Checklist: Creating An Advance Health Care Directive

In order to complete an Advance Directive you must identify the types of treatments you want and don't want at the end of your life. It's comprised of your Living Will and Health Care Proxy (or Health Care Power of Attorney). In order to create an Advance Directive, you're going to need to fill out your state’s particular forms. This worksheet can prepare you for the decisions you’re going to have to make on those forms, and for any conversation you may have with your doctors or your family. To find your state’s forms, click here. To learn more about creating an Advance Directive, click here.

• Decide what kind of life-support treatment you want and do not want at the end of life.
  This will be your Living Will. Life-Support Treatments may include medical devices to aid breathing, medical devices to provide food and water, blood transfusions, dialysis, antibiotics, and surgery.
  • I would like all life support treatments that might prolong my life
  • I would like no life support treatments, even if they might prolong my life
  • I would like some life support treatments, including:
    • ​Medical devices to aid breathing (ventilator)
    • Medical devices to aid nutrition and hydration (tube feeding)
    • Blood transfusions
    • Dialysis
    • Antibiotics
    • Surgery
• Decide who you want to make medical decisions on your behalf should you no longer be able to make your own health care decisions.
  This person will be your Health Care Proxy, also known as a Health Care Power of Attorney.
  • If I should become unable to make my own health care decisions, the person I would like to make my health care decisions for me, according to my wishes, is ______________________________.
  • If this person is unable to serve, I would like my successor health care power of attorney to be ______________________________.
• Decide if you want a Do Not Resuscitate (DNR) order.
  A DNR order is separate from a Living Will, even if your Living Will states that you do not want life-support treatments at the end of your life. If you'd like to have a DNR order, you'll need to meet with your doctor to complete the forms.
  • In case my heart or breathing should stop, I want every effort made to revive me
  • In case my heart or breathing should stop, I want no effort made to revive me
    • I have met with my doctor and filled out my DNR form
    • I have made copies of my DNR forms and distributed them to:
      • My primary care physician
      • My Health Care Proxy
      • Any caregivers, nurses, or other doctors who are managing my care
• Decide if you'd like to become a registered organ donor
  • I would not like to donate my organs
  • If I should die, I would like to donate my organs
    • I have registered as an organ donor with my state’s donor registry
• Complete your state's paperwork to make these decisions legal.
  Use the decisions you've made here to help you complete your state's advance directive forms. Depending on the state you live in, the form for a Living Will and the form for a Health Care Proxy may be combined into a single form, or they may be separate forms.
  • Download your state's forms from our list of State-by-State Advance Directive Forms
  • Have two witnesses over the age of 18 sign the form and get the form notarized, if necessary
  • If you would like a DNR order, contact your doctor and complete the form together
• Store these forms in an obvious, accessible location where they can easily be found in the event of an emergency, and make copies of these forms for your health care agent.
  Be sure to tell your health care power of attorney and your family where you've stored these documents.