Advance Directive Instructions

ADVANCE DIRECTIVE FOR HEALTHCARE

Living Will and Healthcare Power of Attorney

IMPORTANT NOTICE

This document allows you to:

1. Appoint someone to make healthcare decisions for you if you are unable to do so (Healthcare Power of Attorney / Healthcare Proxy)
2. State your wishes about medical treatment if you cannot communicate (Living Will)

Before completing this form:
☐ Consider consulting with your physician about your health conditions and treatment options
☐ Discuss your wishes with your family and proposed healthcare agent
☐ Consider consulting with an attorney, especially regarding state-specific requirements
☐ Review your state's specific advance directive form (many states have statutory forms)

PART I: PERSONAL INFORMATION

Your Name (Principal): [YOUR FULL LEGAL NAME]

Date of Birth: [DATE OF BIRTH]

Address: [ADDRESS]

City, State, ZIP: [CITY, STATE ZIP]

Phone: [PHONE]

Email: [EMAIL]

PART II: HEALTHCARE POWER OF ATTORNEY

Appointment of Healthcare Agent

Section A: Primary Healthcare Agent

I, [YOUR NAME], hereby appoint the following person as my healthcare agent (also known as healthcare proxy, healthcare surrogate, or attorney-in-fact for healthcare):

Primary Agent:

Name: [AGENT NAME]

Relationship: [RELATIONSHIP]

Address: [ADDRESS]

Home Phone: [PHONE]

Cell Phone: [PHONE]

Work Phone: [PHONE]

Email: [EMAIL]

Section B: Alternate Healthcare Agents

If my primary healthcare agent is unwilling, unable, or unavailable to act, I appoint the following alternate agents in the order listed:

First Alternate Agent:

Name: [ALTERNATE 1 NAME]

Relationship: [RELATIONSHIP]

Address: [ADDRESS]

Phone: [PHONE]

Email: [EMAIL]

Second Alternate Agent:

Name: [ALTERNATE 2 NAME]

Relationship: [RELATIONSHIP]

Address: [ADDRESS]

Phone: [PHONE]

Email: [EMAIL]

Section C: Powers Granted to My Healthcare Agent

My healthcare agent shall have the authority to make all healthcare decisions on my behalf, including but not limited to:

☐ Consent to, refuse, or withdraw consent for any medical treatment, procedure, or service

☐ Select and discharge healthcare providers and facilities

☐ Access my medical records and health information

☐ Consent to release of medical information

☐ Make decisions about pain management and comfort care

☐ Make decisions about life-sustaining treatment, including but not limited to:
☐ Mechanical ventilation (breathing machines)
☐ Artificial nutrition and hydration (feeding tubes)
☐ Cardiopulmonary resuscitation (CPR)
☐ Dialysis
☐ Blood transfusions
☐ Antibiotics and other medications

☐ Make anatomical gift decisions (organ and tissue donation)

☐ Make decisions about autopsy

☐ Make decisions about disposition of remains

☐ Admit me to or discharge me from any hospital, nursing home, assisted living facility, hospice, or similar facility

☐ Enter into agreements for my care and pay for care from my assets

Section D: Limitations on Agent's Authority (Optional)

My healthcare agent's authority is limited as follows:

☐ None - My agent has full authority as described above

☐ The following limitations apply:
[DESCRIBE ANY LIMITATIONS]

Section E: When This Power Becomes Effective

My healthcare agent's authority becomes effective:

☐ Immediately upon signing this document

☐ Only when I am determined to lack capacity to make my own healthcare decisions, as determined by my attending physician (and a second physician if required by state law)

Section F: Durability

This healthcare power of attorney shall not be affected by my subsequent incapacity and shall remain in effect until revoked by me.

PART III: LIVING WILL

Instructions for Healthcare Treatment

Section A: When This Living Will Applies

These instructions apply if I:

☐ Have a terminal condition with no reasonable hope of recovery

☐ Am in a persistent vegetative state or permanent unconsciousness

☐ Have an end-stage condition (advanced, progressive, irreversible)

☐ Have an incurable or irreversible condition that will result in death within a short time

☐ Am unable to communicate my wishes

Section B: Life-Sustaining Treatment

If I am in a condition described above, I direct the following regarding life-sustaining treatment:

Option 1: Comfort Care Only
☐ I do NOT want any life-sustaining treatment. I want only comfort care (palliative care) to keep me comfortable and relieve pain. I understand this may hasten my death.

Option 2: Trial Period
☐ I want life-sustaining treatment tried for a reasonable period. If there is no improvement, I want treatment stopped and comfort care provided.

Option 3: All Treatment
☐ I want all life-sustaining treatment to continue as long as possible.

Option 4: Specific Instructions
☐ I have specific instructions for different treatments (complete Section C below)

Section C: Specific Treatment Instructions

Cardiopulmonary Resuscitation (CPR):
If my heart stops or I stop breathing:
☐ Attempt CPR
☐ Do NOT attempt CPR (DNR)
☐ Let my healthcare agent decide

Mechanical Ventilation (Breathing Machine):
☐ Use mechanical ventilation if needed
☐ Do NOT use mechanical ventilation
☐ Trial use, then discontinue if no improvement
☐ Let my healthcare agent decide

Artificial Nutrition and Hydration (Feeding Tubes):
☐ Use artificial nutrition and hydration if needed
☐ Do NOT use artificial nutrition and hydration
☐ Trial use, then discontinue if no improvement
☐ Let my healthcare agent decide

Dialysis:
☐ Use dialysis if needed
☐ Do NOT use dialysis
☐ Trial use, then discontinue if no improvement
☐ Let my healthcare agent decide

Antibiotics:
☐ Use antibiotics to treat infections
☐ Use antibiotics only for comfort (e.g., UTI causing discomfort)
☐ Do NOT use antibiotics
☐ Let my healthcare agent decide

Blood Transfusions:
☐ Use blood transfusions if needed
☐ Do NOT use blood transfusions
☐ Let my healthcare agent decide

Other Medical Interventions:
☐ Use other interventions as medically appropriate
☐ Limit interventions to comfort care only
☐ Let my healthcare agent decide

Section D: Pain Management

☐ I want adequate pain medication to keep me comfortable, even if it may hasten my death

☐ I want pain medication but prefer to remain as alert as possible

☐ Let my healthcare agent decide based on my condition

Section E: Pregnancy Clause (if applicable)

☐ Not applicable (male or past childbearing age)

☐ If I am pregnant, I want these instructions to apply

☐ If I am pregnant, I do NOT want these instructions to apply until after delivery (or as required by state law)

☐ Let my healthcare agent decide

PART IV: ADDITIONAL INSTRUCTIONS

Section A: Personal Values and Beliefs

To help guide decisions, I want my healthcare agent and physicians to know the following about my values, beliefs, and wishes:

Quality of Life Considerations:
[DESCRIBE WHAT QUALITY OF LIFE MEANS TO YOU - e.g., ability to communicate, recognize family, live independently, etc.]

Religious or Spiritual Beliefs:
[DESCRIBE ANY RELIGIOUS OR SPIRITUAL BELIEFS THAT SHOULD GUIDE HEALTHCARE DECISIONS]

Other Important Considerations:
[ANY OTHER WISHES, VALUES, OR INSTRUCTIONS]

Section B: Specific Conditions or Treatments

[ANY SPECIFIC INSTRUCTIONS FOR PARTICULAR CONDITIONS OR TREATMENTS NOT COVERED ABOVE]

PART V: ORGAN AND TISSUE DONATION

☐ I wish to donate my organs and tissues upon death for transplantation, therapy, research, or education

☐ I wish to donate only the following organs/tissues: [SPECIFY]

☐ I do NOT wish to donate any organs or tissues

☐ Let my healthcare agent or family decide

PART VI: AUTOPSY

☐ I consent to autopsy if useful for medical science or legal purposes

☐ I do NOT consent to autopsy except as required by law

☐ Let my healthcare agent or family decide

PART VII: DISPOSITION OF REMAINS

☐ Burial - Location/instructions: [SPECIFY]

☐ Cremation - Instructions for ashes: [SPECIFY]

☐ Other: [SPECIFY]

☐ Let my healthcare agent or family decide

PART VIII: SIGNATURES AND WITNESSES

Declaration

I, [YOUR NAME], being of sound mind, willfully and voluntarily make this Advance Directive. I understand the nature and consequences of this document. I am at least 18 years of age (or the age of majority in my state). This document reflects my informed wishes.

Your Signature: ______________________________________

Date: ______________

Witnesses

WITNESS 1:

I declare that the person who signed this document, or asked another to sign for them, did so in my presence, and that they appear to be of sound mind and under no duress, fraud, or undue influence.

Signature: ______________________________________

Printed Name: [NAME]

Address: [ADDRESS]

Date: ______________

I am not:
☐ Related to the principal by blood, marriage, or adoption
☐ Entitled to any portion of the principal's estate
☐ The principal's attending physician or healthcare provider
☐ An employee of a healthcare facility where the principal is a patient

WITNESS 2:

I declare that the person who signed this document, or asked another to sign for them, did so in my presence, and that they appear to be of sound mind and under no duress, fraud, or undue influence.

Signature: ______________________________________

Printed Name: [NAME]

Address: [ADDRESS]

Date: ______________

I am not:
☐ Related to the principal by blood, marriage, or adoption
☐ Entitled to any portion of the principal's estate
☐ The principal's attending physician or healthcare provider
☐ An employee of a healthcare facility where the principal is a patient

Notarization (if required or desired)

STATE OF [STATE]
COUNTY OF [COUNTY]

On this _____ day of _____________, 20____, before me, the undersigned notary public, personally appeared [YOUR NAME], proved to me through satisfactory evidence of identification to be the person whose name is signed on this document, and acknowledged to me that they signed it voluntarily for its stated purpose.

______________________________________
Notary Public

My Commission Expires: ______________

[NOTARY SEAL]

PART IX: DISTRIBUTION AND STORAGE

Provide copies of this document to:

☐ Your healthcare agent(s)
☐ Your primary care physician
☐ Your specialists
☐ Family members
☐ Hospital(s) where you receive care
☐ Your attorney
☐ Your state's advance directive registry (if available)
☐ Store a copy with your important papers

Original document location: [LOCATION]

PART X: REVOCATION

You may revoke this Advance Directive at any time by:

• Signing and dating a written revocation
• Physically destroying the document
• Verbally stating your intent to revoke (in front of a witness)
• Executing a new Advance Directive (which revokes prior versions)