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Advance Directive Forms

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An advance directive is a combination of a medical power of attorney and a living will that allows a person to both choose their end-of-life treatment options and nominate an agent to make healthcare decisions on their behalf. An advance directive also allows an individual to make organ donation selections and to choose if the agent should be a conservator. Advance directives are provided as a free form by most states.

By State

Contents

What is an Advance Directive?

An advance directive allows a patient to make as many medical decisions for themselves as possible in the event they cannot speak for themselves (“incapacitated”). This is common before someone undergoes surgery or with signs of the onset of dementia or other mind-altering conditions.

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

How to Get an Advance Directive

The five (5) steps below instruct how any adult 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 are:

  • Under eighteen (18) years of age;
  • Incapacitated;
  • Incarcerated (in jail); and
  • 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 an apply for conservatorship or guardianship depending on local laws. This is can be filed immediately to make medical and financial decisions for someone else.

Step 2 – Make Decisions About Your Healthcare

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 make decisions about where their organs will go after their death (i.e. donation options) along with selecting 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, family member, or close friend.

An advance directive does not usually allow co-agents but 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:

  • A family member;
  • A beneficiary of the principal’s Last Will and Testament;
  • A health care professional; and
  • 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 health care 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)

Not 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. Living Will 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 as 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).

STATESIGNING REQUIREMENTSSTATUTE
Alabama2+ Witnesses§ 22-8A-4(c)(4)
Alaska2 Witnesses OR Notary§ 13.52.010(b)
Arizona1 Witness OR Notary§ 36-3282(5)
Arkansas2 Witnesses§ 20-17-202(a)
California2 Witnesses OR Notary§ 4673(3)
Colorado2 Witnesses§ 15-18-106(1)
Connecticut2 Witnesses§ 19a-575
Delaware2+ Witnesses§ 2503(b)(1)(d)
Florida2 Witnesses§ 765.202(1)
Georgia2 Witnesses§ 31-32-5(c)
Hawaii2 Witnesses OR Notary§ 327E-3
Idaho2 Witnesses§ 39-4501
Illinois2 Witnesses755 ILCS 35/3
Indiana2 Witnesses§ 16-36-4-8(b)(5)
Iowa2 Witnesses§ 144A.3(2)(a)
Kansas2+ Witnesses§ 65-28,103(a)(4)(A)
Kentucky2 Witnesses OR Notary§ 311.625
Louisiana2 WitnessesRS 40:1151.4(A)(2)(b)
Maine2 Witnesses§ 5-803(2)
Maryland2 Witnesses§ 5–602(c)(1)
MassachusettsN/ANo statute
MichiganN/ANo statute
Minnesota2 Witnesses OR Notary§ 145B.03(2)(a)
Mississippi2 Witnesses OR Notary§ 41-41-205(2)(a)
Missouri2 Witnesses§ 459.015(4)
Montana2 Witnesses§ 50-9-103(1)
Nebraska2 Witnesses OR Notary§ 20-404(1)
Nevada2 WitnessesNRS 449A.618
New Hampshire2 Witnesses OR Notary§ 137-J:14
New Jersey2 Witnesses OR Notary§ 26:2H-56
New MexicoPrincipal’s Signature§ 24-7A-2(B)
New YorkN/ANo statute
North Carolina2 Witnesses§ 90-321(c)(3)
North Dakota2 Witnesses OR Notary23-06.5-05(2)
Ohio2 Witnesses OR Notary2107.03
Oklahoma2 Witnesses§ 63 3101.4(A)
Oregon2 Witnesses OR Notary127.515(2)
Pennsylvania2 Witnesses§ 54-5442(b)(2)
Rhode Island2 Witnesses§ 23-4.11-3(a)
South Carolina2 Witnesses§ 44-77-40(2)
South Dakota2 Witnesses§ 34-12D-2
Tennessee2 Witnesses OR Notary§ 32-11-104(a)
Texas2 Witnesses§ 166.032(b)
Utah1 Witness§ 75-2a-107(c)
Vermont2+ Witnesses§ 9703(b)
Virginia2 Witnesses§ 54.1-2983
Washington2 Witnesses OR NotaryRCW 70.122.030(1)
West Virginia2+ Witnesses§ 16-30-4(a)(4)
Wisconsin2 Witnesses§ 154.03(1)
Wyoming2+ Witnesses OR Notary§ 35-22-403

Sample

Download: PDF, Word (.docx), OpenDocument (.odt)


How to Write

Download: PDF, Word (.docx), OpenDocument (.odt)

This is a general guide, and the Advance Directive in your state should always be used.

Colors:

  • Red – Required
  • Green – Optional

Section 1 – Living Will

Step 1 – Identifying the Principal (You)

On the first (1st) page of the document, the principal will need to enter:

  1. The date in which they are completing the document (not necessarily the date they are signing);
  2. Their full name;
  3. Street address (Apt # included, if applicable);
  4. City;
  5. County;
  6. State; and
  7. The last four (4) digits of the principal’s social security number.

Step 2 – Life Support

Initial AND check any of the five (5) options presented. The 5th line can be used for specifying a type of quality of life not specified on the form. The section is optional, meaning the principal is not required to select an option.

Step 3 – Intravenous Food + Water

If the principal would like to kept alive by means of intravenous food and/or water (through a tube/needle), they should initial AND check the first option. If they would not like to be treated artificially, they should choose the second option. Only ONE (1) of the two (2) options listed should be selected.

Step 4 – Life-Sustaining Treatment

In the event of a medical emergency in which a medical professional states intervention is necessary to keep the principal alive, they will commonly involve one (1) or all of the treatments listed in this section. The principal will need to check AND initial any of the five (5) means of treatment that they DO NOT want to receive.

Step 5 – End-of-Life Wishes

If the principal has any end-of-life requests, these can be included on the lines provided. An example could be “I would like to be brought home from the hospital to live out my final moments”.

If the principal runs out of space, they can attach a supplemental form, title it “Appendix A” (for example), and write the name of the additional document on one of the lines in section C.

Section 2 – Medical Power of Attorney

Step 6 – Agent Assignment

The agent is the individual that will represent the principal, informing doctors of the principal’s wishes and seeing that they are taken care of in the manner that was set forth in the “Living Will” section.

The principal will need to enter:

  1. Their name (first + last);
  2. The agent’s name (first + last);
  3. If the principal permits the agent to admit them to inpatient psychiatric care (if ordered by a physician), the first line should be initialed. If the principal also wishes to make the form NOT revocable upon their incapacitation (unable to communicate with those around them), the second line should be initiated. None, one (1) or both (2) options can be initialed if the principal so chooses.
  4. The address of the primary agent;
  5. The primary agent’s phone number (#);
  6. If the principal wishes to designate a successor (secondary) agent, they will need to enter their full name on the provided line;
  7. The successor agent’s address; and
  8. Phone number (#).

Step 7 – Principal’s Signature

The last step the principal takes is to sign the form. This may need to be done in the presence of witness(es) and/or a Notary Public depending on the state the principal resides in. By signing their name, they are stating they agree-with and understand all information contained in the form. The following information will need to be entered:

  1. The date (day, month, and year) in which the principal is signing their name;
  2. The principal’s signature (by hand, OR via eSign);
  3. Their full printed name;
  4. Their address (same as in section 1); and
  5. The principal’s phone number, including the area code.

Section 3 – Witnesses and/or Notarization

Step 8 – Witness Signature(s)

If required by the state, the principal may need to have one (1) or more witness(es) sign the document after witnessing the principal sign their name. The witnesses CAN sign digitally via eSign so long they are in the same physical location as the principal.

Step 9 – Notarization

Some states allow the principal to notarize their signature instead of having witnesses sign the form. Alternatively, the principal may decide to have their Advance Directive notarized IN ADDITION to witnesses to add further proof as to the validity of the document. The principal can have the document notarized online via Notarize.com, or by visiting a post office, library, government office, or similar building that has notary services available.


Frequently Asked Questions

Who can get an Advance Directive?

Any individual 18 years or older may create an advance directive. For individuals under 18 years of age, their parents or legal guardians are automatically nominated as their health care agents.

What are the signing requirements?

The majority of advance directives need to be signed by the principal, notarized, and signed by two (2) witnesses. In most cases, a nurse, doctor, parent, and beneficiaries in a patient’s last will are not allowed to be witnesses in an advance directive.

Where can I register an Advance Directive?

An advance directive may be registered either at the local or state government level, or with a 3rd party. Most state registrations are free or are a small fee. For 3rd party registrations, an individual may use the following sites (3):

What is incapacitation?

Incapacity defined by Section 102 (Page 7) of the Uniform Power of Attorney Act:

“Incapacity” means inability of an individual to manage property or business affairs because the individual: (A) has an impairment in the ability to receive and evaluate information or make or communicate decisions even with the use of technological assistance; or (B) is: (i) missing; 8 (ii) detained, including incarcerated in a penal system; or (iii) outside the United States and unable to return.

Can a family member override an Advance Directive?

No, a family member cannot override the terms outlined in a living will unless specific instructions were given to the agent that permits them to do so.

Advance Directive vs Living Will vs Medical Power of Attorney

A living will is used for listing one’s preferences for how one would like to be medically treated if they are incapacitated (e.g., receive CPR, life support, etc.) A medical power of attorney nominates a person (the agent) to communicate one’s preferences to medical professionals.

The combination of both forms creates an advance directive, which contains instructions for treatment and nominates an agent to communicate said instructions.

Advance Directive vs Do Not Resuscitate (DNR)

An advance directive represents a patient’s medical decisions in case they cannot speak for themselves. A do not resuscitate (DNR) informs all medical professionals NOT to perform any life-saving procedures on a patient.