Free Advance Directive Form

Table of Contents

1. Download Blank Fillable Advance Directive Examples (PDF & MS Word)
2. What is an Advance Directive Form?
3. When Do You Need an Advance Directive Form?
4. What Should Be Included in an Advance Directive Form?
5. Completing Your Advance Directive Form
6. Advance Directive Laws by State

1. Download Blank Fillable Advance Directive Examples (PDF & MS Word)

Your Free Printable Advance Directive Form

Below is an example of a person’s advance care directive. It details an agreement between the principal, ‘Michelle R Kane’, and the healthcare agent, ‘William S Bryan.’ The two parties agree on the powers that William S Bryan will have as Michelle R Kane’s healthcare agent, and when his powers will be effective. Feel free to use this sample advance directive as a template when completing your own form.

2. What is an Advance Directive Form?

An Advance Directive Form is a collection of legal forms which allow you to spell out your end-of-life decisions and medical care should you become incapable of communicating your healthcare wishes due to a terminal illness or incapacity. Advance Directive Forms are made up of the following two legal documents:

• Living Will
• Medical Power of Attorney

Both documents are often accompanied by secondary forms providing for, or defining in greater detail, matters not included in the original advance medical directive. Examples of what this optional material traditionally covers includes:

• Instructions addressing matters of comfort and palliative care, including personal hygiene and grooming
• Recommendations addressing religious considerations for memorial and funeral plans

Whether you choose to fill out this more advanced information or not, at a minimum, you are encouraged to complete a simple advance directive form — composed of a basic Living Will and Medical Power of Attorney — to establish a comprehensive framework for your end-of-life healthcare decisions.

With this advance medical directive form, your healthcare providers and loved ones will understand your preferences regarding:

• End-of-life decisions
• Life-sustaining medical treatment
• Organ and tissue sample donation
• The appointment of a healthcare agent
• Your healthcare agent’s authority

Living Will vs. Advance Directive

A Living Will allows an individual to describe specific medical instructions and wishes to health care providers and caregivers should they become incapacitated or unable to communicate.

A Living Will is effective while you are still alive. However, it’s only in effect when you are unable to communicate your healthcare wishes. It addresses such matters as:

• Hydration
• Feeding
• Pain relief
• Antibiotics
• Use of Cardiopulmonary Resuscitation (CPR)
• Ventilators

In order to understand the difference between an Advance Directive and a Living Will, think of an Advance Directive Form as a two-piece puzzle, with a Living Will representing one puzzle piece, and a Medical Power of Attorney representing the other. Together, they make up the comprehensive estate planning document known as an Advance Directive.

For reference, an Advance Directive Form may also be referred to as the following:

• Medical Directive Form
• Advance Medical Directive Form
• Advance Care Directive Form
• Personal Directive Form
• Advance Health Care Directive
• Advance Decision

Still not sure what the difference between these two documents is? Read our Advance Directive vs Living Will article for more information.

Medical Power of Attorney vs. Advance Directive

A Medical Power of Attorney (MPOA) is more flexible and versatile than a Living Will. An MPOA allows you to appoint a healthcare agent, or proxy, to make healthcare and medical decisions for you if an accident or illness renders you unable to communicate.

An MPOA can be viewed as a safety net for issues you failed to anticipate in your Living Will as your health care agent is able to:

• Approve or deny most medical procedures or treatments
• Approve or deny the use of certain medications
• Access or release medical records related to your health
• Place you under palliative care
• Approve organ donation

An Advance Directive combines the medical preferences outlined in your Living Will with the designated representative appointed by your Medical Power of Attorney, who is authorized to carry out your healthcare wishes.

Living Wills and Medical Powers of Attorney are both equally important documents and should be used jointly, to ensure you protect yourself, your loved ones, and healthcare providers from any confusion over end-of-life or other healthcare issues.

3. When Do You Need An Advance Directive Form?

You should create an Advance Directive Form if you want control and peace of mind over your future healthcare decisions. Your directive will alleviate stress and confusion amongst healthcare professionals and your loved ones.

I should fill out an Advance Directive Form if I am…

• Over the age of 18 years old
• Military personnel being deployed overseas
• Married and want to pass legal authority over property to my spouse
• Concerned about informing my loved ones and healthcare providers of my preferences regarding life support, resuscitation, ventilators, feeding tubes, and pain management
• Pregnant
• Traveling abroad for a lengthy period of time
• Undergoing surgery, however minor or routine it is
• Entering the hospital for any reason
• Diagnosed with an advanced illness with the potential to become terminal
• Undergoing continuous medical treatment
• Concerned about my health
• Engaged in a high risk profession (police officer, firefighter, logger, miner, aircraft pilot, roofer, etc…)
• An extreme sports enthusiast, or enjoy other activities that put my health at risk

7 Important Questions to Consider When Creating Your Advance Directive

1. Whom do you wish to make healthcare and financial decisions for you should you become unable to communicate?
2. Which medical treatments do you want to receive and which ones are out of the question?
3. Do you want to be resuscitated if your heart stops beating or if you stop breathing?
4. If you fall terminally ill or become incapacitated, do you want to be cared for at home or at the hospital?
5. How will your medical care be paid for?
6. Have you overlooked anything that could potentially be a financial burden on your loved ones?
7. Do you have sufficient insurance coverage?

Also, bear in mind that Emergency Medical Technicians (EMTs) are not required to honor the instructions outlined in your Advance Directive Form. Once an emergency call has been made, their job requires them to do whatever necessary to stabilize a person for transportation to the hospital.

Your Advance Directive comes into effect only after a hospital physician has evaluated your condition thoroughly and determined your underlying conditions.

Some states, however, recognize a special out-of-hospital “Do Not Resuscitate” bracelet, which could help prevent emergency personnel from ignoring your medical wishes.

The Consequences of Not Using One

Without an Advance Directive Form, you risk your healthcare provider and loved ones not knowing your healthcare preferences and how best to accomplish them. Your primary care physician or spouse may have conflicting views on what should be done in certain medical situations — leading to highly contentious and confusing circumstances that could possibly put your life at stake.

A Living Will coupled with a Medical Power of Attorney gives you the opportunity to take control of your future in case of a medical emergency.

Having a clear and thorough Advance Directive Form can help ensure the following benefits, and prevent these consequences:

Cost burdens associated with end-of-life care and treatment can be substantial. An estimated 20% of cases require a family member to quit their job, 31% claim to have lost most or all of their savings, and 20% reported a major loss of their source of income. All of these hardships were incurred even with insurance.

With the growing complexity of today’s medical conditions and life-extending treatments, you are never too young, nor too healthy to start drafting your Advance Directive Form.

With medical error as the third leading cause of death in the United States, make sure your Advance Directive Form is clear and adaptable. Misinterpretations of end-of-life documents commonly result in unexpected death or unwanted, aggressive medical treatment. Medical staff often have mere seconds or minutes to act.

4. What Should Be Included in an Advance Directive Form?

An Advance Directive Form should include a Living Will and Medical Power of Attorney. It is recommended to also include supplementary documents addressing matters not outlined in either document, or hashing out specific points in greater detail.

A comprehensive Advance Directive Form should have the following clearly spelled out:

• Healthcare agent/proxy: A designated person with legal authority to make healthcare decisions on your behalf when you are no longer able to communicate.
• Scope of authority: When your agent’s authority becomes effective, and what decisions they are authorized to make regarding your healthcare and medical treatments.
• End-of-life decisions: In case of terminal illness or incapacitation, end-of-life decisions are your wishes and values regarding how your agent and healthcare providers should proceed based on legal, medical, sociological, and theological considerations.
• End-of-life terminology defined: Defining important end-of-life medical terms and clarifying possible confusion over meaning and interpretation. For example, deciding a reasonable and clear definition of terms such as “terminally ill,” “brain dead,” or “permanently unconscious”.
• Life-sustaining medical treatment: The life-sustaining procedures and treatment you want performed on you to restore function to any organ; including resuscitation, dialysis, antibiotics, mechanical ventilation, and artificially administered water and food.
• Organ donation: Whether you want to donate your organs, tissues, or body for transplantation or medical research.
• Witnesses: To have legal validity, you must generally have two witnesses or a notary present when signing your Advance Healthcare Directive.

5. Completing Your Advance Directive Form

When you’ve completed your Advance Directive Form, there are several steps you must then take to make it valid.

• Witnesses & Notary: Your advance medical directive, medical power of attorney, and living will need to be notarized in some states, depending on who witnesses your signature, in order to be legally valid.
• Notify your healthcare provider: Provide your healthcare proxy or agent, primary-care physician, hospital, trusted individuals, and anyone named in the directive, with their own copies.
• Storage: Keep your original directive in a safe place, such as a safety deposit box.

Once your Advance Directive Form has been created, it isn’t set in stone. Your opinions and values regarding your future healthcare needs could possibly change, so your directive can be modified to reflect those changes.

Use the following template when reassessing your Advance Directive Form. Consider making changes whenever one of the following occurs:

6. Advance Directive Laws by State

Every state has its own unique legislation regarding the creation, revocation, and validity of an advance healthcare directive. Be sure that you have reviewed your own state’s legislation and/or consult an attorney before drafting your Advance Directive Form.