MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE

(Living Will & Durable Power of Attorney for Health Care)

Effective Date: [MM/DD/YYYY]
Governing Law: Mississippi Uniform Health-Care Decisions Act (“UHCDA”) and other applicable Mississippi health-care laws
Declarant: [DECLARANT FULL LEGAL NAME], residing at [ADDRESS] (“Declarant”)

[// GUIDANCE: This template is designed for use in Mississippi. Remove bracketed guidance and fill all placeholders before execution. Attach additional pages if needed for special instructions.]

TABLE OF CONTENTS

I. Recitals
II. Definitions
III. Designation of Health-Care Agent
IV. Statement of Treatment Preferences (Living Will)
V. Additional Instructions & Special Directives
VI. HIPAA Authorization
VII. Indemnification & Liability Limitation
VIII. Revocation & Amendment
IX. Copies, Portability & Governing Law
X. General Provisions
XI. Execution & Witness / Notary Acknowledgment

I. RECITALS

1.1 Purpose. Declarant executes this Advance Health-Care Directive (“Directive”) to:
a. appoint a trusted individual to make health-care decisions when Declarant lacks capacity; and
b. state Declarant’s wishes concerning life-sustaining treatment and related care.

1.2 Consideration. In consideration of the mutual promises herein and reliance by health-care providers acting in good faith, Declarant adopts the provisions below.

II. DEFINITIONS

For purposes of this Directive, capitalized terms have the meanings set forth below:

“Agent” – The individual named in Section III.
“Alternate Agent” – The successor individual(s) named in Section III(4).
“Artificial Nutrition and Hydration” – Medically supplied food and fluids via tube or intravenous means.
“Good Faith” – Honesty in fact in the conduct or transaction concerned.
“Health-Care Decision” – Any decision regarding the diagnosis, treatment, or care of the Declarant, including life-sustaining measures.
“Life-Sustaining Treatment” – Any medical intervention that serves only to prolong the process of dying or maintain Declarant in a persistent vegetative state.
“Permanent Unconscious Condition” – A medical condition in which Declarant is irreversibly unaware of self and environment.
“Terminal Condition” – An incurable condition that will result in death within a relatively short time regardless of treatment.
“UHCDA” – Mississippi’s Uniform Health-Care Decisions Act, Miss. Code Ann. § 41-41-201 et seq., as amended.

[// GUIDANCE: Add any additional defined terms your client requires.]

III. DESIGNATION OF HEALTH-CARE AGENT

3.1 Primary Agent. Declarant designates:
Name: [PRIMARY AGENT NAME]
Address: [ADDRESS]
Telephone: [PHONE]
Relationship: [RELATIONSHIP]

3.2 Authority of Agent.
a. Make any and all Health-Care Decisions the Declarant could make if capable, including decisions regarding Artificial Nutrition and Hydration.
b. Access confidential medical information and records, and consent to disclosure.
c. Employ and discharge health-care providers.
d. Authorize admission to or discharge from health-care facilities.
e. Sign and deliver any required consents, waivers, or releases.

3.3 Scope & Limitations. The Agent’s authority is subject to the express preferences in Section IV and any special instructions in Section V.

3.4 Alternate Agent(s). If the Primary Agent is unable, unwilling, or unavailable to act, Declarant designates in succession:
a. First Alternate: [ALT AGENT #1 NAME | CONTACT INFO]
b. Second Alternate: [ALT AGENT #2 NAME | CONTACT INFO]

3.5 Commencement & Duration of Authority. Authority commences upon certification in writing by the attending physician (or other provider under UHCDA) that Declarant lacks capacity and continues until revoked under Section VIII.

IV. STATEMENT OF TREATMENT PREFERENCES (LIVING WILL)

4.1 General Intent. Declarant desires to die naturally, with only the administration of medication or performance of medical procedures necessary to provide comfort care and relieve pain, unless indicated otherwise below.

4.2 Life-Sustaining Treatment. If at any time Declarant is determined to have a Terminal Condition or to be in a Permanent Unconscious Condition, Declarant directs:
☐ (Initial) WITHHOLD / WITHDRAW Life-Sustaining Treatment.
☐ (Initial) PROVIDE Life-Sustaining Treatment.

4.3 Artificial Nutrition & Hydration.
☐ (Initial) WITHHOLD / WITHDRAW Artificial Nutrition and Hydration.
☐ (Initial) PROVIDE Artificial Nutrition and Hydration.

4.4 Pain Relief. Declarant requests administration of medication to relieve pain or discomfort even if it may hasten death.

4.5 Pregnancy. If Declarant is known to be pregnant, this Directive shall have no force during pregnancy unless continued application would not permit full development of the fetus:
☐ (Initial) Directive REMAINS in effect during pregnancy.
☐ (Initial) Suspend Directive until after pregnancy.

V. ADDITIONAL INSTRUCTIONS & SPECIAL DIRECTIVES

[Insert any religious, cultural, or organ-donation instructions. If none, state “None.”]

VI. HIPAA AUTHORIZATION

6.1 Authorization. Declarant authorizes any covered entity to disclose protected health information to the Agent and Alternate Agents to the full extent permitted under 45 C.F.R. § 164.502.

6.2 Duration. This authorization is effective immediately and survives Declarant’s death to the extent necessary to carry out post-mortem decisions (e.g., anatomical gifts).

VII. INDEMNIFICATION & LIABILITY LIMITATION

7.1 Provider Protection. No health-care provider or facility acting in Good Faith and in reliance on this Directive shall incur civil or criminal liability or be subject to disciplinary action.

7.2 Agent Indemnity. Declarant’s estate shall indemnify the Agent against liability incurred for Health-Care Decisions made in Good Faith and within the scope of authority granted herein, except for willful misconduct or gross negligence.

7.3 Liability Cap. Any liability of an Agent or provider acting pursuant to this Directive shall be limited to damages proximately caused by actions undertaken in bad faith or contrary to an express directive herein.

[// GUIDANCE: Mississippi law already affords significant provider protection; this clause adds contractual certainty.]

VIII. REVOCATION & AMENDMENT

8.1 Revocation by Declarant. Declarant may revoke this Directive at any time by:
a. A signed, dated writing;
b. Oral or other expression of intent to revoke in the presence of an adult witness;
c. Physically canceling, tearing, burning, or destroying this document; or
d. Executing a subsequent Advance Directive.

8.2 Effect of Divorce. If Declarant’s spouse is named Agent and a dissolution of marriage occurs, the spouse’s authority is revoked unless Declarant re-affirms in writing.

8.3 Partial Revocation & Amendment. Declarant may amend specific provisions by a signed, dated writing executed with the same formalities required for execution (Section XI).

8.4 Notification Responsibility. Declarant (or any person aware of revocation) shall promptly notify the attending physician or health-care facility.

IX. COPIES, PORTABILITY & GOVERNING LAW

9.1 Copies. Photographic or electronically transmitted copies of this Directive have the same legal effect as the original.

9.2 Portability. Declarant intends this Directive to be honored in any jurisdiction where it is presented, to the fullest extent permitted by that jurisdiction’s law.

9.3 Governing Law. This Directive is governed by Mississippi law, without regard to conflict-of-laws principles.

X. GENERAL PROVISIONS

10.1 Severability. If any provision of this Directive is held invalid, the remaining provisions shall remain in full force.

10.2 Integration. This Directive embodies the complete instructions of Declarant regarding Health-Care Decisions and supersedes all prior directives executed by Declarant.

10.3 No Waiver. Failure to enforce any provision shall not constitute a waiver of the right to enforce that or any other provision.

10.4 Electronic Signatures. To the extent permitted by Mississippi law, an electronic signature or digital notarization shall be deemed an original.

XI. EXECUTION & WITNESS / NOTARY ACKNOWLEDGMENT

[// GUIDANCE: Mississippi allows EITHER two qualified witnesses OR a notary. Complete ONE of the following blocks.]

Option A – Two (2) Adult Witnesses

I, [DECLARANT FULL LEGAL NAME], sign my name to this Directive on the date below and declare that I am of sound mind and acting voluntarily.

Declarant:

Signature: ___
Date: _______

Witness Statement

Each witness declares under penalty of perjury that (i) the Declarant voluntarily signed this Directive in the witness’s presence, (ii) the witness is at least 18 years old, (iii) the witness is not the Declarant’s health-care provider, not related to Declarant by blood, marriage, or adoption, not entitled to any portion of Declarant’s estate, and not financially responsible for Declarant’s medical care.

Witness #1
Name: ____
Address: ___
Signature: ___ Date: __

Witness #2
Name: ____
Address: ___
Signature: ___ Date: __

Option B – Notary Public

State of Mississippi )
County of ___ )

On this _ day of _, 20__, before me, the undersigned notary, personally appeared [DECLARANT FULL LEGAL NAME], known to me or satisfactorily proven to be the person whose name is subscribed to this Directive, and acknowledged that he/she/they executed the same for the purposes therein contained.

In witness whereof, I hereunto set my hand and official seal.

Notary Public

My commission expires: ___

[// GUIDANCE: Provide copies to your primary physician, Agent(s), and close family. Consider registering the Directive with any state-approved advance directive registry if available.]