1
MISSISSIPPI
Advance
Directive
Planning for Important Healthcare Decisions
CaringInfo
1731 King St., Suite 100,
Alexandria,
VA
22314
www.caringinfo.org
800/658-8898
CaringInfo, a program of the National Hospice and Palliative Care Organization (NHPCO), is
a national consumer engagement initiative to improve care at the end of life.
It’s About How You LIVE
It’s About How You LIVE is a national community engagement campaign encouraging
individuals to make informed decisions about end-of-life care and services. The campaign
encourages people to:
Learn about options for end-of-life services and care
Implement plans to ensure wishes are honored
Voice decisions to family, friends and healthcare providers
Engage in personal or community efforts to improve end-of-life care
Note: The following is not a substitute for legal advice. While CaringInfo updates the
following information and form to keep them up-to-date, changes in the underlying law can
affect how the form will operate in the event you lose the ability to make decisions for
yourself. If you have any questions about how the form will help ensure your wishes are
carried out, or if your wishes do not seem to fit with the form, you may wish to talk to your
health-care provider or an attorney with experience in drafting advance directives. If you
have other questions regarding these documents, we recommend contacting
your state attorney general's office.
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Revised 2018.
Reproduction and distribution by an organization or organized group without the written permission of the
National Hospice and Palliative Care Organization is expressly forbidden.
2
Using these Materials
BEFORE YOU BEGIN
1. Check to be sure that you have the materials for each state in which you may receive
healthcare
2. These materials include:
Instructions for preparing your advance directive, please read all the instructions.
Your state-specific advance directive forms, which are the pages with the gray
instruction bar on the left side.
ACTION STEPS
1. You may want to photocopy or print a second set of these forms before you start so you
will have a clean copy if you need to start over.
2. When you begin to fill out the forms, refer to the gray instruction bars they will guide
you through the process.
3. Talk with your family, friends, and physicians about your advance directive. Be sure the
person you appoint to make decisions on your behalf understands your wishes.
4. Once the form is completed and signed, photocopy the form and give it to the person
you have appointed to make decisions on your behalf, your family, friends, health-care
providers and/or faith leaders so that the form is available in the event of an emergency.
5. You may also want to save a copy of your form in an online personal health records
application, program, or service that allows you to share your medical documents with
your physicians, family, and others who you want to take an active role in your advance
care planning.
3
INTRODUCTION TO YOUR MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
This packet contains a legal document, a Mississippi Advance Health-Care Directive,
that protects your right to refuse medical treatment you do not want, or to request
treatment you do want, in the event you lose the ability to make decisions yourself. You
may complete any or all of the first four parts, depending on your advance planning needs.
You must complete part 5.
Part 1 is a Power of Attorney for Health Care. This part lets you name someone (an
agent) to make decisions about your health care in the event that you can no longer speak
for yourself. The power of attorney for health care becomes effective when your doctor
determines that you can no longer make or communicate your health-care decisions, unless
you elect for it to be effective immediately.
Part 2 includes your Individual Instructions. This is your states living will. It lets you
state your wishes about health care in the event that you can no longer speak for yourself
and
are terminally ill,
are permanently unconscious, or
the likely risks and burdens of the proposed treatment would outweigh the
expected benefits.
Your individual instructions go into effect when your physician determines that you can no
longer communicate your wishes and one of the conditions listed above exists.
Part 3 allows you to express your wishes regarding organ donation.
Part 4 of this form lets you designate a physician to have primary responsibility for your
health care.
Part 5 contains the signature and witnessing provisions so that your document will be
effective.
This form does not expressly address mental illness. If you would like to make advance
care plans regarding mental illness, you should talk to your physician and an attorney about
an advance directive tailored to your needs.
Note: These documents
will be
legally binding
only if the
person completing
them is a
competent
adult who is 18
years
of age or older or an
emancipated
minor.
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Instructions for Completing Your Mississippi Advance Health-Care Directive
How do I make my Advance Health-Care Directive legal?
In order to make your Advance Health-Care Directive legally binding you have two options:
1. Sign your document in the presence of two witnesses. Your witnesses must be at least
18 years of age. Neither of your witnesses can be:
the person you appointed as your agent,
a health-care provider, or
an employee of a health-care provider or facility.
In addition, one of your witnesses cannot be:
related to you by blood or marriage or adoption,
entitled to any part of your estate either under your last will and testament or by
operation of law.
OR
2. Sign your document in the presence of a notary public.
Who should I appoint as my agent?
Your agent is the person you appoint to make decisions about your health care if you
become unable to make those decisions yourself. Your agent may be a family member or a
close friend whom you trust to make serious decisions. The person you name as your agent
should clearly understand your wishes and be willing to accept the responsibility of making
health-care decisions for you.
You can appoint a second person as your alternate agent. The alternate will step in if the
first person you name as an agent is unable, unwilling, or unavailable to act for you.
Unless related by blood, marriage, or adoption, your agent cannot be an owner, operator,
or employee of a residential long-term health-care institution at which you are receiving
care.
Should I add personal instructions to my Advance Health-Care Directive?
One of the strongest reasons for naming an agent is to have someone who can respond
flexibly as your health-care situation changes and deal with situations that you did not
foresee. If you add instructions to this document it may help your agent carry out your
wishes, but be careful that you do not unintentionally restrict your agent’s power to act in
your best interest. In any event, be sure to talk with your agent about your future medical
care and describe what you consider to be an acceptable “quality of life.
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What if I change my mind?
To revoke the designation of an agent in Part 1 of your Mississippi Advance Health-Care
Directive, you must do so in a signed writing or by personally informing your primary
physician or the provider who has undertaken primary responsibility for your healthcare.
Unless you provide otherwise, a decree of annulment, divorce, dissolution of marriage, or
legal separation automatically revokes a previous designation of your spouse as your agent.
You make revoke all or part of your advance health-care directive, other than the
designation of an agent, at any time and in any manner that communicates an intent to
revoke by, for example, destroying the advance health-care directive.
A later advance directive that conflicts with an earlier advance directive will revoke the
earlier advance directive to the extent of the conflict.
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MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 1 OF 11
EXPLANATION
© 2005 National
Hospice and
Palliative Care
Organization
2018 Revised.
Explanation
You have the right to give instructions about your own health care. You
also have the right to name someone else to make health-care
decisions for you. This form lets you do either or both of these things.
It also lets you express your wishes regarding the designation of your
primary physician. If you use this form, you may complete or modify all
or any part of it. You are free to use a different form.
Part 1 of this form is a power of attorney for health care. Part 1 lets
you name another individual as agent to make health-care decisions for
you if you become incapable of making your own decisions or if you
want someone else to make those decisions for you now even though
you are still capable. You may name an alternate agent to act for you if
your first choice is not willing, able, or reasonably available to make
decisions for you. Unless related to you, your agent may not be an
owner, operator, or employee of a residential long-term health-care
institution at which you are receiving care.
Unless the form you sign limits the authority of your agent, your agent
may make all health-care decisions for you. This form has a place for
you to limit the authority of your agent. You need not limit the authority
of your agent if you wish to rely on your agent for all health-care
decisions that may have to be made. If you choose not to limit the
authority of your agent, your agent will have the right to:
(a) Consent or refuse consent to any care, treatment, service,
or procedure to maintain, diagnose, or otherwise affect a
physical or mental condition;
(b) Select or discharge health-care providers and institutions;
(c) Approve or disapprove diagnostic tests, surgical procedures,
programs of medication, and orders not to resuscitate; and
(d) Direct the provision, withholding, or withdrawal of artificial
nutrition and hydration and all other forms of health care.
Part 2 of this form lets you give specific instructions about any aspect
of your health care. Choices are provided for you to express your
wishes regarding the provision, withholding, or withdrawal of treatment
to keep you alive, including the provision of artificial nutrition and
hydration, as well as the provision of pain relief. Space is provided for
you to add to the choices you have made or for you to write out any
additional wishes.
Part 3 of this form lets you designate a physician to have primary
responsibility for your health care.
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MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 2 OF 11
Part 4 of this form lets you authorize your agent to make an
anatomical gift on your behalf in accordance with your wishes if you
have not done so yourself.
EXPLANATION
CONTINUED
© 2005 National
Hospice and
Palliative Care
Organization
2018 Revised.
After completing this form, sign and date the form at the end in Part
5 and have the form witnessed by one of the two alternative
methods listed below. Give a copy of the signed and completed form
to your physician, to any other health-care providers you may have,
to any health-care institution at which you are receiving care, and to
any health-care agents you have named. You should talk to the
person you have named as agent to make sure that he or she
understands your wishes and is willing to take the responsibility.
You have the right to revoke this Advance Health-Care Directive or
replace this form at any time.
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MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 3 OF 11
PART 1
POWER OF ATTORNEY FOR HEALTH CARE
PRINT YOUR NAME
PRINT THE NAME,
HOME ADDRESS
AND HOME AND
WORK TELEPHONE
NUMBERS OF YOUR
PRIMARY
AGENT
(1) DESIGNATION OF AGENT:
I, , designate the
(your name)
following individual as my agent to make health-care decisions for me:
(Name of individual you choose as agent)
(address) (city) (state) (zip code)
(home phone) (work phone)
PRINT THE NAME,
HOME ADDRESS
AND HOME AND
WORK TELEPHONE
NUMBERS OF YOUR
OPTIONAL: If I revoke my agent’s authority or if my agent is not willing,
able, or reasonably available to make a health-care decision for me, I
designate as my first alternate agent:
(Name of individual you choose as first alternate agent)
FIRST
ALTERNATE
AGENT
PRINT THE NAME,
HOME ADDRESS
AND HOME AND
WORK TELEPHONE
NUMBERS OF YOUR
SECOND
ALTERNATE AGENT
© 2005 National
Hospice and
Palliative Care
Organization
2018 Revised.
(address) (city) (state) (zip code)
(home phone) (work phone)
OPTIONAL: If I revoke the authority of my agent and first alternate agent
or if neither is willing, able, or reasonably available to make a health-care
decision for me, I designate as my second alternate agent:
(Name of individual you choose as second alternate agent)
(address) (city) (state) (zip code)
(home phone) (work phone)
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MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 4 OF 11
2) AGENTS AUTHORITY: My agent is authorized to make all health-care
decisions for me, including decisions to provide, withhold, or withdraw
artificial nutrition and hydration, and all other forms of health care to keep
me alive, except as I state here:
ADD PERSONAL
INSTRUCTIONS
ONLY IF YOU WANT
TO LIMIT
THE POWER OF
YOUR
AGENT
(Add
additional sheets
if needed.)
INITIAL THE BOX
ONLY IF YOU WISH
YOUR AGENTS
AUTHORITY TO
BECOME EFFECTIVE
IMMEDIATELY
CROSS OUT AND
INITIAL ANY
STATEMENTS IN
PARAGRAPHS
3, 4 OR 5 THAT
DO NOT REFLECT
YOUR WISHES
© 2005 National
Hospice and
Palliative Care
Organization
2018 Revised.
(3) WHEN AGENTS AUTHORITY BECOMES EFFECTIVE: My agent’s
authority becomes effective when my primary physician determines that I
am unable to make my own health-care decisions unless I mark the
following box. If I mark this box [ ], my agent’s authority to make
health-care decisions for me takes effect immediately.
(4) AGENTS OBLIGATION: My agent shall make health-care decisions
for me in accordance with this power of attorney for health care, any
instructions I give in Part 2 of this form, and my other wishes to the extent
known to my agent. To the extent my wishes are unknown, my agent shall
make health-care decisions for me in accordance with what my agent
determines to be in my best interest. In determining my best interest, my
agent shall consider my personal values to the extent known to my agent.
(5) NOMINATION OF GUARDIAN: If a guardian of my person needs to
be appointed for me by a court, I nominate the agent designated in this
form. If that agent is not willing, able, or reasonably available to act as
guardian, I nominate the alternate agents whom I have named, in the
order designated.
MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 5 OF 11
PART 2
INSTRUCTIONS FOR HEALTH CARE
If you are satisfied to allow your agent to determine what is best for you in
making end-of-life decisions, you need not fill out this part of the form. If
you do fill out this part of the form, you may strike any wording you do not
want.
INITIAL THE
PARAGRAPH THAT
BEST REFLECTS
YOUR WISHES
REGARDING
LIFE-SUPPORT
MEASURES
INITIAL ONLY ONE
BOX
INITIAL THE BOX
ONLY IF YOU WANT
ARTIFICIAL
NUTRITION AND
HYDRATION
REGARDLESS OF
YOUR MEDICAL
CONDITION
ADD PERSONAL
INSTRUCTIONS
ONLY IF YOU WANT
(6) END-OF-LIFE DECISIONS: I direct that my health-care providers
and others involved in my care provide, withhold or withdraw treatment in
accordance with the choice I have marked below:
[ ] (a) Choice NOT To Prolong Life
I do not want my life to be prolonged if (i) I have an incurable and
irreversible condition that will result in my death within a relatively short
time, (ii) I become unconscious and, to a reasonable degree of medical
certainty, I will not regain consciousness, or (iii) the likely risks and
burdens of treatment would outweigh the expected benefits, or
[ ] (b) Choice To Prolong Life
I want my life to be prolonged as long as possible within the limits of
generally accepted health-care standards.
(7) ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutrition and
hydration must be provided, withheld or withdrawn in accordance with the
choice I have made in paragraph (6) unless I mark the following box.
If I mark this box [ ], artificial nutrition and hydration must be provided
regardless of my condition and regardless of the choice I have made in
paragraph (6).
(8) RELIEF FROM PAIN: Except as I state in the following space, I direct
that treatment for alleviation of pain or discomfort be provided at all times,
even if it hastens my death:
TO LIMIT
COMFORT
TREATMENT
© 2005 National
Hospice
and
Palliative
Care
Organization
2018 Revised.
(Add
additional sheets
if needed.)
10
MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 6 OF 11
ADD OTHER
INSTRUCTIONS, IF
ANY, REGARDING
YOUR ADVANCE
CARE PLANS
THESE
INSTRUCTIONS CAN
FURTHER ADDRESS
YOUR HEALTH-CARE
PLANS, SUCH AS
YOUR WISHES
REGARDING
HOSPICE
(9) OTHER WISHES: (If you do not agree with any of the optional
choices above and wish to write your own, or if you wish to add to the
instructions you have given above, you may do so here.) I direct that:
TREATMENT,
BUT
CAN
ALSO ADDRESS
OTHER ADVANCE
PLANNING ISSUES,
SUCH AS YOUR
BURIAL WISHES
ATTACH
ADDITIONAL PAGES
IF NEEDED
(Add
additional sheets
if needed.)
© 2005 National
Hospice and
Palliative Care
Organization
2018 Revised.
(10) EFFECT OF COPY: A copy of this form has the same effect as the
original.
11
MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 7 OF 11
PRINT THE NAME,
ADDRESS AND
TELEPHONE
NUMBER OF YOUR
PRIMARY
PHYSICIAN
PART 3
PRIMARY PHYSICIAN
(OPTIONAL)
(11) I designate the following physician as my primary physician:
(name of physician)
(address) (city) (state) (zip code)
PRINT THE NAME,
ADDRESS AND
TELEPHONE
NUMBER OF YOUR
ALTERNATE
PRIMARY
PHYSICIAN
(phone)
If the physician I have designated above is not willing, able, or reasonably
available to act as my primary physician, I designate the following
physician as my primary physician:
(name of physician)
(address) (city) (state) (zip code)
(phone)
© 2005 National
Hospice and
Palliative Care
Organization
2018 Revised.
12
MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 8 OF 11
CROSS OUT AND
INITIAL THIS
STATEMENT IF YOU
DO NOT
AUTHORIZE YOUR
PART 4
AUTHORIZATION FOR ORGAN DONATION
(OPTIONAL)
(12) I authorize my agent to make this anatomical gift, if medically acceptable, to
take effect upon my death. The words and marks below indicate my desires.
Upon my death, I wish to donate:
My body for anatomical study if needed.
AGENT TO MAKE AN
Any needed organs, tissues, or eyes.
ANATOMICAL GIFT
OF YOUR ORGANS
OR PHYSICAL
PARTS
OTHERWISE,
INITIAL YOUR
ORGAN DONATION
WISHES
ADD INSTRUCTIONS
HERE ONLY IF YOU
WANT TO LIMIT
YOUR ANATOMICAL
GIFT
Only the following organs, tissues, or eyes:
I authorize the use of my organs, tissues, or eyes:
For transplantation
For therapy
For research
For medical education
For any purpose authorized by law.
This authority granted to my patient advocate to make an anatomical gift
is limited as follows (here list
limitations
or
special wishes,
if any):
© 2005 National
Hospice and
Palliative Care
Organization
2018 Revised.
(Add
additional sheets
if needed.)
13
MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 9 OF 11
PART 5: EXECUTION
This advance directive will not be valid unless it is EITHER:
IF YOU CHOOSE TO
SIGN WITH
WITNESSES, USE
ALTERNATIVE 1,
BELOW (P. 15)
IF YOU CHOOSE TO
HAVE YOUR
SIGNATURE
NOTARIZED, USE
ALTERNATIVE 2,
BELOW (P. 16)
© 2005 National
Hospice and
Palliative Care
Organization
2018 Revised.
(A) Signed in the presence of two adult witnesses, at least 18 years of
age, who must also sign the document to show that they personally know
you and believe you to be of sound mind and under no duress, fraud, or
undue influence.
Neither of your witnesses can be:
the person you appointed as your agent,
a health-care provider, or an employee of a health-
care provider or facility.
In addition, one of your witnesses cannot be:
related to you by blood or marriage or adoption,
entitled to any part of your estate either under your
last will and testament or by operation of law.
(If you choose to sign with witnesses, use alternative 1 below).
OR
(B) Witnessed by a notary.
(If you choose to have your signature notarized, use alternative 2,
below).
14
MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 10 OF 11
SIGN AND DATE
YOUR ADVANCE
DIRECTIVE
PRINT YOUR NAME
Alternative No. 1: Sign Before Witnesses
(signature) (date)
(printed name)
AND
ADDRESS
(address)
YOUR WITNESSES
MUST SIGN, DATE,
AND PRINT THEIR
NAMES HERE
Witness No. 1
DECLARATION OF WITNESSES
WITNESS NO. 1
MUST BE
UNRELATED TO YOU
AND NOT HAVE ANY
INTEREST IN YOUR
ESTATE
I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code
of 1972, that the principal is personally known to me, that the principal signed
or acknowledged this advance directive in my presence, that the principal
appears to be of sound mind and under no duress, fraud or undue influence,
that I am not the person appointed as agent by this document, and that I am
not a health-care provider, nor an employee of a health-care provider or facility.
I am not related to the principal by blood, marriage or adoption, and to the best
of my knowledge, I am not entitled to any part of the estate of the principal
upon the death of the principal under a will now existing or by operation of law.
(signature of witness) (date)
(printed name of witness)
Witness No. 2
I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code
of 1972, that the principal is personally known to me, that the principal signed
or acknowledged this advance directive in my presence, that the principal
appears to be of sound mind and under no duress, fraud or undue influence,
that I am not the person appointed as agent by this document, and that I am
not a health-care provider, nor an employee of a health-care provider or facility.
© 2005 National
Hospice and
Palliative Care
Organization
2018 Revised.
(signature of witness) (date)
(printed name of witness)
15
MISSISSIPPI ADVANCE HEALTH-CARE DIRECTIVE
PAGE 11 OF 11
Alternative No. 2: Sign Before a Notary Public
SIGN AND DATE
YOUR ADVANCE
DIRECTIVE
PRINT YOUR NAME
AND ADDRESS
(signature) (date)
(printed name)
(address)
Notary Public
A NOTARY PUBLIC
SHOULD
COMPLETE
THIS
SECTION OF YOUR
DOCUMENT
State of
County of
On this day of , in the year ,
before me, (insert name of notary
public)
appeared , personally 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 or
she executed it. I declare under the penalty of perjury that the person
whose name is subscribed to this instrument appears to be of sound mind
and under no duress, fraud or undue influence.
Notary Seal
(Signature of Notary Public)
© 2005 National
Hospice and
Palliative Care
Organization
2018 Revised.
Courtesy
of
Cari
ng
Info
1731 King St., Suite 100,
Alexandria,
VA
22314
www.caringinfo.org, 800/
65
8
-8898
You Have Filled Out Your Health-Care Directive, Now What?
1. Your Mississippi Advance Health-Care Directive is an important legal document. Keep the
original signed document in a secure but accessible place. Do not put the original
document in a safe deposit box or any other security box that would keep others from
having access to it.
2. Give photocopies of the signed original to your agent and alternate agents, doctor(s),
family, close friends, clergy, and anyone else who might become involved in your health-
care. If you enter a nursing home or hospital, have photocopies of your document placed in
your medical records.
3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes
concerning medical treatment. Discuss your wishes with them often, particularly if your
medical condition changes.
4. You may also want to save a copy of your form in an online personal health records
application, program, or service that allows you to share your medical documents with your
physicians, family, and others who you want to take an active role in your advance care
planning.
5. If you want to make changes to your documents after they have been signed and
witnessed, you must complete a new document.
6. Remember, you can always revoke your Mississippi document.
7. Be aware that your Mississippi document will not be effective in the event of a medical
emergency. Ambulance and hospital emergency department personnel are required to
provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive that
states otherwise. These directives called prehospital medical care directives or “do not
resuscitate orders are designed for people whose poor health gives them little chance of
benefiting from CPR. These directives instruct ambulance and hospital emergency personnel
not to attempt CPR if your heart or breathing should stop.
Currently not all states have laws authorizing these orders. We suggest you speak to your
physician if you are interested in obtaining one. CaringInfo does not distribute these
forms.
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