Fillable Missouri Advance Directive Form

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Missouri Advance Directive Form

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Missouri: Advance Directive
NOTE: This form is being provided to you as a public service. The attached forms
are provided “as is” and are not the substitute for the advice of an attorney.
By providing these forms and information, Everplans is not providing legal advice
to you. Consult an attorney if you need legal advice of any nature.
Read more and get more forms at Everplans’ Advance Directive page.
__________________________________________________________________________
__________________________________________________________________________
DURABLE POWER OF ATTORNEY FOR HEALTH CARE CHOICES
&
HEALTH CARE CHOICES DIRECTIVE
6-PAGE
FORM
Part I. Durable power of attorney for health care choices
I, _____________________________________________, _________________________,
Name Social Security number
appoint
___________________________________________, _____________________________,
Name Phone
Address
as my agent for health care choices when I am unable to make decisions or communicate my
wishes. In the case the person above cannot serve as my agent, or if I am divorced from or
legally separated from the agent above, I appoint the person below:
___________________________________________, _____________________________,
Name Phone
Address
This alternate agent may make health care decisions for me when I am unable to do so or to
communicate my wishes.
This durable power of attorney becomes effective when two physicians certify that I am
incapacitated and unable to make and communicate health care choices.
You may choose to have one physician, instead of two, determine whether
you are incapacitated. If you want to exercise this option — allowing one
physician to determine whether you are incapacitated — initial here.
COMMUNICATING ABOUT THE END OF LIFE
15
DURABLE POWER OF ATTORNEY FOR HEALTH CARE & HEALTH CARE DIRECTIVE
PAGE
2 of 6
By completing this durable power of attorney, I authorize my agent to make all decisions for
me regarding my health care. This includes the power to withdraw any type of health care,
treatment or procedure, even if I may die in the process. I expect my agent to follow my
health care choices directive. My agent has the power to:
● Consent, refuse or withdraw consent to articially supplied nutrition and hydration.
● Make all necessary arrangements for health care on my behalf. This includes admitting
me to any hospital, psychiatric treatment facility, hospice, nursing home or other health
care facility.
● Hire or re health care personnel on my behalf.
● Request, receive and review my medical and hospital records.
● Take legal action if necessary to do what I have directed.
● Carry out my wishes regarding autopsy and organ donation, and decide what should be
done with my body.
My agent under this durable power of attorney will not incur any personal nancial liability.
The agent also should not be compensated for services performed for me. However, the
agent shall be reimbursed for reasonable expenses that are p
art of my care.
THIS IS A DURABLE POWER OF ATTORNEY AND THE AUTHORITY OF MY
ATTORNEY IN FACT, WHEN EFFECTIVE, SHALL NOT TERMINATE OR BE VOID
OR VOIDABLE IF I AM OR BECOME DISABLED OR INCAPACITATED OR IN THE
EVENT OF LATER UNCERTAINTY AS TO WHETHER I AM DEAD OR ALIVE.
LIFE CHOICES ago.mo.gov
16
DURABLE POWER OF ATTORNEY FOR HEALTH CARE & HEALTH CARE DIRECTIVE
PAGE
3 of 6
Part II. Health care choices directive
I want those involved in my health care to understand my wishes if I cannot communicate or
make decisions on my own. I make this directive to provide clear and convincing proof of
my wishes and instructions about my health care and treatment.
If my doctor believes medical treatment will lead to my recovery, I want to have the
treatment. I also want to have care and treatment for pain or discomfort even if this
treatment might shorten my life, affect my appetite, slow my breathing or be habit-forming.
If I have a terminal illness or condition and there is no reasonable hope I will
recover, or if I am persistently unconscious, I direct all of the life-prolonging
procedures I have initialed below to be withheld or withdrawn.
I direct the following treatments to be withheld or withdrawn:
Surgery or other invasive procedures
Cardiopulmonary resuscitation (CPR) to restart my heart or breathing
Antibiotics
Dialysis
Mechanical ventilator (respirator)
Articially supplied nutrition and hydration (including tube feeding)
Chemotherapy
Radiation therapy
All other “life-prolonging” medical treatments or surgeries that are merely intended to
keep me alive without reasonable hope of making me better or curing my illness or injury.
I consent to the donation of my organs or tissues. I realize my body may need to be
maintained articially after my death until my or
gans can be removed.
I refuse to make anatomical gifts of part or all of my body. I prohibit my agent from
consenting to such gifts before or after my death.
COMMUNICATING ABOUT THE END OF LIFE
17
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
DURABLE POWER OF ATTORNEY FOR HEALTH CARE & HEALTH CARE DIRECTIVE
PAGE
4 of 6
I also give the following directions regarding my health care:
Optional: Describe what you consider an acceptable quality of life. For example, being able
to recognize my loved ones, make decisions, communicate or feed yourself.
Attach extra pages if necessary. Sign and date the attached pages.
Make sure to talk about this directive and your wishes with your agent, your doctors,
family, friends and clergy. Give each of them a copy of the directive. Bring a copy with
you when you go to a hospital or other health care facility. Keep the original with your
important papers.
LIFE CHOICES ago.mo.gov
18
DURABLE POWER OF ATTORNEY FOR HEALTH CARE & HEALTH CARE DIRECTIVE
PAGE
5 of 6
Part III. Relationship between health care choices directive
and durable power of attorney for health care choices
As I have executed the health care choices directive and durable power of attorney for
health care choices, I trust and encourage my agent to:
● First, follow my wishes as expressed in the directive or otherwise from knowledge about
me or having had discussions with me about making choices regarding life-prolonging
medical treatment.
● Second, if my agent does not know my wishes for a specic decision, but my agent has
evidence of what I might want, my agent can try to gure out how I would decide. This
is called substituted judgment and requires my agent imagining himself or herself in my
position. My agent should consider my values, religious beliefs, past choices and past
statements I have made. The aim is to choose as I probably would choose, even if it is not
what my agent would choose for himself or herself.
● Third, if my agent has very little or no knowledge of what I would want, then my agent
and the doctors will have to make a decision based on what a reasonable person in the
same situation would decide. This is called making decisions in my best interest. I have
condence in my agent’s ability to make decisions in my best interest if my agent does
not have enough information to follow my preferences or use substituted judgment, and if
this is the case, I authorize my agent to make decisions that might even be contrary to my
directive in his or her best judgment.
● Finally, if the durable power of attorney for health care choices is determined to be
ineffective, or if my agent is unable to serve, the health care choices directive is intended
to be used on its own as rm instructions to my health care providers regarding life-
prolonging procedures.
COMMUNICATING ABOUT THE END OF LIFE
19
___________________________________ _____________________________________
_______________________________________
DURABLE POWER OF ATTORNEY FOR HEALTH CARE & HEALTH CARE DIRECTIVE
PAGE
6 of 6
Sign this form before two witnesses who are not related to you or financially connected to your estate.
IN WITNESS THEREOF, I have executed this document on __________
______ ____, ________.
MONTH DAY YEAR
Signature _____________________________________________________________________________
Print name _____________________________________________ SS No.________________________
Address ______________________________________________________________________________
The person who signed this document is of sound mind and voluntarily signed this document
in our presence. Each of the undersigned witnesses is at least 18 years of age.
Signature ________________________________ Signature ___________________________________
Print name _______________________________ Print name _________________________________
Address _________________________________ Address _______________________________
Notarization required
STATE OF MISSOURI )
) SS
COUNTY OF _____________________ )
On this ____ day of ____________________, in the year of ________, personally appeared
before me the person signing, known by me to be the person who completed this document
and acknowledged it as his/her free act and deed.
IN WITNESS WHEREOF, I have set my hand and afxed my ofcial seal in the County of
________________________, State of Missouri, the day and year rst above written.
Notary public’s signature
LIFE CHOICES ago.mo.gov
20
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Missouri Advance Directive Form

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Completed 20 November 2021

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