Advanced Directive Form printable pdf download

Advance Directive for Health Care

Introduction to the Attached Form

The form provided here will help guide the decisions that need to be made about your health care

should you lose the ability to communicate your wishes more directly.

To fill out this form you need not consult with anyone—including family, physician or

attorney—but you would be wise to do so. It can be very helpful to think through your goals for

health care, along with the convictions and values on which they are based, with a close friend or

family member. Similarly (and perhaps even first), consulting with your physician can give you

invaluable understanding about the kinds of end-of-life situations that the form is intended to

address. Consulting with an attorney can also be useful, particularly if your state has unique

legal requirements related to advance directives.

To find out if your state has any special requirements, you can contact Legal Counsel for the

Elderly, American Association of Retired Persons, P.O. Box 96474, Washington, DC 20090-

6474 (phone: 202-434-2197). A few states, for example, require one witness to be a Notary

Public, forbid certain people from being your agent, or require the use of a state form if the

document is to have legal (and not just advisory) status. In most cases a form for health care

decisions is required even if you already have a power of attorney document for other decisions.

This cover sheet and the attached form do not constitute legal advice. Nevertheless, they are

designed to give you a way to communicate your health care wishes effectively—which can

prove helpful should you become unable to do so more directly. Moreover, the form attempts to

incorporate virtually all of the provisions required in most states at the time of publication.

The ethical justifications of the guidelines included in this advance directive form, plus other

ethical issues involved in end-of-life treatment decisions, are discussed in the easy-to-read 80-

page End of Life Decisions question-and-answer book available from The Center for Bioethics

and Human Dignity. You are strongly encouraged to read through this book and to think through

the issues it raises, in conjunction with completing the advance directive form.

You—as the person whose health care is the focus of this advance directive form—are called the

“Principal.” The form includes two documents in one. It includes a durable power of attorney

for health care, in that it specifies the person (your “agent”) who is to make decisions on your

behalf should you lose the capacity to do so. It also includes living will guidelines, in that it

contains written guidance—not for your physician as in traditional living wills—but for your

agent (and your alternate agents if your agent becomes unwilling or unable to act as your agent).

The form specifies that the guidance can be disregarded only when your agent deems that

following it would result in an action contrary to your wishes—for example, in unanticipated

exceptional situations. This provision avoids the problem with most advance directives, which

fail to indicate whether the living will instructions or the judgment of the agent take priority

when the two appear to conflict. But you still need to select an agent who knows your values and

wishes, can make difficult decisions, and is usually available.

(OVER)

Advanced Directive Form