ADVANCE HEALTH CARE DIRECTIVE
(Living Will – Indiana)

[// GUIDANCE: This template is drafted to comply with current Indiana
advance-directive statutes and administrative rules in effect as of the
date set forth below. Counsel should confirm no statutory revisions
have become effective after that date before finalizing for client use.]

TABLE OF CONTENTS

I. Document Header........................................ 2
II. Definitions............................................ 3
III. Operative Provisions................................... 5
A. Designation of Health-Care Representative........... 5
B. Treatment Preferences & Instructions................ 6
C. HIPAA Authorization................................. 8
D. Anatomical Gifts.................................... 8
E. Post-Death Directions............................... 9
IV. Representations & Warranties........................... 9
V. Covenants & Restrictions............................... 10
VI. Revocation & Amendment Procedures...................... 11
VII. Risk Allocation........................................ 12
VIII. Administrative Provisions.............................. 13
IX. General Provisions..................................... 13
X. Execution Block (Declarant, Witnesses, Notary)......... 15

I. DOCUMENT HEADER

This Advance Health Care Directive (“Directive”) is executed on
[DATE] (the “Effective Date”) by:

Declarant: [FULL LEGAL NAME]
Date of Birth: [MM/DD/YYYY]
Residential Address: [STREET, CITY, STATE, ZIP]

Recitals
A. Indiana law recognizes the right of competent adults to give
instructions concerning their own health-care decisions and to
appoint a health-care representative to make such decisions if they
become incapable.
B. Declarant executes this Directive voluntarily and in sound mind to
ensure that Declarant’s wishes regarding medical treatment, life-
prolonging procedures, and related matters are honored.
C. This Directive shall be governed by the health-care consent laws of
the State of Indiana (“Governing Law”).

II. DEFINITIONS

Unless the context clearly requires otherwise, the following terms have
the meanings set forth below. Defined terms appear in initial capital
letters throughout this Directive.

1. “Advance Directive” or “Directive” – This written instrument,
   including all amendments, revocations, and any valid copy.

2. “Artificial Nutrition and Hydration” – Medically administered
   nourishment (food) or fluids via intravenous, gastric, nasogastric,
   or similar tube.

3. “Attending Physician” – The physician (or physician assistant/
   advanced practice registered nurse acting within scope) who has
   primary responsibility for the Declarant’s care and treatment.

4. “Declarant” – The individual executing this Directive.

5. “Decision-Making Incapacity” – A condition in which Declarant,
   as determined by the Attending Physician, lacks sufficient
   understanding or ability to make or communicate health-care
   decisions.

6. “Health-Care Representative” – An individual appointed in Section
   III.A with authority to make health-care decisions on Declarant’s
   behalf during Decision-Making Incapacity.

7. “Life-Prolonging Procedure” – Any medical procedure, treatment, or
   intervention that uses mechanical or other artificial means to
   sustain, restore, or replace a vital bodily function and thereby
   serve only to prolong the moment of death when, in the judgment of
   the Attending Physician, death is imminent. The term does not
   include palliative care or procedures necessary to provide comfort.

8. “Palliative Care” – Medical care focused on comfort, pain relief,
   and alleviation of symptoms, not primarily aimed at cure.

9. “Surrogate” – An individual authorized under Indiana health-care
   consent statutes to act if no Health-Care Representative is
   available, able, or willing.

10. “Withhold” or “Withdraw” – To discontinue or not initiate a medical
    treatment or Life-Prolonging Procedure.

III. OPERATIVE PROVISIONS

A. Designation of Health-Care Representative
1. Primary Representative
Name: [FULL LEGAL NAME]
Relationship: [RELATIONSHIP]
Address: [ADDRESS]
Phone / E-mail: [CONTACT]

2. First Alternate Representative
   (to serve only if the Primary Representative is unavailable,
   unwilling, or incapacitated)
   Name: [FULL LEGAL NAME]
   Relationship: [RELATIONSHIP]
   Address: [ADDRESS]
   Phone / E-mail: [CONTACT]

3. Second Alternate Representative
   Name: [FULL LEGAL NAME]
   Relationship: [RELATIONSHIP]
   Address: [ADDRESS]
   Phone / E-mail: [CONTACT]

4. Scope of Authority
   a. Full Authority. The Health-Care Representative (“HCR”) shall
   have authority to give, refuse, or withdraw consent to any
   care, treatment, service, or procedure, including but not
   limited to Life-Prolonging Procedures, pain management,
   psychiatric care, home-based care, and placement in or
   discharge from health-care facilities.
   b. Post-Death Authority. The HCR may make anatomical gift
   decisions, authorize autopsy where permitted by law, and
   direct disposition of remains, subject to specific
   instructions in this Directive.
   c. Access to Information. The HCR is an authorized personal
   representative under HIPAA and may receive all protected
   health information necessary to carry out duties.
   d. Nomination as Guardian. Declarant nominates the Primary HCR
   to serve as guardian of Declarant’s person if a court
   determines guardianship necessary.

[// GUIDANCE: Consider adding limitations on authority (e.g., mental
health, ECT, experimental treatments) if desired by client.]

B. Treatment Preferences & Instructions
1. Terminal Condition or Permanent Unconsciousness
a. Directive to Withhold or Withdraw Life-Prolonging
Procedures
☐ I DIRECT that Life-Prolonging Procedures be withheld or
withdrawn, and that I be permitted to die naturally,
receiving only Palliative Care.
☐ I DIRECT that Life-Prolonging Procedures be continued to
the fullest extent reasonably possible.
[CHOOSE ONE OR ADD CUSTOM INSTRUCTIONS]

2. Artificial Nutrition & Hydration
   a. ☐ I do NOT want Artificial Nutrition and Hydration if such
   measures would merely prolong the dying process.
   b. ☐ I DO want Artificial Nutrition and Hydration under all
   circumstances unless medically contraindicated.

3. Pain Management
   Declarant authorizes medication as necessary to alleviate pain
   or distress, even if such medication may unintentionally hasten
   death, provided it is consistent with prevailing medical
   standards.

4. Pregnancy Provision
   If I am pregnant and the fetus is viable in the opinion of my
   Attending Physician:
   ☐ I UNDERSTAND Indiana law may mandate continuation of
   life-sustaining treatment to preserve fetal life, and I
   INTEND that this Directive be construed consistent with that
   law.

5. Mental Health Treatment (Optional)
   [INSERT any special instructions or limitations relating to
   psychotropic medication, inpatient treatment, or electroconvul-
   sive therapy.]

C. HIPAA Authorization
Declarant authorizes any covered entity to disclose protected
health information to the HCR or Surrogate as necessary for the
exercise of authority under this Directive, effective immediately
and surviving Declarant’s death as permitted by 45 C.F.R. § 164.502.

D. Anatomical Gifts
☐ I DO NOT wish to make an anatomical gift.
☐ I WISH to make an anatomical gift of (check all that apply):
☐ Any needed organs/tissues.
☐ Specific organs/tissues: [SPECIFY].
Purpose(s): ☐ Transplant ☐ Research ☐ Education
The HCR is authorized to carry out these wishes.

E. Post-Death Directions
1. Disposition of Remains: ☐ Burial ☐ Cremation ☐ Other: [ ]
2. Preferred funeral home or instructions: [DETAILS]

IV. REPRESENTATIONS & WARRANTIES

1. Capacity. Declarant represents that Declarant is of sound mind,
   at least eighteen (18) years of age, and under no duress,
   fraud, or undue influence.
2. Completeness. Declarant has reviewed this Directive in its
   entirety, understands its contents, and affirms that it expresses
   Declarant’s preferences.
3. No Conflicts. Declarant has revoked or intends to revoke all prior
   advance directives to avoid conflicting instructions.
4. Witness Eligibility. The witnesses executing in Section X are each
   at least eighteen (18) years old and are neither (a) the HCR nor
   (b) persons entitled to any portion of Declarant’s estate or
   directly financially responsible for Declarant’s medical care.

V. COVENANTS & RESTRICTIONS

1. Declarant Covenants
   a. To inform the HCR, family, and Attending Physician of this
   Directive’s existence and provide copies as practicable.
   b. To promptly execute any additional documents reasonably
   requested by health-care providers to effectuate this Directive.

2. Health-Care Representative Covenants
   a. To act in good faith and in accordance with Declarant’s known
   wishes or best interests if wishes are unknown.
   b. To consult with medical professionals and seek ethics committee
   review where appropriate.

3. Restrictions
   a. HCR shall not delegate decision-making authority except as
   expressly permitted by Governing Law.
   b. No health-care provider may condition admission or discharge on
   the execution or non-execution of this Directive.

VI. REVOCATION & AMENDMENT PROCEDURES

1. Revocation by Declarant
   This Directive may be revoked at any time by Declarant, regardless
   of mental or physical condition, through:
   a. A signed, dated writing expressing intent to revoke;
   b. Physical destruction of the original Directive by Declarant or
   at Declarant’s direction; or
   c. An oral statement of intent to revoke, made in the presence of
   an adult witness who thereafter documents the statement.

2. Automatic Revocation
   Appointment of Declarant’s spouse as HCR is revoked upon entry of a
   decree of dissolution, annulment, or legal separation unless
   Declarant indicates otherwise in writing after such decree.

3. Amendment
   Declarant may amend this Directive by executing and properly
   witnessing a new document clearly labeled “Amendment” that refers
   to this Directive’s date. All unchanged provisions remain in
   effect.

4. Effectiveness of Earlier Directives
   Upon the Effective Date, any prior advance directive executed by
   Declarant is hereby revoked in its entirety unless specifically
   incorporated by reference herein.

VII. RISK ALLOCATION

1. Provider Immunity
   Any health-care provider, facility, or individual who in good faith
   relies on this Directive, a copy thereof, or the directions of a
   Health-Care Representative shall be deemed to have acted in good
   faith and shall be released and indemnified by Declarant’s estate
   from any civil, criminal, or professional liability arising from
   such reliance, to the fullest extent permitted under Governing Law.

2. Limitation of Liability
   No Health-Care Representative shall incur personal financial
   liability for decisions made in good faith and in accordance with
   this Directive or applicable law.

VIII. ADMINISTRATIVE PROVISIONS

1. Governing Law
   This Directive shall be construed in accordance with the health-
   care consent laws of the State of Indiana, without regard to
   conflict-of-law principles.

2. Injunctive Relief
   Because money damages are inadequate to redress violations of
   Declarant’s fundamental health-care rights, injunctive relief shall
   be available to enforce this Directive.

[// GUIDANCE: Litigation-oriented dispute provisions (arbitration,
jury waiver, etc.) are intentionally omitted as inconsistent with the
nature of an advance directive.]

IX. GENERAL PROVISIONS

1. Copies
   A photocopy, facsimile, or digitally imaged copy of this Directive
   shall have the same legal effect as an original.

2. Severability
   If any provision is held invalid or unenforceable, the remaining
   provisions shall remain in full force and effect, and the invalid
   provision shall be reformed to best accomplish Declarant’s intent.

3. Integration
   This Directive constitutes the complete expression of Declarant’s
   health-care instructions and appointment of Health-Care
   Representative and supersedes all prior written or oral directives
   concerning the subject matter herein.

4. Amendment & Waiver
   No amendment or waiver of any provision shall be effective unless
   in a signed writing executed in accordance with Section VI.

5. Electronic Signatures
   To the extent permitted by Indiana law, electronic execution or
   notarization of this Directive is valid and enforceable.

X. EXECUTION BLOCK

DECLARANT
I, the undersigned Declarant, understand the purpose and effect of this
Directive and sign it voluntarily on the Effective Date.

______ ____
[DECLARANT SIGNATURE] [PRINTED NAME]
Date: _______

A. WITNESS ATTESTATION (Two adult witnesses OR a notary is required.)

We declare that the Declarant appears to be of sound mind and free from
duress, fraud, or undue influence, and that Declarant signed or
acknowledged this Directive in our presence.

Witness #1: ______ Date: __
Print Name: ______
Address: _________

Witness #2: ______ Date: __
Print Name: ______
Address: _________

Eligibility Confirmation (check all that apply):
☐ Neither witness is (i) the appointed Health-Care Representative,
(ii) related to the Declarant by blood, marriage, or adoption,
or (iii) entitled to any part of Declarant’s estate.

B. NOTARY ACKNOWLEDGMENT (Optional if two witnesses provided)

State of Indiana )
County of ____ ) ss:

On this _ day of __, 20__, before me, the undersigned
Notary Public, personally appeared ____ (“Declarant”)
and proved to me on the basis of satisfactory evidence to be the person
whose name is subscribed to this instrument and acknowledged that he or
she executed the same for the purposes therein contained.

IN WITNESS WHEREOF, I hereunto set my hand and affix my notarial seal.

Notary Public
My commission expires: ______

[// GUIDANCE: After execution, provide copies to (i) each HCR, (ii) the
Declarant’s primary care physician, and (iii) any hospital likely to
provide treatment. Consider uploading to the state-approved registry,
if available, and carrying a wallet card noting the Directive’s
existence.]