Advance Directive (Living Will)

Full Legal Name *

Date of Birth

Address *

Phone

Email

Agent Name *

Agent Address

Agent Phone *

Agent Email

Relationship to Principal

Alternate Agent Name

Alternate Agent Phone

Note: Your healthcare agent will make medical decisions on your behalf only when you are unable to communicate your own wishes. The alternate agent serves as a backup if your primary agent is unavailable.

Life-Sustaining Treatment

Comfort Only: Focus on pain relief and comfort measures; no aggressive life-prolonging treatment.

Artificial Nutrition and Hydration

CPR (Cardiopulmonary Resuscitation)

Mechanical Ventilation

Dialysis

Antibiotics

Important: These preferences will guide your healthcare agent and medical providers. Discuss your choices with your physician and agent to ensure they understand your wishes.

Pain Medication Preference

Maximum Relief: Administer all available medication to control pain, even if it may hasten death.

Organ Donation

Anatomical Gift Purpose

Body Disposition

Religious/Spiritual Considerations (optional)

Specific Medical Conditions (optional)

Describe any condition-specific instructions for your healthcare team.

Personal Statement (optional)

Express your values, beliefs, and what quality of life means to you.

Physician Orders

POLST: Physician Orders for Life-Sustaining Treatment (a separate medical order signed by your doctor).

Date of Execution *

County

State *

Witness 1 Name *

Witness 1 Address

Witness 2 Name *

Witness 2 Address

Notarization

Notary Name

Notary Commission Number

Important: Most states require two witnesses who are not related to you and not named as your healthcare agent. Some states also require notarization. Check your state's specific requirements.