Advance Directive Forms

Advance Directive Forms

Last updated November 3rd, 2023

  1. Home »
  2. Power of Attorney »
  3. Advance Directive

An advance directive allows a person to plan their end-of-life treatment and nominate an agent responsible for carrying out their medical wishes. It goes into effect when the principal (the one completing the form) enters into an incapacitated medical state. Medical incapacitation refers to an inability to communicate effectively due to reduced cognitive function and is determined by a licensed physician.

An Advance Directive is a combination of both a medical power of attorney and a living will.

By State

Contents

What is an Advance Directive?

An advance directive allows a patient to make many medical decisions for themselves in advance in case they cannot speak for themselves or make important decisions (a state referred to as being “incapacitated”). This is common before someone undergoes surgery or if they starting showing signs of onset of dementia or other mind-altering conditions.

In most states, there are five (5) parts to an advance directive:


Sample

Download: PDF (Blank) | PDF (Sample Data)

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determined that my condition will not improve (is irreversible), I direct that all treatments that extend my life be withdrawn.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)


How to Get an Advance Directive

The five (5) steps below provide instructions on how a person of sound mind can obtain an advance directive in their state.

Step 1 – Qualify

Any person residing in the United States is qualified to create an advance directive, except those that fall under any of the following categories:

  • Under eighteen (18) years of age
  • Incapacitated
  • Incarcerated (in jail)
  • Outside of the country and not able to return

Conservatorship / Guardianship – If a person is already incapacitated, a spouse or family member may need to seek an attorney so they can apply for conservatorship or guardianship. This is can be filed immediately to make medical and financial decisions for someone else.

Step 2 – Make Decisions About Your Health Care

For the living will section, the principal will need to decide whether or not to withhold end-of-life treatment options such as breathing assistance, artificial nutrition and hydration, and prolonged relief from pain.

In addition, the principal will be able to decide where their organs will go after their death (i.e., donation options) and select their preferred primary care physician.

Step 3 – Choose an Agent

For the medical power of attorney section, the principal will need to decide who to select as their agent (also known as a “proxy” or “attorney-in-fact”). In most cases, the agent selected is the spouse, a family member, or a close friend.

An advance directive does not usually allow co-agents, but it does allow alternate agents in the event the first (1st) selected agent is unable to serve.

Step 4 – Sign the Form

An advance directive is not complete until it has been executed in accordance with the signing requirements of the principal’s state of residence. This often involves the principal and their agents signing the document in the presence of two (2) witnesses, a notary public, or both.

In the case of using witnesses, most states require that a witness cannot be the following individuals:

  • A family member;
  • A beneficiary of the principal’s Last Will and Testament;
  • A health care professional; or
  • A person under the age of 18.

Step 5 – Make Copies and Distribute

After the advance directive has been properly executed, it should be distributed to all healthcare agencies of the principal including their primary care physician. Most importantly, the agents of the principal should all receive copies so they can effectively communicate the principal’s wishes in the unfortunate circumstance they can no longer speak for themselves.

Step 6 – Registry Filing (optional)

This step isn’t required, but some states have a registry where the principal can record the advance directive to prove its existence. There are national registries that may be used, such as the U.S. Advance Care Plan Registry and DocuBank, that help to ensure the form is safely stored.

Filing an advance directive in an official registry helps to safeguard against any family member or third (3rd) party disagreeing with the principal’s intentions that are outlined in the form.


Advance Directive: Laws

The Uniform Health-Care Decisions Act is a federally recognized law that has been adopted in seven (7) states (Alaska, Delaware, Hawaii, Maine, Mississippi, New Mexico, and Wyoming). Each state has its own laws pertaining to the execution and application of advance directives.

STATE SIGNING REQUIREMENTS STATUTE
Alabama 2+ Witnesses § 22-8A-4(c)(4)
Alaska 2 Witnesses OR Notary § 13.52.010(b)
Arizona 1 Witness OR Notary § 36-3282(5)
Arkansas 2 Witnesses § 20-6-103(c)(1)
California 2 Witnesses OR Notary § 4673(3)
Colorado 2 Witnesses § 15-18-106(1)
Connecticut 2 Witnesses § 19a-575
Delaware 2+ Witnesses § 2503(b)(1)(d)
Florida 2 Witnesses § 765.202(1)
Georgia 2 Witnesses § 31-32-5(c)
Hawaii 2 Witnesses OR Notary § 327E-3
Idaho N/A No statute
Illinois 2 Witnesses 755 ILCS 35/3
Indiana 2 Witnesses § 16-36-4-8(b)(5)
Iowa 2 Witnesses § 144A.3(2)(a)
Kansas 2+ Witnesses § 65-28,103(a)
Kentucky 2 Witnesses OR Notary § 311.625
Louisiana 2 Witnesses RS 40:1151.4(A)(2)(b)
Maine 2 Witnesses § 5-803(2)
Maryland 2 Witnesses § 5–602(c)(1)
Massachusetts N/A No statute
Michigan N/A No statute
Minnesota 2 Witnesses OR Notary § 145B.03(2)(a)
Mississippi 2 Witnesses OR Notary § 41-41-205(2)(a)
Missouri 2 Witnesses § 459.015(4)
Montana 2 Witnesses § 50-9-103(1)
Nebraska 2 Witnesses OR Notary § 20-404(1)
Nevada 2 Witnesses NRS 449A.618
New Hampshire 2 Witnesses OR Notary § 137-J:14
New Jersey 2 Witnesses OR Notary § 26:2H-56
New Mexico Principal’s Signature § 24-7A-2(B)
New York N/A No statute
North Carolina 2 Witnesses § 90-321(c)(3)
North Dakota 2 Witnesses OR Notary 23-06.5-05(2)
Ohio 2 Witnesses OR Notary 2107.03
Oklahoma 2 Witnesses § 63 3101.4(A)
Oregon 2 Witnesses OR Notary 127.515(2)
Pennsylvania 2 Witnesses § 54-5442(b)(2)
Rhode Island 2 Witnesses § 23-4.11-3(a)
South Carolina 2 Witnesses § 44-77-40(2)
South Dakota 2 Witnesses § 34-12D-2
Tennessee 2 Witnesses OR Notary § 32-11-104(a)
Texas 2 Witnesses § 166.032(b)
Utah 1 Witness § 75-2a-107(c)
Vermont 2+ Witnesses § 9703(b)
Virginia 2 Witnesses § 54.1-2983
Washington 2 Witnesses OR Notary RCW 70.122.030(1)
West Virginia 2+ Witnesses § 16-30-4(a)(4)
Wisconsin 2 Witnesses § 154.03(1)
Wyoming 2+ Witnesses OR Notary § 35-22-403(b)