(44) Refusing Medically Administered Nutrition. If you have determined that receiving nutrition and fluids intravenously or artificially outweigh the benefits of preventing death from starvation or dehydration, then select the final statement.

(45) Additional Instructions. You may document instructions such as a trial period for nutrients and fluids to be delivered artificially by supplying your nutrition directives to the space provided on the right.

Part D. Documentation Of Discussion

(46) Source Of Patient Information. For our purpose, it has been assumed that you are the Patient being discussed in this POLST. If this is the case, it must be indicated by marking the first checkbox in Part C. However, if you are acting as an Agent under the Patient’s Health Care Power of Attorney, are filling out this POLST as the Patient’s Parent because he or she is a minor, or are an appointed Health Care Surrogate Decision Maker, then mark the appropriate selection to define your role.

Signature Of Patient Or Legal Representative

(47) Signature. You must sign this document regardless of your role. Thus, provide your signature before a Witness once the POLST has been filled out with the licensed Physician you are working with

(48) Printed Name.

(49) Signature Date.

Signature Of Witness To Consent

(50) Witness Signature. The individual who has watched you sign your name must review the confirmation statement, then, upon agreement, sign his or her name.

(51) Printed Name.

(52) Witness Signature Date.

Part E. Signature Of Authorized Practitioner

(53) Practitioner Printed Name. The licensed Physician, Second Year or Higher Resident, Advanced Practice Nurse or Physician Assistant providing oversight for this POLST must present his or her printed name.

(54) Practitioner Phone Number.

(55) Authorized Practitioner Signature. The Physician or licensed Practitioner must sign his or her name to prove that he or she participated in the completion of this document.

(56) Practitioner Signature Date.

Patient Information For Medical Practitioner Use

(57) Patient Name. The full name of the Illinois Patient must be provided at the top of the second page so that the information it contains can be applied properly to his or her file.

Advance Directive Information

(58) Issued Directives. If the Illinois Patient has issued a Health Care Power of Attorney (in any state), a Living Will Declaration, and/or a Mental Health Treatment Preference Declaration, then this should be reported since it will aid Illinois Physicians in making sure that the Patient’s treatment goals and preferences are met. Check every box that corresponds to a directive the Patient has issued.

(59) Directive Contact. The name and phone number of the Person or Institution that can be contacted to obtain a copy of the Patient’s medical directives should be supplied.

Health Care Professional Information

(60) Preparer Name. The Party who has supplied the information to the document above must self-identify as the Preparer.

(61) Preparer Phone Number.

(62) Preparer Title. Present the formal job title the Preparer holds with the Medical Office or Facility aiding the Patient in completing this document.

(63) Date Prepared.

Illinois Statutory Short Form Power Of Attorney For Health Care

(64) Illinois Principal. As the Illinois Principal completing this directive and the MOLST, you have the option of appointing a Health Care Agent that can be counted on to wield the authority you give him or her to inform Physicians (in this state) of your medical directives. This means that the Illinois Health Care Agent will be able to deny treatments that you tell him or her to or consent to them as per your instructions. Begin the process of granting such authority by printing the full name of the Principal (You) granting authority to an Illinois Health Care Agent.

(65) Illinois Principal Address. Include the address formally associated with your federal and/or state ID’s, Insurance Companies, and Health Care Providers. This must be the address where you, as the Principal, can be contacted or found easily.

Health Care Agent

(66) Illinois Health Care Agent Information. In order for this appointment to be effective, you must make sure that the full name of your Health Care Agent, his or her complete mailing address, and every telephone number where he or she can be reached is documented. This will solidify your choice of Illinois Health Care Agent and give future Illinois Physicians using your directives the ability to reach your Health Care Agent for your consent to receive treatment(s) or refusal. Keep in mind, that your Illinois Health Care Agent must be someone who you trust with this role and can be depended upon to decide and act on your behalf to ensure that you receive the medical treatment you expect in the State of Illinois.

(67) Guardian Nomination Of Agent. A convenient way to nominate your Health Care Agent for the consideration of Illinois Courts seeking to formally appoint a Guardian to your person has been included. Select the checkbox corresponding to the nomination statement to suggest that your Health Care Agent can also serve as your Guardian if necessary. Do not mark this checkbox if you do not wish to make such a nomination.

Authorized Health Care Agent Powers

Select Item 68 Or Select Item 69 Or Select Item 70

(68) Power To Make Decisions On Principal Incapacitation. The default status of this document is set to grant the Health Care Agent power only upon a Physician diagnosing you as incapacitated and unable to effectively communicate. To confirm this setting for when your Illinois Health Care Agent can make medical decisions for you, select the first statement in this section.

(69) Immediate Access To Medical Records. The right to access your medical records before your Health Care Agent is able to make medical decisions on your behalf can be granted through the second statement. If selected, this statement will set the medical decision-making powers this document grants to your Illinois Health Care Agent to go in effect only upon your formally diagnosed incapacitation but allow him or her to access and review your medical records immediately. This can be useful if you have a complicated medical condition that requires the Health Care Agent to be prepared with information before you are incapacitated (i.e., a Patient with a pacemaker and an advanced stage of cancer).

(70) Power To Decide On Treatments Immediately. If you wish your Illinois Health Care Agent to immediately be able to deliver your treatment preferences to Physicians in this state and perform actions such as obtaining sensitive medicine from your Pharmacy then, select the final statement. This will grant your Illinois Health Care Agent the power to carry out your medical directives immediately upon signing this document.

Life-Sustaining Treatments

Select Item 71 Or Select Item 72

(71) Comfort Care As A Priority.  An important decision that is often faced when an Illinois Patient is unable to communicate and enduring a life-threatening medical condition is the treatment goals he or she wishes adopted by attending Physicians. If you wish to be allowed a natural death to occur (as a result of a terminal or incurable condition) and only wish medical treatment to focus on keeping you comfortable, clean, and pain-free (if possible) then mark the checkbox corresponding to the statement setting the quality of life as the top priority of your medical preferences.

(72) Principal Longevity Decision. If staying alive as long as possible is your preferred treatment goal, even if there is no cure for your medical condition and you are in untreatable pain, then select the second statement to inform Illinois Physicians to administer whatever treatment allowed and necessary to keep you alive and as comfortable as possible.

Specific Limitations To Agent’s Decision-Making Authority

(73) Limitations Imposed. You may set specific limitations to the powers of your Health Care Agent by either documenting your end-of-life and post-death preferences directly in this document or by declaring that your Health Care Agent may not make certain decisions. Use the space provided for such additional provisions. Your direct report may be as extensive as needed. If needed, you may also cite the name of a document you compose to deliver these additional directives or Agent limitations and attach it to this one before the signing.

Witnessed Signature Of Illinois Principal

(74) Signature. Review this paperwork and any attachments that you wish included. If you are confident that Illinois Physicians may use this document and the appointments it makes to accurately understand and comply with your medical treatment wishes, then sign your name.

(75) Today’s Date. The current date when you sign this document must be used as your signature date.

Principal Oriented Witness Statement

(76) Circumstances Of Principal Signature. The default statement the Witness must agree to by signature to validate your signature as authentic requires that the testimony is defined as being made after visually observing your act of signing or if the Witness’s testimony is the result of you directly informing him or her that you have signed this document with a full understanding of its content. .Select the checkbox that should be used to define how the Witness knows of your signing. This act may also be left up to the Witness (suggested).

(77) Witness Printed Name.

(78) Witness Address.

(79) Witness Signature. The Witness must sign and date the area that immediately follows the Witness statement after he or she has read it and recorded his or her name and contact information.

Illinois Successor Health Care Agents

(80) Successor Agent 1. You will rely heavily on your Illinois Health Care Agent to effectively wield the principal power of making medical decisions on your behalf, to access and manage your medical records, and to generally safeguard your medical preferences in the State of Illinois. There is always the possibility that your Health Care Agent may fail as a result of being unavailable, unable to wield principal authority, or simply refuses to act for any reason. To make sure that Illinois Physicians will still have someone to consult with on your behalf regarding your treatment, you can set a Successor Health Care Agent. Produce the name, address, and telephone number of the Party that should be contacted to take over the Health Care Agent role should your current Choice be ineffective. Be advised, that only one Health Care Agent will actively hold power, so this Successor is an Agent in name only until needed.

(81) Successor Agent 2. In a case where neither the Illinois Health Care Agent nor the Successor Agent are able or available to represent your medical decisions, it will be useful to have a Second Successor Agent in place. Record the full name, address, and phone number(s) of the Party who you wish to act as your Health Care Representative in the State of Illinois should both your original choice and the first Successor fail to accept or act in this role.

 

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