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Missouri Living Will Declaration Form

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The Missouri living will declaration only allows a patient to make end of life decisions on their part by writing instructions to medical staff through this document. If the patient would like to make instructions and select an agent to act on their behalf they should fill-in the Advance Directive (includes durable power of attorney for healthcare).

Definition – § 459.010(4)

LawsChapter 459 (Declarations, Life Support)

Medical Power of Attorney – Select a proxy to help a patient, in the chance they cannot do so for themselves, to help with tough health care decisions in the chance the principal is mentally not capable to make it themselves.

How to Write

Step 1 – Declaration of Declarant/Principal – The Declarant must review the information at the top of the form. If in agreement enter the following:

  • Date the document in dd/mm/yyyy format
  • Printed name of the Declarant
  • Signature of the Declarant
  • Complete physical address of the Declarant

Step 2 – Witnesses – There must be two witnesses to acknowledge the document. Both must read the brief statement. If in agreement, enter the following:

  • Signature of witness
  • Printed name
  • Complete physical address

Step 3 – Revocation Provision – Should the Declarant decide against the living will they have created and are of sound mind, it may revoked at any time by providing the following information:

  • Printed name of Declarant
  • Signature of Declarant
  • Date of signature in mm/dd/yyyy format

Step 4 – Missouri Durable Power of Attorney for Healthcare – Enter the following:

  • Name of Principal/Declarant
  • Complete address of Principal
  • Full name of Attorney in Fact
  • Complete address of Attorney in Fact
  • Home telephone number
  • Work telephone number
  • Name of Alternate Attorney in Fact
  • Complete address of Attorney in Fact
  • Home Phone number
  • Work Phone number

Step 5 – Acknowledgement of Principal – Read the statement. If in agreement:

  • Enter the name of the Principal
  • Date of the document in dd/mm/yyyy format
  • Signature of the Principal

Step 6 – Notarization – Once the notary has witnessed all signatures, they will acknowledge by completing the remainder of the form as required by Missouri law and authenticating with the state seal.


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