Your Health Care Directive
What to initial
Your health care directive names the person who makes health choices for you if you cannot. That person is called your health care agent. It also says what care you want at the end of your life.
The form has 18 lines for your initials. This guide tells you what each line means.
StopDecide now. Do not write on your real document yet. You initial on signing day, while your 2 witnesses watch.
Welcome back.
How this page works
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Type your initials
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Read each line
Most lines ask for something. A few take a power away from your agent. Each of those is marked "This one says no."
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Bring your list
Write down the lines you choose, or print the blank sheet at the end of this page.
This page remembers your choices on this phone or computer. It does not send them to us. Married? Each of you has your own health care directive, and makes your own choices. Sharing this phone or computer? Clear the choices before the second person starts.
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After your death
On your paper, look for this heading(5) POWERS OF HEALTH CARE AGENT AFTER DEATH
Your health care agent can decide three things after you die: an autopsy, donating your body or organs, and your burial or cremation. Initial a line here only to change that.
(A) Autopsy
No autopsy This one says no
An autopsy is a medical exam of the body to find the cause of death. Initial this and your agent may not allow one. One may still be done if the law requires it. Leave it empty and your agent may decide.
On the formMy health care agent will not have the power to authorize an autopsy of my body (unless an autopsy is required by law).
(B) Organ donation and donation of body
No giving my body to a medical study This one says no
Initial this and your agent may not give your body to a medical school or a medical study.
On the formMy health care agent will not have the power to make a disposition of my body for use in a medical study program.
No organ donation This one says no
Initial this and your agent may not donate your organs.
On the formMy health care agent will not have the power to donate any of my organs.
(C) Final disposition of body
"Final disposition" means your burial or cremation.
A different person decides my burial or cremation
Leave this empty and your health care agent decides. Initial it only if you want a different person to decide. Then write that person’s name, address, and phone number on the lines under it. Most people leave this empty.
On the formI want the following person to make decisions about the final disposition of my body:
Buried
Initial this if you want to be buried. Initial only one of the two. You may leave both empty.
Cremated
Initial this if you want to be cremated. Initial only one of the two. You may leave both empty.
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When your end‑of‑life choice applies
On your paper, look for this heading(6) CONDITIONS
The next section holds your end‑of‑life choice. That choice only applies in a condition you initial here. Two doctors must examine you and agree, in writing, that you are in that condition.
There are two. Initial one, both, or neither. If you initial neither, your choice in the next section will not apply. Your health care agent would then decide for you.
A terminal condition
You have an illness or injury that cannot be cured and you will die from it soon.
On the formA terminal condition, which means I have an incurable or irreversible condition that will result in my death in a relatively short period of time.
Permanent unconsciousness
You are not aware of yourself or what is around you, and doctors say that will not change.
On the formA state of permanent unconsciousness, which means I am in an incurable or irreversible condition in which I am not aware of myself or my environment and I show no behavioral response to my environment.
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Your end‑of‑life choice
On your paper, look for this heading(7) TREATMENT PREFERENCES
This is the care you want if you are in a condition you initialed above and you cannot tell anyone what you want. Initial one: (A), (B), or (C). Whatever you pick, you still get comfort care and medicine for pain.
Check this. You picked an end-of-life choice, but no condition in the part before it. Your choice will not apply. Go back and initial a condition. Go to that part
(A) Keep me alive as long as possible
Keep me alive as long as you can. Use every medicine and machine, and a feeding tube if I need one.
On the formTry to extend my life for as long as possible, using all medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means.
(B) Allow my natural death
Let me die naturally. No medicine, machines, or other treatment that only keeps me alive and cannot cure me. No food or water through a tube, unless it is needed to give me pain medicine.
On the formAllow my natural death to occur. I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication.
(C) Natural death, except what I initial under it
The same as (B), but you keep the kinds of care you initial under it. Choose (C) first. Then initial any of the four you want.
On the formI do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me, except as follows:
Food by tube
Feed me through a tube if I cannot eat.
On the formIf I am unable to take nutrition by mouth, I want to receive nutrition by tube or other medical means.
Fluids by tube
Give me water and fluids through a tube if I cannot drink.
On the formIf I am unable to take fluids by mouth, I want to receive fluids by tube or other medical means.
A ventilator
Use a breathing machine if I cannot breathe on my own.
On the formIf I need assistance to breathe, I want to have a ventilator used.
CPR
Try to restart my heart if it stops.
On the formIf my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR) used.
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Guardian
On your paper, look for this headingPART THREE: GUARDIANSHIP
A guardian is a person a court puts in charge of your care if a judge decides you cannot make your own decisions. This line lets you tell the court who you want. A court only names a guardian if one is needed.
Initial (A) or (B). You may leave both empty.
(A) My health care agent
You want your health care agent to be your guardian.
On the formI nominate the person serving as my health care agent under PART ONE to serve as my guardian.
(B) A different person
You want a different person. Write that person’s name, address, and phone number on the lines under it.
On the formI nominate the following person to serve as my guardian:
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Start and end dates
On your paper, look for this headingPART FOUR: EFFECTIVENESS AND SIGNATURES
This line is only for a directive that starts or stops on a set date.
Leave this line empty. Then your directive is in place from the day you sign it until you die. Your health care agent only steps in if you cannot make or tell your own choices, or if you ask your agent to.
Leave this line empty
On the formThis advance directive for health care will become effective on or upon ______ and will terminate on or upon ______.
That is every line.
There is nothing else to initial on this form. On signing day you sign and date at the end. There is a place called "Additional Statements." You may write more wishes there, or leave it empty.
The lines you chose
You have not chosen any lines yet. Tap a line above to choose it.
Choose a line above first. If you will leave every line empty, there is nothing to bring.
Print a blank sheet to fill in by hand
On signing day
- Initial only the lines you chose.
- Leave every other initial line empty. Do not write "no" or draw a line through it.
- Initial only while your 2 witnesses are watching.
Not sure about a line? Reply to our email and ask.