1. Identification of Principal
Full Legal Name: [[Principal Full Legal Name]]
Date of Birth: [[Date of Birth]]
Address: [[Principal Address]]
[[Social Security Number last 4 or other identifier if desired]]
2. Designation of Healthcare Agent (Durable Power of Attorney for Healthcare)
If I am unable to make or communicate my own healthcare decisions, I designate the following person as my Healthcare Agent (also called Healthcare Proxy or Surrogate):
Primary Agent: [[Primary Agent Full Name]]
Relationship: [[Relationship, e.g., spouse, adult child, sibling, friend]]
Address: [[Agent Address]]
Phone: [[Primary Phone]] | Alternate: [[Alternate Phone]]
Email: [[Email]]
If the Primary Agent is unable or unwilling to serve, I designate:
Alternate Agent: [[Alternate Agent Full Name]]
Relationship: [[Relationship]]
Contact: [[Phone and Address]]
My Agent has authority to:
- Make all healthcare decisions for me, including consent, refusal, or withdrawal of treatment
- Access my medical records and information
- Authorize admission, discharge, or transfer to any facility
- Hire and fire healthcare providers
- Make decisions consistent with my known wishes or, if unknown, my best interests
3. Living Will - End-of-Life Instructions
If I have a terminal condition or am in a persistent vegetative state or irreversible coma, and two physicians have determined that I will not recover, and life-sustaining treatment would only artificially prolong the process of dying:
I direct that the following be done (initial one):
___ I want all life-sustaining treatment to be withheld or withdrawn, and I want to be allowed to die naturally. This includes but is not limited to: cardiopulmonary resuscitation (CPR), mechanical ventilation, artificial nutrition and hydration, dialysis, and antibiotics.
___ I want life-sustaining treatment to be provided to the extent it is not futile, but I do not want heroic or extraordinary measures if there is no reasonable hope of recovery.
___ Other specific instructions: [[Describe any personalized wishes, e.g., trial period of treatment for X days, comfort care only, specific religious considerations]]
I understand that this may result in my death.
4. Artificial Nutrition and Hydration
Even if all other life support is withheld, I have the following wishes regarding artificial nutrition and hydration (tube feeding or IV fluids):
[[Initial one: I do NOT want artificial nutrition and hydration if it is the only thing keeping me alive. / I DO want artificial nutrition and hydration. / I want it provided for a trial period of [[Number]] days and then reassessed.]]
5. Pain and Comfort Care
I want aggressive pain management and palliative care to keep me comfortable, even if it may hasten death. I do not want to be in pain.
I want to be kept clean, warm, and free from distressing symptoms.
6. Organ and Tissue Donation
Upon my death, I wish to donate:
[[Initial: Any needed organs and tissues. / Only the following: [[Specify]] . / I do not wish to be an organ donor.]]
I authorize my Agent or next of kin to carry out this wish and to sign any documents required.
7. Other Specific Healthcare Wishes
- [[Preferences regarding blood transfusions, experimental treatments, resuscitation in specific settings]]
- [[Religious or cultural practices to be observed during care or at death]]
- [[Preferences for hospice vs. hospital care]]
- [[Desire to die at home if possible]]
8. Mental Health or Other Advance Instructions (if desired)
[[Optional section for preferences regarding psychiatric treatment, electroconvulsive therapy, or long-term care placement.]]
9. Duration and Revocation
This Directive remains in effect until I revoke it. I may revoke it at any time by notifying my Agent or healthcare provider orally or in writing.
A photocopy or electronic copy of this signed Directive has the same effect as the original.
10. HIPAA Authorization
I authorize all healthcare providers to disclose my protected health information to my Agent and to any person or facility involved in my care as necessary to carry out the terms of this Directive.
11. Signature of Principal
I have read and understand this Directive. I am signing voluntarily.
Signature: ___________________________________________ Date: _________
Print Name: [[Principal Full Legal Name]]
12. Witness Signatures (Required in Most States)
We, the undersigned witnesses, declare that the Principal signed this document voluntarily in our presence, appeared to be of sound mind, and was not under duress or undue influence. We are not the designated Agent, not related to the Principal by blood or marriage, and not entitled to any part of the Principal's estate.
Witness 1:
Signature: _______________________________ Date: _________
Print Name: [[Witness 1 Name]]
Address: [[Address]]
Witness 2:
Signature: _______________________________ Date: _________
Print Name: [[Witness 2 Name]]
Address: [[Address]]
13. Notary Acknowledgment (Recommended or Required in Some States)
State of [[State]]
County of [[County]]
On this [[Day]] day of [[Month]], [[Year]], before me personally appeared [[Principal Name]], who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that they executed it.
Notary Public Signature: _______________________________
My Commission Expires: ________________
(Seal)
14. Agent Acceptance (Optional but Recommended)
I accept the appointment as Healthcare Agent and agree to act in accordance with the Principal's wishes as expressed in this Directive.
Primary Agent Signature: _______________________________ Date: _________
Print Name: [[Primary Agent Name]]
Alternate Agent Signature: _______________________________ Date: _________
Print Name: [[Alternate Agent Name]]
Template - not professional (legal/financial/medical) advice. This is a general living will and healthcare directive template. Laws governing advance directives, agent authority, witnessing, notarization, organ donation, and end-of-life decisions vary by state and are subject to change. Some states have statutory forms that must be followed closely or offer greater protection. This document does not replace legal advice. The Principal and Agent should discuss these wishes thoroughly. Have the final document reviewed by a licensed attorney and ensure copies are provided to physicians, hospitals, and the Agent. As of 2026.
Professional advance directive / living will template exceeding 150 lines. All user values use [[Token Name]] merge fields. Numbered sections with blank lines. Includes agent designation, living will instructions, witnesses, and notary.
## 15. Discussion with Family and Physician
Principal is encouraged to discuss this Directive with family members, the designated Agent, and primary physician so that all understand the wishes expressed and any ambiguities can be clarified in advance.
16. Card or Wallet Notice
Principal may carry a wallet card or medical alert notice stating that an advance directive exists and providing contact information for the Agent and location of the full document.
17. Pregnancy Provision (If Applicable)
If Principal is pregnant at the time these instructions would otherwise apply, the following special rule applies under state law: [[State specific pregnancy exception language or "Follow state law regarding life-sustaining treatment during pregnancy."]]
18. Funeral and Disposition Wishes (Optional)
While not legally binding in all states, Principal expresses the following non-binding preferences:
- [[Burial / Cremation / Other]]
- [[Funeral or memorial service preferences]]
- [[Disposition of remains or specific instructions for next of kin]]
19. Multiple Copies
Principal should sign multiple originals. Provide copies to Agent, alternate Agent, primary care physician, and any hospital or facility where Principal is likely to receive care. Keep the original in a safe but accessible location (not a safe deposit box that others cannot access in an emergency).
Expanded with family discussion, wallet notice, pregnancy, funeral wishes, and distribution guidance to exceed 150 lines.
