ADVANCE DIRECTIVE

This form was completed and signed on [MM/DD/YYYY].

1. HEALTH CARE DIRECTIVE (LIVING WILL).

I, [PRINCIPAL NAME], with a street address of [PRINCIPAL STREET], City of [PRINCIPAL CITY], County of [PRINCIPAL COUNTY], State of [PRINCIPAL STATE], with the last four (4) digits of my social security number (SSN) being XXXX – XX – [XXXX] (Hereinafter referred to as the “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.

a. Life Support

I desire that my doctor make a concerted effort to return me to an acceptable quality of life using the 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determined that my condition will not improve (is irreversible), I direct that all treatments that extend my life be withdrawn.

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

[INITIAL] ☐ – Chronic coma or persistent vegetative state
[INITIAL] ☐ – no longer able to communicate my needs
[INITIAL] ☐ – no longer able to recognize family or friends
[INITIAL] ☐ – total dependence on others for daily care
[INITIAL] ☐ – Other: [OPTIONAL – OTHER UNACCEPTABLE QUALITY OF LIFE].

Initial and check only one:

[INITIAL] ☐ – 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).
[INITIAL] ☐ – 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).

b. 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 treatments below, if any, that you do not wish to have under any circumstances:

[INITIAL] ☐ – Cardiopulmonary Resuscitation (CPR)
[INITIAL] ☐ – Ventilation (breathing machine)
[INITIAL] ☐ – Feeding tube
[INITIAL] ☐ – Dialysis
[INITIAL] ☐ – Other: [OTHER UNWANTED TREATMENT (OPTIONAL)].

c. End of Life Wishes (hospice care, funeral arrangements, etc.):

When I am near death, it is important to me that: [WRITE END-OF-LIFE WISHES HERE].

2. MEDICAL POWER OF ATTORNEY.

I, [PRINCIPAL NAME], as Principal, designate [AGENT NAME] as my agent to act in all matters relating to my health care (including my mental health care) and including, without limitation, the power to give or refuse consent to all medical and surgical treatments, hospitalizations and related health care. This power of attorney is effective at the point when I am no longer able to communicate my health care wishes. My agent’s decisions under this power of attorney, during any period when I am unable to make and/or communicate my health care decisions or when there is uncertainty as to whether I am dead or alive, are binding on my heirs, devisees, and personal representatives.

[INITIAL] – I specifically consent to giving my agent the power to admit me to an inpatient or partial psychiatric hospitalization program if ordered by my physician.
[INITIAL] – This Advance Directive, including Medical Power of Attorney, may not be revoked if I am incapacitated.

My agent’s address and phone number are as follows:

Agent Address: [AGENT ADDRESS]
Agent Phone Number: [AGENT PHONE NUMBER]

If my agent is unwilling or unable to serve, I hereby appoint [SUCCESSOR AGENT NAME] as my successor agent.

My successor agent’s address and phone number are as follows:

Successor Agent Address: [SUCCESSOR AGENT ADDRESS]
Successor Agent Phone Number: [SUCCESSOR AGENT PHONE NUMBER]

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.

I have signed this document on [MM/DD/YYYY].

Principal’s Signature: ___________________________
Printed Name: [PRINCIPAL NAME]
Principal Address: [PRINCIPAL ADDRESS]
Principal Phone Number: [PRINCIPAL PHONE NUMBER]

You may either choose two witnesses or a notary to witness and acknowledge your signature.

WITNESS ACKNOWLEDGMENT

On the date set forth above, I (the witnesses) hereby state as follows:

The above-named person is personally known to me, and I believe them to be of sound mind and to have voluntarily executed this document. I am at least 18 years old, not related to them by blood, marriage, or adoption, and I am not an agent or successor agent named in this document. To my knowledge, I am not a beneficiary of their will or any codicil, and I have no claim against their estate. I am not directly involved in their health care.

Witness Signature: ___________________________
Printed Name: [WITNESS NAME]
Address: [WITNESS ADDRESS]
Phone: [WITNESS PHONE NUMBER]

Witness Signature: ___________________________
Printed Name: [WITNESS NAME]
Address: [WITNESS ADDRESS]
Phone: [WITNESS PHONE NUMBER]

NOTARY ACKNOWLEDGMENT

State of [STATE]
County of [COUNTY]

Signed and sworn to me this [MM/DD/YYYY].

I, the undersigned authority in and for said County in said State, hereby certify that the Principal [PRINCIPAL NAME], whose name is signed above in this living will and who is known to me, acknowledged before me on this day that, being informed of the contents of the said document, (s)he executed the same voluntarily on the day the same date.

Notary Public Signature: ___________________________
Printed Name: [NOTARY NAME]
My commission expires: [EXPIRATION].

(Notary Seal)