Advance Healthcare Directive
LIVING WILL AND ADVANCE DIRECTIVE
I, Declarant Name, date of birth Date of Birth, residing at Street Address, City, State ZIP Code, phone Phone Number, being of sound mind and acting of my own free will, and not under any duress, fraud, or undue influence, do hereby make this Living Will and Advance Directive to declare my wishes regarding healthcare decisions to be made on my behalf in the event that I become unable to communicate such decisions myself.
1. APPOINTMENT OF HEALTHCARE AGENT.
I hereby designate and appoint Healthcare Agent Name (Relationship), residing at Agent Address, telephone Agent Phone, email Agent Email, as my Healthcare Agent (also known as Healthcare Proxy or Attorney-in-Fact for Healthcare) to make healthcare decisions on my behalf when I am unable to make or communicate such decisions myself. My Healthcare Agent shall have the authority to consent to, refuse, or withdraw consent for any medical treatment, procedure, or service, consistent with the wishes expressed in this Advance Directive.
In the event that my designated Healthcare Agent is unable, unwilling, or unavailable to serve in this capacity, I hereby designate Alternate Agent, telephone Alternate Agent Phone, as my Alternate Healthcare Agent, who shall assume all rights, powers, and duties granted herein.
2. HEALTHCARE INSTRUCTIONS AND DIRECTIVES.
I direct that the following instructions be followed by my Healthcare Agent, attending physicians, and all healthcare providers involved in my care:
a) Life-Sustaining Treatment.
If I am diagnosed with a terminal condition, am in a persistent vegetative state, or am otherwise in an end-stage condition from which there is no reasonable expectation of recovery, my preference regarding life-sustaining treatment is as follows: Life-Sustaining Preference.
b) Artificial Nutrition and Hydration.
Regarding the provision of nutrition and hydration through artificial means (including but not limited to intravenous feeding, nasogastric tubes, and gastrostomy tubes), my preference is: Artificial Nutrition Preference.
c) Cardiopulmonary Resuscitation (CPR).
In the event of cardiac or respiratory arrest, my preference regarding resuscitation efforts is: CPR Preference.
d) Pain Management and Comfort Care.
I direct that I receive adequate pain management and comfort care at all times, regardless of any other directives in this document. My preference for pain management is: Pain Management Preference. I understand that certain pain management measures may have the effect of hastening my death, and I accept this consequence if it is necessary to ensure my comfort.
3. ORGAN AND TISSUE DONATION.
Upon my death, my preference regarding the donation of my organs and tissues for transplantation, research, or medical education is: Organ Donation Preference. I direct my Healthcare Agent and family members to honor this preference and to take all necessary steps to effectuate my wishes regarding organ donation.
4. AUTHORITY AND LIMITATIONS OF HEALTHCARE AGENT.
My Healthcare Agent shall have the authority to: (a) access my medical records and personal health information; (b) consent to or refuse any medical treatment, surgery, or diagnostic procedure; (c) select or discharge healthcare providers and institutions; (d) authorize admission to or discharge from any hospital, nursing home, or other healthcare facility; and (e) make all other healthcare decisions necessary to carry out my wishes as expressed herein. My Healthcare Agent shall act in accordance with my wishes as stated in this document and, for any situation not addressed herein, shall act in my best interest.
5. GOVERNING LAW.
This Living Will and Advance Directive shall be governed by and construed in accordance with the laws of the State of State. I intend this document to be honored in any jurisdiction in which it is presented, to the fullest extent permitted by the laws of that jurisdiction.
6. SEVERABILITY.
If any provision of this Advance Directive is held to be invalid or unenforceable, such invalidity or unenforceability shall not affect the remaining provisions, which shall continue in full force and effect.
7. REVOCATION.
I reserve the right to revoke this Living Will and Advance Directive at any time, in any manner, and without regard to my mental or physical condition. Any such revocation shall be effective upon communication to my Healthcare Agent and attending physician. This document supersedes any and all prior advance directives, living wills, or healthcare proxies executed by me.
IMPORTANT NOTICE
This document is a legally binding statement of your healthcare wishes. You should provide copies to your healthcare agent, alternate agent, primary care physician, and any hospitals or healthcare facilities where you receive care. Keep the original document in a safe but accessible location and inform your family members of its existence and location. This document should be reviewed and updated periodically, particularly after significant changes in your health, family situation, or medical treatment preferences.
IN WITNESS WHEREOF, I have executed this Living Will and Advance Directive on the date set forth below.
Declarant:
Name: Declarant Name
Date: Declarant Sign Date
Acceptance by Healthcare Agent:
I, Healthcare Agent Name, hereby accept the appointment as Healthcare Agent under this Advance Directive and agree to act in accordance with the wishes and instructions of the Declarant as expressed herein.
Name: Healthcare Agent Name
Date: Agent Sign Date
Party 1
________________
Signature
Date: ________________
Party 2
________________
Signature
Date: ________________
What Is a Advance Healthcare Directive?
An Advance Healthcare Directive in the United States sets out advance healthcare wishes and may appoint someone to make medical decisions on the maker's behalf. It is recognized under the Patient Self-Determination Act (42 U.S.C. Section 1395cc) and state advance-directive statutes.
Every state has enacted advance directive legislation, though requirements vary significantly. The Uniform Health-Care Decisions Act (UHCDA), adopted by approximately 20 states, provides a complete framework covering both treatment instructions and agent designation in a single document. States that have not adopted the UHCDA maintain their own statutory forms, such as California's Advance Health Care Directive (Probate Code Sections 4700-4701), New York's Health Care Proxy (Public Health Law Article 29-C), and Texas's Directive to Physicians (Health & Safety Code Chapter 166).
The Supreme Court's decision in Cruzan v. Director, Missouri Department of Health (497 U.S. 261, 1990) established that competent individuals have a constitutionally protected liberty interest in refusing unwanted medical treatment. The Court acknowledged that states may require clear and convincing evidence of a patient's wishes before withdrawing life-sustaining treatment, which makes a properly executed advance directive the most reliable evidence of those wishes.
When Do You Need a Advance Healthcare Directive?
Every competent adult over 18 should execute an advance directive regardless of current health status. Medical emergencies occur without warning: a 35-year-old involved in a car accident, a 50-year-old who suffers a stroke, or a 28-year-old with a sudden aneurysm. Without a directive, family members may disagree about treatment, leading to court intervention as occurred in the highly publicized Terri Schiavo case in Florida.
Patients undergoing elective surgery benefit from executing or updating a directive before the procedure. Surgical complications, anesthesia reactions, or post-operative infections can result in temporary or prolonged incapacity. Hospitals routinely ask about advance directives during pre-admission processing under Patient Self-Determination Act requirements.
Individuals diagnosed with progressive conditions such as Alzheimer's disease, ALS, Parkinson's disease, or terminal cancer should execute directives while they still have decisional capacity. Capacity to execute a directive requires understanding the nature of the document, the types of decisions covered, and the consequences of the choices expressed. Once capacity is lost, the individual can no longer create or modify the directive.
Persons who are estranged from next-of-kin or whose family members hold conflicting views on end-of-life care particularly need advance directives. Without a designated agent, most state surrogate consent statutes assign decision-making authority to a spouse, then adult children, then parents, in descending order, which may not reflect the patient's actual preferences.
What to Include in Your Advance Healthcare Directive
The healthcare agent designation must name a primary agent and at least one successor agent with full legal names, addresses, and telephone numbers. The agent's authority should be defined with specificity: the power to consent to or refuse treatment, access medical records under HIPAA (45 C.F.R. Section 164.502(g)), choose healthcare providers and facilities, authorize organ donation under the Uniform Anatomical Gift Act, and make post-death decisions regarding autopsy and disposition of remains.
Treatment instructions should address specific medical scenarios: the use of mechanical ventilation, artificial nutrition and hydration (tube feeding), CPR/resuscitation, dialysis, antibiotics for terminal infections, and blood transfusions. The directive should distinguish between situations where recovery is expected and situations involving terminal illness, permanent unconsciousness, or advanced dementia. Instructions should be medically specific rather than vague.
Pain management preferences should state whether the principal prioritizes comfort care even if pain medication may hasten death, consistent with the doctrine of double effect recognized in Vacco v. Quill (521 U.S. 793, 1997). Organ and tissue donation preferences should specify whether the principal wishes to donate, and if so, whether for transplantation, research, or both.
Execution requirements vary by state. Most states require the principal's signature, notarization, and two adult witnesses who are not the designated agent, not related to the principal, and not entitled to inherit from the principal's estate. Some states, such as New Hampshire, require only witnesses. Others, such as Missouri, require notarization. The HIPAA authorization provision should be included as a separate section authorizing the agent to access the principal's protected health information. Copies should be provided to the designated agent, primary care physician, local hospital, and family members.
Sources & Citations
Statutory citations link to official government sources.
- HIPAAUS – Cornell LII
Cite this page
Reference this free template in an article, syllabus, or research note:
Forms Legal. (2026). Advance Healthcare Directive (United States) [Legal document template]. Forms Legal. https://forms-legal.com/usa/estate-planning/wills/living-will-advance-directive
"Advance Healthcare Directive (United States)." Forms Legal, 2026, https://forms-legal.com/usa/estate-planning/wills/living-will-advance-directive.
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title = {Advance Healthcare Directive (United States)},
year = {2026},
howpublished = {\url{https://forms-legal.com/usa/estate-planning/wills/living-will-advance-directive}},
note = {Free legal document template. Based on Patient Self-Determination Act (42 U.S.C. Section 1395cc); state advance-directive acts}
}
Frequently Asked Questions
Yes, a properly executed Living Will / Advance Directive is legally binding in United States when it meets the formal requirements established by applicable local law.
A valid Living Will / Advance Directive in United States requires: (1) legal capacity of the parties, (2) free and informed consent, (3) a lawful purpose, and (4) compliance with any formal requirements specified by local legislation.
While not always legally required, consulting a lawyer in United States is recommended to ensure compliance with all applicable laws and regulations.
In United States, electronic signatures are generally recognized for most contracts. However, certain types of documents may require wet signatures or notarization. Check local requirements.
Breach of a Living Will / Advance Directive in United States may result in damages, specific performance, or injunctive relief. The aggrieved party can seek remedies through the competent courts.
Yes, electronic signatures are legally valid under the E-SIGN Act (15 U.S.C. 7001) and the Uniform Electronic Transactions Act (UETA) adopted by most states.
The non-breaching party may seek remedies including compensatory damages, specific performance, injunctive relief, or termination. Remedies vary by state law.
Notarization requirements depend on the document type and state law. While not always required, notarization adds authentication and may be necessary for government filing.
This template is provided for informational purposes only and does not constitute legal advice. Laws vary by jurisdiction and change over time. Consult a qualified attorney for advice specific to your situation.Full disclaimer
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