Pennsylvania Advance Health-Care Directive

(Living Will & Health-Care Power of Attorney)

[// GUIDANCE: This comprehensive template is drafted to satisfy Pennsylvania’s Health-Care Agents and Living Wills statute (20 Pa. C.S. Ch. 54) without citing specific sections. Practitioners should confirm no material statutory amendments have occurred since drafting.]

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

1. Title. Pennsylvania Advance Health-Care Directive (the “Directive”).
2. Declarant. This Directive is made by [DECLARANT FULL LEGAL NAME], residing at [ADDRESS] (“Declarant”).
3. Effective Date. This Directive is effective immediately upon execution (the “Effective Date”) and remains in effect until revoked pursuant to Section IX.4 herein.
4. Governing Law. This Directive shall be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania.
5. Purpose & Consideration. Declarant executes this Directive to (i) give legally-binding instructions regarding future health-care decisions, and (ii) appoint an agent to make such decisions when Declarant lacks capacity.
6. No Compensation. Declarant’s agent serves without compensation except for reimbursement of reasonable expenses actually incurred.

II. DEFINITIONS

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

“Advance Health-Care Decision” – A decision regarding health care, including consent, refusal, or withdrawal of treatment.
“Agent” – The individual appointed under Section III.A to make health-care decisions on Declarant’s behalf.
“Alternate Agent” – A successor agent designated under Section III.A.4.
“Attending Physician” – The physician who has primary responsibility for Declarant’s care.
“End-Stage Medical Condition” – An incurable condition in which death will occur within a relatively short time and/or treatment provides no reasonable hope of recovery.
“Good Faith” – Honesty in fact in the conduct of the transaction concerned.
“Health-Care Provider” – A person licensed or certified to provide health-care services.
“Life-Sustaining Treatment” – Mechanical ventilation, dialysis, CPR, artificial nutrition/hydration, or any medical procedure that serves only to prolong the process of dying.
“Permanent Unconsciousness” – An irreversible condition in which Declarant is unaware of self and environment and unable to interact.
“Revocation” – Any act indicating Declarant’s intent to revoke, including written revocation, physical destruction, or oral statement to an attending physician.
“Witness” – An individual meeting the criteria in Section X.4 who observes Declarant’s execution.

III. OPERATIVE PROVISIONS

A. Appointment of Health-Care Agent

1. Primary Agent. Declarant appoints [PRIMARY AGENT NAME], whose address is [ADDRESS], and phone [PHONE], as Agent.
2. Scope of Authority. In the event Declarant lacks capacity as determined by the Attending Physician, Agent is authorized to make any and all Advance Health-Care Decisions the Declarant could make if able, including but not limited to:
   a. Consent to, refuse, or withdraw any treatment, including Life-Sustaining Treatment;
   b. Arrange for hospital, hospice, nursing, or home health services;
   c. Hire and fire medical personnel;
   d. Access medical records and disclose them as necessary;
   e. Authorize autopsy and disposition of remains.
3. HIPAA Authorization. Agent is a “personal representative” for HIPAA purposes and may obtain all protected health information.
4. Alternate Agents. If the Primary Agent is unavailable, unwilling, or unable to act, the following, in listed order, shall serve:
   i. [ALTERNATE AGENT 1];
   ii. [ALTERNATE AGENT 2].
   [// GUIDANCE: Omit any agent who will also serve as a witness; statute prohibits dual roles.]

B. Statement of Treatment Preferences (Living Will)

1. Terminal Condition or End-Stage Medical Condition.
   • I direct that Life-Sustaining Treatment [BE WITHHELD / BE PROVIDED / OTHER].
2. Permanent Unconsciousness.
   • I direct that Life-Sustaining Treatment [BE WITHHELD / BE PROVIDED / OTHER].
3. Artificial Nutrition & Hydration.
   • I direct that artificial nutrition/hydration [MAY / MAY NOT] be provided if they only prolong the dying process.
4. Pain Management.
   • I request aggressive palliative care to maintain comfort, even if such care may hasten my death.
5. Pregnancy.
   • If I am pregnant, it is my wish that [INSTRUCTIONS].
6. Mental-Health Treatment Preferences (optional).
   • [INSTRUCTIONS].
   [// GUIDANCE: Pennsylvania permits separate mental-health declarations; include only if client wishes.]

C. Anatomical Gifts (Organ & Tissue Donation)

Declarant [DOES / DOES NOT] wish to donate organs/tissues for transplantation, therapy, research, or education. Specify limitations: [LIMITATIONS].

D. Nomination of Guardian

Should a court deem it necessary to appoint a guardian of my person, I nominate my Agent (or Alternate Agent) in the order named above.

E. Compensation & Reimbursement

Agent shall serve without compensation other than reimbursement for reasonable out-of-pocket expenses incurred in Good Faith.

F. Delivery & Reliance

A photocopy or electronic copy of this Directive has the same effect as the original. Health-Care Providers may rely on the most recent copy in their possession.

IV. REPRESENTATIONS & WARRANTIES

1. Declarant represents that:
   a. Declarant is at least 18 years of age and of sound mind;
   b. Declarant understands the nature and consequences of executing this Directive;
   c. No undue influence or duress has been exerted.
2. Agent represents, by signing the Acceptance in Section X.3, that Agent:
   a. Is willing and qualified to serve;
   b. Will act in Good Faith and consistent with Declarant’s known wishes;
   c. Will comply with applicable law.

V. COVENANTS & RESTRICTIONS

1. Agent shall consult with health-care professionals and family members when practical but is not bound by their views.
2. Agent shall keep contemporaneous records of major decisions for potential judicial review.
3. Health-Care Providers covenant to honor this Directive unless it is facially invalid or revoked. A provider who cannot in Good Faith comply must promptly transfer Declarant to another provider.

VI. DEFAULT & REMEDIES

1. Events of Default.
   a. A Health-Care Provider’s refusal, in violation of its statutory obligations, to honor this Directive;
   b. An Agent’s failure to act in Good Faith or within the scope of authority.
2. Cure Period. A defaulting party has 24 hours after written or oral notice to cure, unless immediate action is medically necessary.
3. Remedies.
   a. Injunctive relief compelling compliance;
   b. Reassignment or removal of the Agent by majority of Alternate Agents or by court order;
   c. Recovery of reasonable attorney fees and costs from a willfully non-complying provider or Agent.

VII. RISK ALLOCATION

1. Indemnification of Health-Care Providers. Declarant agrees that any Health-Care Provider acting in Good Faith reliance on this Directive shall be indemnified and held harmless by Declarant’s estate from liability, expense, or loss arising from such reliance.
2. Limitation of Liability. No Health-Care Provider or Agent shall be liable for civil damages or criminal prosecution for Good Faith acts or omissions consistent with this Directive.
3. Force Majeure. Providers and Agents shall not be liable for non-performance caused by emergencies, unavailability of treatments, or other circumstances beyond reasonable control.

VIII. DISPUTE RESOLUTION

1. Governing Law. Pennsylvania law governs all matters arising under this Directive.
2. Forum. Any judicial proceeding shall be brought in the court of common pleas for the county where Declarant is receiving care.
3. Arbitration. Not applicable unless all interested parties execute a separate written agreement.
4. Injunctive Relief. Parties reserve the right to seek immediate injunctive relief to enforce this Directive.

IX. GENERAL PROVISIONS

1. Amendment. Declarant may amend this Directive in writing at any time while competent, effective upon proper execution and witnessing.
2. Waiver. Failure to enforce any provision does not constitute waiver of future enforcement.
3. Assignment. Agent’s authority is personal and non-delegable, except to an Alternate Agent expressly named herein.
4. Revocation. Declarant may revoke this Directive at any time and in any manner that communicates intent to revoke, including oral statement, physical destruction, or execution of a subsequent directive.
5. Severability. If any provision is held unenforceable, the remaining provisions shall remain in full force.
6. Integration. This Directive constitutes the entire advance health-care directive of Declarant and supersedes all prior directives.
7. Counterparts; Electronic Signatures. This Directive may be executed in counterparts and by electronic signature, each of which is deemed an original.

X. EXECUTION BLOCK

1. Declarant Signature

I, [DECLARANT FULL LEGAL NAME], sign my name to this Pennsylvania Advance Health-Care Directive on this _ day of _, 20__, at [CITY, STATE].

Signature: _____
Print Name: ______

2. Statement of Witnesses

We declare that (i) the Declarant is personally known to us, (ii) the Declarant signed or acknowledged this Directive in our presence, (iii) the Declarant appears to be of sound mind and under no duress, (iv) neither of us is the appointed Agent, a Health-Care Provider currently caring for Declarant, or financially responsible for Declarant’s care, and (v) at least one of us is not related to the Declarant by blood, marriage, or adoption.

Witness #1
Name: ___ Address: _____
Signature: ___ Date: ______

Witness #2
Name: ___ Address: _____
Signature: ___ Date: ______

[// GUIDANCE: Pennsylvania requires TWO adult witnesses meeting the criteria above. Notarization is optional but recommended for ease of interstate recognition.]

3. Agent Acceptance (Optional but Recommended)

I have read this Directive and accept the appointment as Agent. I understand and will carry out Declarant’s wishes to the best of my ability and in Good Faith.

Agent Signature: ____ Date: _
Print Name: ____

4. Notary Acknowledgment (Optional)

State of Pennsylvania )
County of _______ )

On _/_/20__, before me, the undersigned notary public, personally appeared [DECLARANT NAME], proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to this instrument, and acknowledged that he/she executed the same for the purposes therein contained.

Notary Public Signature: ______
My Commission Expires: _______

[// GUIDANCE:
1. Filing/Distribution – Provide copies to the Agent, Alternate Agents, primary physician, and any medical facility where Declarant is likely to receive care.
2. Review Cycle – Recommend clients review the Directive at least every two years or upon major life events.
3. Cross-Border Use – Some states require notarization; consider notarizing if Declarant frequently travels.]