ADVANCE HEALTH CARE DIRECTIVE
In the event that the time comes and I am incapacitated to the point that I am no longer able to
actively take part in decisions for my own life, and I am unable to direct my healthcare physician
as to my own medical care, I hereby authorize this Living Will as my Advance Health Care
Directive to stand as a testament of my wishes.
I, ________________________, residing at ________________________,
________________________ in the County of ________________________ in the State of
________________________ in the zip code ________________________ and whose telephone
number is ________________________, being of sound mind, and acting willingly and without
duress, fraud or undue influence, herein direct that the instructions provided herein are to be
recognized as a formal statement of my desires with regards to my health care, custody and medical
treatment, and as such I hereby voluntarily declare and make this designation with regards to my
Living Will (aka Advance Health Care Directive and/or Health Care Proxy). These instructions
and directives shall be binding upon all involved to the fullest extent allowable by law.
DESIGNATION OF HEALTH CARE ADVOCATE
I herein designate ________________________, residing at ________________________,
________________________, ________________________ ________________________ and
whose telephone number is ________________________, as my advocate and agent to make any
and all health care decisions on my behalf should I ever be diagnosed with a terminal illness,
disease, injury, or should I become incapacitated or permanently unconscious (in a coma or
persistent vegetative condition) where I would remain permanently unable to make decisions.
ADVOCATE'S GENERAL POWERS
My health care advocate or agent shall have the power to make health care, custody and medical
treatment decisions on my behalf if my attending and/or primary physician makes the
determination that I am unable to make said decisions.
I have specific directives regarding the delivery of medical care in certain health care conditions.
Therefore, I wish to direct my medical treatment by way of the following conditions:
LIFE-SUSTAINING MEDICAL TREATMENT
Should any of the aforementioned events occur, I wish to leave the following directives regarding
the treatment and procedures which may be used, withheld or withdrawn:
- I wish to ________________________ cardiac resuscitation (CPR) in an attempt to try and
prolong my life.
- I wish to ________________________ life-support (e.g., respirators, ventilators) used in
an effort to replace or support my natural breathing.