Advance Healthcare Directive: How to Make One, Step by Step

An advance healthcare directive is a legal document that names the person who will make medical decisions for you and records the care you do or don't want if you can't speak for yourself. You can make one for free by filling in your state's form, naming a health care agent and a backup, and signing it in front of the witnesses or notary your state requires. Then give copies to your agent, your doctor and your family, because the document only helps if people can find it.

What is an advance healthcare directive?

"Advance directive" is the umbrella term for documents about your future medical care. CaringInfo explains that it covers both the state-approved forms and related papers such as a living will, a health care proxy (also called a health care power of attorney), a DNR order and a POLST. California calls its version an "advance health care directive," and other states use similar names.

Most state forms combine two parts:

• An appointment of a health care agent. This is the person who speaks for you when you can't.
• A statement of your wishes. This describes the treatments you would or wouldn't want, such as CPR, breathing machines, tube feeding or dialysis. It guides your agent and your doctors.

The directive applies only when you can't make or communicate your own decisions. While you can, you decide. For how a living will and a health care agent differ, see advance directive vs living will.

How to choose a health care agent

Your agent can talk with your doctors, look at your medical records and make decisions for you. In most states, CaringInfo notes, that authority applies any time you lose the ability to decide, not only near the end of life.

CaringInfo suggests choosing someone who:

• knows you well and understands how you would decide
• stays calm in a crisis
• isn't afraid to ask questions and speak up to doctors
• can reassure and communicate with your family

Ask the person before you name them, and talk through your values, not only your treatment choices. Situations come up that no form anticipates, so your agent may have to decide based on what they know about what makes life worth living for you. Name a backup in case your first choice can't serve. If you have no spouse or adult children, this choice matters even more, and our guide to pre-planning when you are single covers how to set up the rest.

What to put in your directive

Start with what matters to you, then get specific where you can. CaringInfo's advice is that when you are healthy, you can speak in general terms about your priorities. If you have a chronic or serious illness, you know more about what may happen, so you can be more specific.

Topics that forms and the National Cancer Institute commonly list include:

• CPR if your heart or breathing stops
• machines to keep you alive, such as ventilators and dialysis
• tube feeding and artificial hydration
• organ and tissue donation
• comfort care, meaning treatment for pain and other symptoms (NCI notes that this care continues even if you decide to stop treatment aimed at your illness)

Plain, specific wording helps. A phrase like "no heroic measures" can mean different things to different people, so say what you mean about each treatment. Talk to your doctor about what these treatments involve before you decide. The CaringInfo page on creating an advance directive links to free decision aids and videos that show what resuscitation and other treatments involve.

How to make an advance healthcare directive, step by step

1. Think and talk first. Consider your values and what you would want in a serious illness. Talk with the people closest to you and, if you can, with your doctor.
2. Choose your agent and a backup. Ask each of them first.
3. Get your state's form. CaringInfo provides free forms and instructions for every state. Check the instructions, because states differ on witnesses, notarization and other requirements.
4. Fill it in. Use clear wording about the treatments you do and don't want. Ask your doctor or a lawyer to review it if you want to be sure it says what you mean.
5. Sign it the way your state requires. That may mean two witnesses, a notary or either one. The NCI says most states require a witness at the signing.
6. Share copies and store it properly. See the next sections.
7. Review it now and then. Look at it after a diagnosis, a divorce, a move or the death of your agent.

Witness and notary rules

Signing rules are set by each state, so the form's instructions come first. California shows the kind of detail involved. Under its Probate Code, a written directive must be dated, signed by you and then either acknowledged before a notary or signed by at least two qualified witnesses. Its witnesses must be adults, and the following people can't act as witnesses:

• your health care provider or an employee of your provider
• the operator or an employee of a community care facility or a residential care facility for the elderly
• the agent you named in the directive

At least one of the two witnesses must also be someone who isn't related to you by blood, marriage or adoption and isn't entitled to any part of your estate. Other states have different lists, so don't assume the California rules apply where you live.

Where to keep it and who gets copies

CaringInfo says an advance directive is only as good as its availability when it is needed. Its advice:

• Make several copies and give them to your agent, your closest family and your doctor.
• Take a copy to the hospital with you. Hospitals often ask for one at admission, and your local hospital may be willing to file it.
• Keep the original somewhere safe but easy to find, and tell people where it is. Don't put it in a safe deposit box.
• If you can scan it, services such as MedicAlert, MyDirectives and the U.S. Advance Care Plan Registry can store it and make it available wherever you are. Some are free and some charge, so read the terms.
• The NCI suggests keeping a card in your wallet that says you have an advance directive and where to find it.

Why a directive isn't enough for an emergency

CaringInfo points out that emergency medical technicians generally can't act on an advance directive or health care power of attorney. They can honor a DNR order or a POLST, and without one they must do what is needed to stabilize you for transport. If you want CPR withheld, ask your clinician about a DNR order or, if you are seriously ill, a POLST. Our guide to DNR orders explains how they work.

Does it work in another state?

Not always. The NCI warns that a living will or health care power of attorney accepted in one state may not be accepted in another. CaringInfo says advance directives are legally valid throughout the United States, but the laws vary by state, so you should complete and sign one that complies with your state's law. If you split your year between two states, or you move, consider completing a form for each state or having a lawyer check the document.

How to change or cancel your directive

You can change your mind at any time while you are able to decide. CaringInfo says advance directives don't expire, and that if you want to change anything you should complete a whole new document. A new directive invalidates the old one. The NCI adds that when new directives are signed, the old ones should be destroyed. Then give the new version to everyone who held a copy.

Other kinds of directives to know about

• Psychiatric (mental health) advance directive. CaringInfo describes it as a legal tool that records your treatment preferences before a mental health crisis and can name a mental health agent. It says 25 states have laws that allow these. In other states you can add mental health wishes to your standard form.
• POLST (portable medical orders). This is for people who are seriously ill or very frail, is signed by a clinician and travels with you between hospital, home and nursing home. It does not name an agent.
• Five Wishes. The NCI describes this as an easy-to-read living will that is legal in all 50 states and DC in its digital version. For the paper version, it says you may need extra steps in New Hampshire, Kansas, Ohio and Texas.

What does it cost, and what do hospitals have to do?

A directive can cost nothing. State forms from CaringInfo are free. Medicare Part B covers voluntary advance care planning conversations: you pay nothing if your provider accepts assignment and the conversation is part of your Welcome to Medicare or yearly Wellness visit, but if it happens during other treatment the Part B deductible and coinsurance apply.

Under federal rules at 42 CFR 489.102, providers that take part in Medicare, including hospitals, skilled nursing facilities and home health agencies, must give adult patients written information about their right to make decisions and to make an advance directive. They must also record in your chart whether you have one, and they can't make care depend on whether you do.

What to do next

1. Download your state's free form from CaringInfo and read its signing instructions.
2. Ask the person you want as your agent, and choose a backup.
3. Sign and witness the form as your state requires, then share copies with your agent, doctor and family.
4. If you are seriously ill, ask your clinician about a DNR order or POLST.
5. Add the directive to the rest of your plan with the end-of-life planning checklist, and see how a power of attorney works after a death.