Pennsylvania Advance Directive (Medical POA & Living Will)

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This person is known as the "Patient"


County
Where the Patient lives

Health Care Agent

The Agent can make medical decisions for the Patient ONLY IF the Patient cannot make the decisions for themselves.

2nd Agent

The 2nd Health Care Agent would not have the power to act UNLESS the original Health Care Agent is not available.

3rd Agent

Priorities

Powers to End Life

Clear
If the Principal is not available, click "Next" and they can enter at a later time.
Clear

If the Principal is not available, click "Next" and they can enter at a later time.

Drugs

This is even if the drugs could be considered to have addictive properties.

Withdrawal of Life-Support

In the event of brain damage or the Principal is in a terminal stage.

CPR Authorization

Mechanical Ventilator Authorization

Dialysis Authorization

Surgery Authorization

Chemotherapy Authorization

Radiation Treatment Authorization

Antibiotics Authorization

Feeding and Breathing

Clear

If the Principal is not available, click "Next" and they can enter at a later time.

Clear

If the Principal is not available, click "Next" and they can enter at a later time.

Directions to Agent

Clear

If the Principal is not available, click "Next" and they can enter at a later time.

Clear

If the Principal is not available, click "Next" and they can enter at a later time.

Organ Donation

Clear
Clear

Signing Requirements

It is preferable, although not required, that the witnesses are not your heirs, creditors, nor employed by any of your health care providers.

Signing Date

Notarization

Notarizing is not required under Pennsylvania law. Although, it would allow this Form to be accepted in another State.
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