Advance Directive (Medical POA & Living Will)

Who is this for?

This person is known as the "Patient"

Residing in the county of County

Where the Patient lives

Health Care Agent

Who will be the Agent that can make MEDICAL DECISIONS for the Patient?

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

Health Care Agent's Address

Street Address

Address Line 2

City

State

ZIP Code

Relationship to the Principal

Spouse Family Member Friend Other

Enter Relationship:

Health Care Agent's Telephone

Health Care Agent's E-Mail

2nd Agent

If the Health Care Agent is not available, do you want to appoint a 2nd Health Care Agent?

Yes No

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

2nd Agent's Name

2nd Agent's Mailing Address

Street Address

Address Line 2

City

State

ZIP Code

Relationship to the Principal

Spouse Family Member Friend Other

Enter the Relationship:

2nd Agent's Phone Number

2nd Agent's E-Mail

3rd Agent

Do you want to select a 3rd Health Care Agent?

Yes No

3rd Health Care Agent's Name

3rd Agent's Mailing Address

Street Address

Address Line 2

City

State

ZIP Code

Relationship to the Principal

Spouse Family Member Friend Other

Enter the Relationship:

3rd Agent's Phone Number

3rd Agent's E-Mail

Priorities

What are the Principal's priorities for medical care? (check all that apply)

Comfort Pain Relief Prolong Life as Long as Possible Other

Enter the Additional Requests:

Powers to End Life

If the Principal should be in a terminal condition, will the Health Care Agent have the power of end their life?

Yes No

Enter the Principal's Initials

Clear

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

Enter the Principal's Initials

Clear

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

Drugs

Do you request that drugs be given to the Principal to provide comfort?

Yes No

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

Withdrawal of Life-Support

Does the Principal direct that all life-prolonging procedures be WITHDRAWN if there are no curable options?

Yes No

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

CPR Authorization

Do you authorize Heart-Lung Resuscitation (CPR) if you cannot speak for yourself?

Yes No

Mechanical Ventilator Authorization

Do you authorize a Mechanical Ventilator (breathing machine) if you cannot speak for yourself?

Yes No

Dialysis Authorization

Do you authorize a Dialysis (kidney machine) if you cannot speak for yourself?

Yes No

Surgery Authorization

Do you authorize Surgery if you cannot speak for yourself?

Yes No

Chemotherapy Authorization

Do you authorize Chemotherapy if you cannot speak for yourself?

Yes No

Radiation Treatment Authorization

Do you authorize Radiation Treatment if you cannot speak for yourself?

Yes No

Antibiotics Authorization

Do you authorize Antibiotics if you cannot speak for yourself?

Yes No

Feeding and Breathing

If the Principal is in a Terminal Condition, do they request Feeding and Breathing tubes?

Yes No

Enter the Principal's Initials

Clear

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

Enter the Principal's Initials

Clear

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

Directions to Agent

This Form should be followed by the Agent as: (choose one)

Strict instructions when when making medical decisions for the Principal. Guidance when making medical decisions for the Principal.

Enter the Principal's Initials

Clear

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

Will there be any exceptions?

Yes No

Enter any Exceptions:

Enter the Principal's Initials to Confirm

Clear

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

Organ Donation

Does the Principal wish to donate their organs after death?

Yes Yes with conditions No

Enter the Principal's Initials

Clear

Enter the Principal's Initials

Clear

Enter any limitations:

Signing Requirements

Under Pennsylvania law, this Form must be signed with Two (2) Witnesses

I Agree

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

Do you know the DATE this Form will be signed?

Yes No

Enter the Signing Date

Notarization

Are you going to have this Form be Notarized?

Yes No

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

Pennsylvania Advance Directive (Medical POA & Living Will)

Health Care Agent

2nd Agent

3rd Agent

Priorities

Powers to End Life

Drugs

Withdrawal of Life-Support

CPR Authorization

Mechanical Ventilator Authorization

Dialysis Authorization

Surgery Authorization

Chemotherapy Authorization

Radiation Treatment Authorization

Antibiotics Authorization

Feeding and Breathing

Directions to Agent

Organ Donation

Signing Requirements

Signing Date

Notarization