This form is a legally binding document that specifies what actions should be taken for your health if you can no longer make decisions for yourself due to illness or incapacity.

It clarifies your healthcare preferences, ensuring your autonomy and dignity in health-related decisions.


Step 1: Date


This is where you fill in the current date. This field is important to ensure that the document reflects your most recent wishes about your healthcare.

If your preferences change in the future, the document will need to be updated and the date will help differentiate between different versions.


Step 2: Your Name


This section should contain your full name, starting with your last name, followed by your first name, and finally your middle initial.

This information is crucial as it identifies the person to whom the healthcare instructions apply.


Step 3: Street Address, City, State, Zip


This information provides your full address.

Providing this information helps to confirm your identity and ensures that your healthcare providers know where you reside, which can be crucial for various legal and practical reasons.

Part 1: Individual Instructions For Health Care


This section asks you to make key decisions about potential healthcare scenarios. You must initial only one choice in each section to avoid any ambiguity about your preferences.


Step 1: Choice To Prolong Or Not To Prolong Life


This is where you indicate whether you wish to have your life prolonged as much as possible within the confines of generally accepted healthcare standards.

For example, if you were in a coma and there was a treatment that could possibly extend your life, your choice here would guide your caregivers in making the decision.


Step 2: Artificial Nutrition And Hydration (Food And Fluids) By Tube Into Stomach Or Vein


Here, you decide if you want to receive nutrition and hydration artificially, through a tube into your stomach or vein, if you cannot eat or drink normally.

This choice could apply when you are in a coma or otherwise incapacitated.


Step 3: Relief From Pain


This choice concerns your preference for treatment to relieve pain or discomfort.

For instance, if you had a terminal illness that was causing you significant pain, your instructions here would guide whether you receive medication to alleviate your pain.


Step 4: Ethical, Religious, Or Spiritual Instructions 


In this section, you can indicate if there is a church, temple, spiritual group, or special person from whom you wish to receive spiritual care.

This ensures your spiritual needs are met according to your preferences.


Step 5: Hospice Care


This is where you express your wish to receive hospice care if it becomes appropriate.

Hospice care is a type of care and philosophy of care that focuses on palliating a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs.


Step 6: Primary Care Physician


Here, you will fill in your primary care physician’s name and phone number. Your physician is typically the main person responsible for your healthcare and will play a key role in executing this directive.


Step 7: Other Wishes


This section allows you to add any other instructions or wishes, such as body and organ donation.

This is where you can express any specific desires that haven’t been covered elsewhere in the form.

For example, if you have particular wishes about where you want to spend your final days, or if you wish to donate your organs or body to science, you would express those wishes here.

Part 2: Healthcare Power Of Attorney Agent’s Authority And Obligation


This part outlines the person you designate to make healthcare decisions if you become incapacitated.


Step 1: Name of Agent (Spouse, adult child, friend, or other trusted person) Relationship


This is where you identify your chosen healthcare agent. You’ll need to fill in their name and relationship to you.

Suppose your best friend, Alex, is a nurse, and you trust them implicitly with your health. In this case, you’d write, “Alex Smith, Friend.”


Step 2: Street Address, City, State, Zip, Home Phone, Work Phone, E-mail


These fields help to provide complete contact information for your agent. This ensures healthcare providers can get in touch with them quickly when needed.


Step 3: Name of Alternate Agent (Spouse, adult child, friend, or another trusted person) Relationship


Sometimes your primary agent may not be available when needed. This field lets you appoint an alternate agent.

For example, if your sister, “Jane Doe, Sister,” is your second choice, you would put her details here.


Step 4: Street Address, City, State, Zip, Home Phone, Work Phone, E-mail


Just like with your primary agent, you need to provide the complete contact details of your alternate agent.

After identifying your agents, you’ll need to decide on the extent of their powers.


Step 5: My agent may make all healthcare decisions for me


If your initial here, it means you’re giving your agent full authority to make any healthcare decision that might come up. This is a big decision and requires a lot of trust in your agent.


Step 6: My agent may make all healthcare decisions for me except for the following


Alternatively, you can restrict your agent’s powers by initialing this line and writing out any exceptions.

For example, you might stipulate that your agent cannot approve treatments against your religious beliefs.

Lastly, it would be best to determine when your agent’s authority comes into effect.


Step 7: Agent’s authority

Initialing this line means your agent can only start making decisions once your primary physician has declared you incapacitated.


Step 8: My agent’s authority to make healthcare decisions for me takes effect immediately


If you initial here, your agent can immediately make healthcare decisions. This might be useful if you anticipate being unable to decide for yourself shortly, even if you’re not incapacitated.

With this part of the document, you are putting your health and possibly your life into the hands of someone you trust.

It’s a big decision that can give you peace of mind, knowing that even if you can’t speak for yourself, someone who understands your values and wishes can advocate for you.

Step 9: Print Your Full Name, Your Signature Date


This is the finishing touch! After you’ve filled out everything to your satisfaction, print your full name, sign, and date the document. By signing, you affirm that your choices reflect your desires for future health care.




For the document to be legally enforceable, you must have it witnessed or notarized.

Remember that witnesses cannot be your healthcare agent, a healthcare provider, an employee of a healthcare facility, a relative, or anyone who stands to inherit from you.


Option 1: Witnesses


Two witnesses must sign the form if you’re choosing this route. Each witness will have to print their name, sign, date, and provide their address. 

For example, if you asked your neighbors, Mr. and Mrs. Johnson, to be your witnesses, they would fill in their details here. This verifies that you willingly filled out and signed the form.


Option 2: Notary Public


You won’t need the two witnesses if you choose to go with a notary public. The notary public will fill out this section, confirming that you are the person you claim to be and signed the document willingly. 

For example, let’s say you’re signing this document in the presence of notary public John Doe in Maui, Hawaii, on July 1, 2023. John would fill in those details in the provided fields and stamp the document with his official notary seal.




Completing an advance health care directive is an empowering act of self-determination.

By thoroughly thinking through your values, priorities, and preferences – and committing them to paper – you ensure your healthcare wishes are honored even if illness or injury renders you unable to speak for yourself.

Appointing a trusted person to act as your healthcare agent grants them the legal authority to carry out your choices.

Having witnesses or a notary public validate the document helps guarantee it will be legally binding.

With your advance care planning properly in order, you can face the future with greater peace of mind knowing your healthcare autonomy is secure.