Combined Durable Power of Attorney for Healthcare
and Declaration of Wishes
Prepared for:
(Print Full Legal Name)
Date Executed: / /
State of:
⚠ IMPORTANT LEGAL NOTICE: This document is a general template for informational purposes only and does not constitute legal advice. Laws governing advance healthcare directives vary significantly by state. Before executing this document, you are strongly encouraged to consult a licensed attorney in your state. This template references common requirements under the federal Patient Self-Determination Act (42 U.S.C. § 1395cc(f)) and general state statutory frameworks but does not guarantee compliance with any specific state's current statutes. Always verify requirements with a local legal professional.
Advance Healthcare Directive & Living Will Template — General Use — Not Legal Advice — Consult a Licensed Attorney
State of | County of
I, , residing at:
Address:
City: State: ZIP:
Date of Birth: / /
being of sound mind and not acting under duress, fraud, or undue influence, hereby make this Advance Healthcare Directive. This document expresses my wishes regarding healthcare decisions in the event I am unable to make or communicate those decisions myself.
This directive shall become effective upon my incapacity as determined by one or more licensed physicians, or as otherwise required by the laws of the state named above.
Name:
Relationship:
Address:
Phone (Primary): Phone (Alt):
Email:
Name:
Relationship:
Address:
Phone (Primary): Phone (Alt):
Email:
I grant my Healthcare Agent the authority to make healthcare decisions on my behalf, including but not limited to:
The following limitations apply to my Healthcare Agent's authority (check all that apply or write "NONE"):
Agent may NOT authorize voluntary admission to a mental health facility
Agent may NOT consent to experimental treatments or clinical trials
Agent may NOT override my religious or spiritual objections noted below
Other limitations:
The following instructions apply if I have a terminal condition, am in a persistent vegetative state, or have an end-stage condition from which there is no reasonable medical expectation of recovery.
Check ONE of the following:
Option 1 — Comfort Care Only: I do NOT wish to receive life-sustaining treatment if it only serves to artificially prolong the dying process. I want care focused on comfort and relief of pain (palliative/hospice care).
Option 2 — Prolong Life: I WANT all available life-sustaining treatment used to prolong my life to the extent possible, regardless of my condition.
Option 3 — Agent Decides: I authorize my Healthcare Agent to make these decisions based on the circumstances and my values expressed in this document.
For each treatment below, indicate your wish by checking the appropriate column:
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Treatment |
I WANT |
I DO NOT WANT |
AGENT DECIDES |
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Cardiopulmonary Resuscitation (CPR) |
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Mechanical Ventilation / Breathing Machine |
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Artificial Nutrition and Hydration (Feeding Tube) |
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Dialysis (Kidney Treatment) |
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Antibiotics / Antiviral Medications |
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Blood Transfusions |
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Invasive Diagnostic Tests / Surgery |
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Hospitalization (vs. Home/Hospice Care) |
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Pain Medication (even if it may hasten death) |
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Pregnancy: If I am pregnant and my life-sustaining treatment wishes conflict with the continuation of the pregnancy, I direct that:
My healthcare directives above shall apply regardless of my pregnancy.
Life-sustaining treatment shall be provided as long as necessary to allow the fetus to reach viability.
My Healthcare Agent shall decide.
Dementia / Cognitive Decline: If I am diagnosed with severe and irreversible dementia and no longer recognize family members or myself, I direct that:
The directives above apply.
Additional wishes:
Regardless of any other directive in this document, I direct that:
Additional comfort care instructions:
Upon my death, I direct that:
I WISH to donate the following (check all that apply):
Any organs or tissues needed Organs only Tissues only
Specific organs/tissues:
For any purpose Transplant only Research only Therapy/education
I DO NOT WISH to donate any organs or tissues.
My Healthcare Agent shall make this decision.
In the event I am unable to make mental health decisions due to a psychiatric crisis or cognitive incapacity:
Preferred Treatment Facility (if applicable):
Medications I have previously responded well to:
Medications I refuse (list and reason):
Other mental health instructions:
The following statements reflect my personal values and should guide my Healthcare Agent and providers in interpreting this document:
Religious / Spiritual Beliefs:
Quality of Life Considerations (what conditions would make life not worth living for me):
Other Instructions or Wishes:
I authorize all healthcare providers, hospitals, insurance companies, and other covered entities to release my medical records and health information to my Healthcare Agent named in Part II of this document. This authorization is made pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. § 164.508, and shall remain in effect until revoked in writing.
I understand I may revoke this Advance Healthcare Directive at any time while I am competent by:
I, the undersigned, declare that this document reflects my wishes and that I am of legal age (18 or older, or as required by state law), of sound mind, and acting voluntarily and free from undue influence.
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Signature of Principal |
Date (MM/DD/YYYY) |
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Print Full Legal Name: |
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This document must be signed by two witnesses. Witness requirements vary by state. Generally, witnesses may NOT be: the Healthcare Agent named above; a relative by blood, marriage, or adoption; a beneficiary of the Principal's estate; the Principal's physician or any employee of the Principal's healthcare provider; or anyone financially responsible for the Principal's care. Check your state's laws for specific requirements.
I declare that I am at least 18 years old, that the Principal signed or acknowledged this document in my presence, that the Principal appears to be of sound mind and free of duress, and that I am not disqualified from serving as a witness under applicable state law.
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Signature of Witness 1 |
Date (MM/DD/YYYY) |
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Print Name: Address: Phone: |
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I declare that I am at least 18 years old, that the Principal signed or acknowledged this document in my presence, that the Principal appears to be of sound mind and free of duress, and that I am not disqualified from serving as a witness under applicable state law.
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Signature of Witness 2 |
Date (MM/DD/YYYY) |
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Print Name: Address: Phone: |
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Many states require notarization of an Advance Healthcare Directive. Even where not required, notarization is recommended to strengthen the document's legal validity. Check your state's requirements.
STATE OF
COUNTY OF
On this day of , , before me personally appeared
(name of Principal),
known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he/she/they executed the same as their free and voluntary act for the purposes therein stated.
Notary Public Signature
Notary Public in and for the State of
My commission expires:
[NOTARY SEAL]
I, , accept the appointment as Healthcare Agent for . I understand and accept the responsibilities of this role and agree to act in accordance with the wishes expressed in this document and in the best interest of the Principal.
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Signature of Healthcare Agent |
Date (MM/DD/YYYY) |
I have provided copies of this document to (check all that apply):
My Primary Healthcare Agent
My Alternate Healthcare Agent
My Primary Care Physician:
My Hospital / Healthcare Facility:
My Attorney:
My Spiritual Advisor:
Registered with state advance directive registry (if available in my state)
Stored digitally at:
Other:
Document Version: 1.0 Template Last Reviewed: 2025 Next Review:
Advance Healthcare Directive & Living Will — General Template for Personal Use
This template is provided for informational purposes only and does not constitute legal advice. Laws vary by state. Consult a licensed attorney before executing. Compliant with the Patient Self-Determination Act (42 U.S.C. § 1395cc(f)) general framework and HIPAA (45 C.F.R. § 164.508). Not a substitute for state-specific statutory forms.
References: Patient Self-Determination Act | HIPAA Privacy Rule | Uniform Health-Care Decisions Act (UHCDA) | State-specific advance directive statutes