ILLINOIS LIVING WILL & ADVANCE HEALTH-CARE DIRECTIVE
(Comprehensive Form – 755 Ill. Comp. Stat. 35/ et seq. compliant)
[// GUIDANCE: This template intentionally integrates (i) a statutory-compliant “Declaration” (Living Will) and (ii) an optional Health-Care Power of Attorney (“HCPOA”) section so attorneys may deliver a single, coordinated advance-directive instrument. Omit or tailor any portion inapplicable to your client. All bracketed items require client-specific input.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Declarant’s Statement of Intent
3.2 Conditions Precedent to Effectiveness
3.3 Treatment Instructions
3.4 Appointment of Health-Care Agent (optional) - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Revocation Procedures
- Execution Blocks
11.1 Declarant Signature
11.2 Health-Care Agent Acceptance (if any)
11.3 Witness Attestation (statutorily required)
11.4 Optional Notary Acknowledgment
1. DOCUMENT HEADER
THIS ILLINOIS LIVING WILL & ADVANCE HEALTH-CARE DIRECTIVE (this “Directive”) is made as of [EFFECTIVE DATE] (the “Effective Date”) by [FULL LEGAL NAME OF DECLARANT], residing at [ADDRESS] (the “Declarant”), pursuant to and intended to be interpreted in conformity with the Illinois Living Will Act, 755 Ill. Comp. Stat. 35/1 et seq., the Illinois Power of Attorney Act (Healthcare Power of Attorney), 755 Ill. Comp. Stat. 45/4-1 et seq., and other applicable Illinois and federal health-care laws (collectively, the “State Health-Care Law”).
2. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings set forth below. Terms defined herein appear alphabetically and are cross-referenced throughout the instrument.
“Agent” means the individual designated in Section 3.4 to make Health-Care Decisions for the Declarant if Declarant lacks Capacity.
“Artificial Nutrition and Hydration” means medically supplied food and fluids, including via intravenous (IV) tube or feeding tube.
“Capacity” means the present ability to understand and appreciate the nature and consequences of Health-Care Decisions and to communicate a decision.
“Declarant” has the meaning set forth in the Document Header.
“Good Faith” means honest belief, without malice or intent to defraud, and with reasonable diligence under the circumstances.
“Health-Care Decision” includes consent, refusal of consent, or withdrawal of consent to any medical procedure, treatment, or intervention.
“Life-Sustaining Treatment” means any medical procedure or intervention that, when administered to a patient in a terminal condition or permanently unconscious state, will serve only to prolong the dying process.
“Provider” means any health-care professional, institution, or facility providing services to Declarant.
“Witness” or “Witnesses” means the two attesting individuals satisfying Section 11.3.
3. OPERATIVE PROVISIONS
3.1 Declarant’s Statement of Intent
3.1.1 Voluntary Declaration. I, the Declarant, of my own free will, being of sound mind and at least 18 years of age, declare that I understand my diagnosis, treatment alternatives, and the consequences of this Directive.
3.1.2 Scope. This Directive expresses my instructions regarding Life-Sustaining Treatment, pain management, and other Health-Care Decisions, and (if Section 3.4 is completed) appoints an Agent to implement these wishes if I lack Capacity.
3.2 Conditions Precedent to Effectiveness
This Directive becomes operative only upon both:
a) Certification in writing by my Attending Physician that I lack Capacity; and
b) Either (i) a terminal condition or (ii) a permanent unconscious state, each as defined by State Health-Care Law.
3.3 Treatment Instructions
[// GUIDANCE: Tailor selections, add sub-options as client directs.]
3.3.1 Life-Sustaining Treatment.
☐ I direct that Life-Sustaining Treatment be WITHHELD OR WITHDRAWN.
☐ I direct that Life-Sustaining Treatment be CONTINUED.
3.3.2 Artificial Nutrition and Hydration.
☐ Withhold/Withdraw.
☐ Continue.
☐ Decide in accordance with Agent’s judgment.
3.3.3 Pain Management. Irrespective of the above, I request medication or procedures necessary to alleviate pain or discomfort, even if such measures may hasten death.
3.3.4 Cardiopulmonary Resuscitation (CPR).
☐ Do Not Resuscitate (DNR).
☐ Full Code.
3.3.5 Organ/Tissue Donation.
☐ I consent to donate [SPECIFY OR “any needed”] organs/tissue.
☐ I do not consent.
3.3.6 Additional Instructions.
[FREE-FORM TEXT BOX]
3.4 Appointment of Health-Care Agent (OPTIONAL)
3.4.1 Appointment. I hereby appoint [AGENT NAME], of [ADDRESS], telephone [NUMBER], as my Agent.
3.4.2 Successor Agent. If the Agent is unable or unwilling to serve, I appoint [SUCCESSOR AGENT NAME] as successor.
3.4.3 Agent Authority. My Agent is authorized to:
a) Make any Health-Care Decisions I could make if I had Capacity;
b) Access medical records;
c) Hire/fire Providers;
d) Authorize my admission to or discharge from health-care facilities; and
e) Enforce this Directive under Section 6 (Default & Remedies).
3.4.4 Agent Limitations. The Agent’s authority is subject to the express instructions in Section 3.3 and any limitations stated here: [LIMITATIONS].
4. REPRESENTATIONS & WARRANTIES
4.1 Declarant represents and warrants that:
a) Declarant executes this Directive voluntarily and without duress;
b) Declarant is not, to the best of Declarant’s knowledge, pregnant at the time of signing (if pregnant, Section 3.3 instructions apply only as permitted by State Health-Care Law); and
c) Declarant understands the legal effect of this Directive.
4.2 Each Witness represents and warrants, upon execution, that the Witness:
a) Is at least 18 years old and competent;
b) Is not the Declarant’s attending or alternate physician, Agent, spouse, parent, child, grandchild, sibling, or entitled to any portion of Declarant’s estate; and
c) Observed the Declarant sign (or acknowledge signature on) this Directive.
5. COVENANTS & RESTRICTIONS
5.1 Declarant covenants to provide copies of this Directive to the Agent, Providers, and family members.
5.2 Agent covenants to act in Good Faith, consistent with Declarant’s preferences and best interests.
5.3 Providers covenant to honor this Directive to the fullest extent permitted by law and professional standards, subject to Section 7 (Risk Allocation).
6. DEFAULT & REMEDIES
6.1 Event of Default. Failure of any Provider to comply with this Directive after receiving actual notice constitutes a default.
6.2 Cure. Provider shall use reasonable efforts to transfer Declarant to a willing Provider within 24 hours following notice of default.
6.3 Injunctive Relief. Any court of competent jurisdiction sitting in Illinois may, upon petition by the Agent or an interested person, issue injunctive or declaratory relief to enforce this Directive.
6.4 Attorneys’ Fees. In any action to enforce this Directive, the prevailing party shall be entitled to recover reasonable attorneys’ fees and costs.
7. RISK ALLOCATION
7.1 Indemnification (Provider Protection). Declarant’s estate shall indemnify and hold harmless any Provider or Agent who, in Good Faith, honors or attempts to honor this Directive, from and against any liability, loss, or expense (including reasonable attorneys’ fees) arising out of such Good-Faith compliance.
7.2 Limitation of Liability (Good-Faith Standard). No Provider or Agent acting in Good Faith and in substantial compliance with this Directive shall incur civil, criminal, or professional liability.
7.3 Insurance. Nothing herein waives or limits coverage under any professional liability policy carried by a Provider.
7.4 Force Majeure. Provider’s non-performance directly caused by events beyond reasonable control (including disaster or shortage) shall not constitute a default, provided reasonable efforts are made to comply.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Directive and all disputes arising hereunder shall be governed by and construed in accordance with the State Health-Care Law and other applicable United States federal law.
8.2 Forum Selection. Not applicable.
8.3 Arbitration. Not applicable; parties reserve the right to seek judicial relief.
8.4 Jury Waiver. Not applicable.
8.5 Preservation of Injunctive Relief. Nothing in this Section 8 shall limit the right to seek equitable relief under Section 6.3.
9. GENERAL PROVISIONS
9.1 Amendment. Declarant may amend this Directive at any time by executing a written instrument signed and dated before two qualified Witnesses.
9.2 Revocation. See Section 10.
9.3 Assignment. This Directive is personal and non-assignable except to the extent assignments occur by law upon death.
9.4 Severability. If any provision is held invalid, the remaining provisions shall remain in full force and effect.
9.5 Integration. This Directive constitutes the entire advance-directive agreement of the Declarant, superseding all prior oral or written statements.
9.6 Copies. Photocopies and electronically transmitted copies shall have the same effect as originals.
9.7 Electronic Signatures. Permitted to the extent recognized under 5 Ill. Comp. Stat. 175/ (“Illinois Electronic Commerce Security Act”) and applicable federal law.
9.8 Counterparts. This Directive may be executed in multiple counterparts, each of which shall be deemed an original and all of which constitute one instrument.
10. REVOCATION PROCEDURES
10.1 Methods. Declarant may revoke this Directive by:
a) A signed, dated written revocation;
b) Physically destroying all executed originals; or
c) Oral or other expression of intent to revoke in the presence of two qualified Witnesses or the Agent.
10.2 Effectiveness. Revocation is effective upon communication to the attending physician, Agent, or Provider.
10.3 Automatic Revocation. Appointment of Declarant’s spouse as Agent is revoked upon divorce or legal separation, unless Declarant affirms otherwise in writing dated after the decree.
11. EXECUTION BLOCKS
11.1 Declarant Signature
I have read this Directive and understand its purpose and effect.
[DECLARANT SIGNATURE] ____ Date: _____
Print Name: ___________
11.2 Health-Care Agent Acceptance (complete only if Section 3.4 is included)
I accept the appointment as Agent and agree to act in accordance with this Directive and State Health-Care Law.
[AGENT SIGNATURE] ____ Date: _____
Print Name: ___________
11.3 Witness Attestation (required by 755 Ill. Comp. Stat. 35/3-1)
We, the undersigned Witnesses, certify that (i) the Declarant signed or acknowledged this Directive in our presence; (ii) we are each at least 18 years old, competent, and disinterested as defined in Section 4.2; and (iii) Declarant appeared to be of sound mind and under no duress, fraud, or undue influence.
Witness #1 Signature: ___ Date: __
Name (print): ____
Address: _______
Witness #2 Signature: ___ Date: __
Name (print): ____
Address: _______
11.4 Optional Notary Acknowledgment (not required under Living Will Act but may ease interstate recognition)
State of Illinois )
County of ____)
On this ___ day of _, 20, before me, the undersigned Notary Public, personally appeared [DECLARANT NAME], known to me or satisfactorily proven to be the person whose name is subscribed to this Directive, and acknowledged that he/she executed the same for the purposes therein contained.
Notary Public Signature: ___
Printed Name: _____
Commission Expires: _________
[// GUIDANCE: File copies with (i) primary care physician, (ii) hospital medical-records office, and (iii) family. Recommend clients carry a wallet card referencing the existence/location of the Directive.]