Living Will and Advance Health-Care Instruction Requirements in Missouri

At a glance

Missouri uses a narrow written declaration under Chapter 459. It addresses an adult's own request to withhold or withdraw defined death-prolonging procedures; it is not the health-care-agent appointment governed elsewhere in Missouri law.

Requirements one by one

The declaration must be written, signed, and dated

Section 459.015.1 permits a competent adult to sign personally or direct another person to sign in the adult's presence. The declaration must be dated. Missouri provides an optional statutory form and permits additional specific directions, but does not require the sample wording.

Witnesses depend on handwriting. A declaration not wholly in the adult's own handwriting must be signed in the presence of two witnesses age 18 or older. Neither witness may be the person who signed at the adult's direction. The paragraph does not require witnesses for a wholly handwritten declaration and does not offer notarization as an alternative.

Terminal condition and inability to decide are both required

Under § 459.025, the declaration becomes operative only when the condition is terminal and the adult cannot make treatment decisions. Both determinations must be placed in the medical record. A capable adult's current direction always supersedes the earlier document.

The terminal-condition definition uses the attending physician's opinion: the condition is incurable or irreversible and death will occur within a short time regardless of medical procedures. Chapter 459 does not add permanent unconsciousness or an end-stage-condition alternative.

Nutrition, hydration, pain relief, and comfort are outside the defined withdrawal

The declaration may direct withholding or withdrawal of a "death-prolonging procedure." Section 459.010(3) expressly excludes medication or procedures needed for comfort or pain relief and also excludes every procedure that provides nutrition or hydration from that defined term.

Section 459.015.3 allows other specific directions in the document. That permission does not rewrite the chapter's defined death-prolonging-procedure mechanism or its express exclusions.

Pregnancy suspends the declaration's withdrawal instruction

Section 459.025 says a declaration to withdraw or withhold treatment has no effect during the pregnancy after the attending physician diagnoses the adult as pregnant. The sentence states no gestational-age, viability, live-birth, or prognosis exception.

Chapter 459 separately says it does not authorize mercy killing, euthanasia, or an affirmative or deliberate act or omission to shorten or end life.

Revocation is deliberately broad

Under § 459.020, the adult may revoke at any time and in any manner that communicates an intent to revoke, regardless of mental or physical condition. The provider places the revocation in the medical record. A person is not liable for failing to act on it unless it is charted or that person actually knows of it.

Section 459.250 authorizes optional electronic submission of directives and revocations to an Advance Health Care Directives Registry. Registration is not an execution requirement, and failure to update the registry does not invalidate an otherwise valid revocation.

A refusal triggers reasonable transfer steps

A provider with actual knowledge should not act contrary to the declaration without a serious reason consistent with the adult's best interest, recorded in the medical record. An unwilling attending physician must take reasonable steps to transfer the adult to another physician; a facility whose policy prevents compliance must take reasonable steps toward facility transfer.

Good-faith compliance under usual and customary medical standards receives the immunity stated in § 459.040. Chapter 459 contains no separate rule giving an out-of-state treatment instruction automatic recognition.

What trips people up

• Two witnesses are conditional. They are required when the declaration is not wholly in the adult's handwriting, not for every Missouri declaration.
• Nutrition and hydration are not included in the defined procedure. The statute expressly excludes them, along with pain relief and comfort care.
• Pregnancy is categorical in this chapter. The declaration has no effect during the pregnancy; the statute does not provide a customizable exception.
• Registry filing does not create validity. It is optional storage and access, not a substitute for the writing, signature, date, and witness rules.

Common questions

May I use a notary instead of witnesses?

No notary alternative appears in § 459.015. If the declaration is not wholly in your handwriting, the statute calls for two adult witnesses.

May the declaration be oral?

No. Missouri's Chapter 459 declaration must be in writing, signed, and dated. The broad communication rule applies to revocation, not initial execution.

Does the declaration control while I can still decide?

No. Your current direction supersedes the document. The declaration operates only after the terminal-condition and inability-to-decide findings are recorded.

Statutes and sources

• Mo. Rev. Stat. §§ 459.010 and 459.015 — competence, terminal condition, death-prolonging-procedure exclusions, writing, signature, date, conditional witnesses, optional form, and physician notice. § 459.010 and § 459.015 (accessed 2026-07-30).
• Mo. Rev. Stat. §§ 459.020 and 459.025 — broad revocation, record notation, terminal-and-incapacity trigger, current wishes, serious-reason notation, and pregnancy. § 459.020 and § 459.025 (accessed 2026-07-30).
• Mo. Rev. Stat. §§ 459.030, 459.040, and 459.055 — transfer, immunity, and the euthanasia boundary. § 459.030, § 459.040, and § 459.055 (accessed 2026-07-30).
• Mo. Rev. Stat. §§ 459.016 and 459.250 — DHSS form direction and optional registry. § 459.016 and § 459.250 (accessed 2026-07-30).