What Should Be Included in Advance Directive Forms? (With Examples)

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Certified Care Manager, Aging Life Care Professional, and National Master Guardian Emeritus

Advance directives are one of the critical pre-planning tools to complete as part of your pre-planning process. Most people think about advance directives later in life, either during a crisis or medical event where a family needs to advocate for a loved one.

The potential problem with that scenario is that it could be challenging to put all the documents you need in place, given your loved one’s cognitive \or physical condition. Starting as early as possible, while everyone is calm and relatively healthy, is often a better option.

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Different types of advance directives can be confusing since every state has slightly different forms and terms for the same components of advance directives. Regardless of the terms used, the idea behind advance directives is to allow you and your loved ones to state what medical interventions you want and don’t want and under what circumstances. The other critical part of advance directives is selecting the person who will speak on your behalf if you cannot do so.

Information You Should Include in Each Advance Directive Form

Each advance directive form will give you instructions on what to include. Some forms allow you to expand on specific questions, and others are a basic checklist.

1. Healthcare proxy or healthcare power of attorney

Naming your healthcare proxy is a fundamental part of any advance directive. Your health care proxy is the person you designate to make healthcare decisions on your behalf if you cannot due to unconsciousness or incapacity. You’ll need to include the following information: 

  • The name and contact information of your healthcare proxy
  • Whether you want the same person named as your healthcare proxy as your guardian, should you need one
  • An alternate healthcare power of attorney if the first person isn’t able to perform their duties
  • Any limits to the powers of the designated healthcare power of attorney
  • Signature of the healthcare power of attorney
  • Notary, if required, or witnesses since some states do not permit a list of witnesses such as a spouse, business partner, health care provider, etc. 
  • Date of signing

2. Financial power of attorney

A financial power of attorney grants the authority to manage your assets, bill-paying, financial transactions, and property management if you can't do it yourself.

Generally included in the financial power of attorney is this information:

  • The person’s name and contact information
  • Whether your financial power of attorney has the authority to act on your behalf immediately, with your permission, or only in the event of incapacitation
  • An alternate agent
  • Any limitations to the financial power of attorney
  • Signatures of financial power of attorneys
  • Notary or witness if required

3. Living will

A living will is a document or series of statements that indicate the life-saving or life-prolonging interventions you want and under what circumstances. Each document, depending on what state you live in, will be a little different. But they all essentially have this information:

  • A resuscitate order or DNR if your heart has stopped
  • If you want CPR performed and when
  • Whether you want a respirator used if you’re unable to breathe on your own
  • If you want dialysis if your kidneys stop working
  • Whether you want a feeding tube or intravenous fluids if you can’t eat or drink
  • If you want antibiotics used to treat serious infections
  • Whether you want narcotics used for pain control
  • Your preference for where you do and don’t want to receive health care

4. POLST

The Physician’s Order for Life-Sustaining Treatment (POLST) is a document used by a limited population of patients for specific life-threatening circumstances. It is a portable medical order for situations like surgery or terminal illness. 

Not everyone who has a healthcare power of attorney will have a POLST.

A POLST document includes: 

  • Whether you want CPR if your heart stops
  • Whether you want to be transferred to a hospital, intensive care, or another healthcare setting
  • Whether you want a ventilator or breathing tube to keep you alive
  • Whether you want artificial hydration or nutrition
  • The use of cardioversion (to reset the heart rhythm)
  • Whether you want dialysis if your kidneys stop working
  • Signature of your primary care or other physician attending to your emergent healthcare needs

5. Organ donation

Organ donation registration is different in each state. You can complete most organ donations online or at your local DMV. You’ll generally need the following information:

  • Demographic information
  • Which organs you’re willing to donate
  • Whether you want to donate your body to science
  • Any limitations to your organ donation

6. HIPPA Release Form

You may ask why a HIPPA release form is necessary if you have a healthcare power of attorney. The reason is that many healthcare power of attorney forms only allow you to designate someone with authority if you can’t speak for yourself. If you want and need someone to advocate on your behalf while you can still speak for yourself, you’ll need a HIPPA release form. Sometimes a separate form is required for each healthcare entity. 

Is There Anything You Shouldn’t Include in an Advance Directive?

There are some things you shouldn’t include in an advance directive. Since forms vary across the states, it could be wise to consult with an estate planning attorney to ensure you haven’t included anything that’s not appropriate. 

In general, these are the items you shouldn’tinclude in an advance directive:

  • Your will. Your last will and testament is a separate document and should not be included in advance directives.
  • An accounting of your estate. Advance directives are not the place for you to provide an accounting of your estate and assets.
  • Detailed medical information. Detailed medical information like lists of medications and healthcare providers should not be part of advance directives. The reason is that medical information changes through time, and updating an advance directive every time these factors change isn't feasible or practical.

Examples of What to Include in an Advance Directive

We’ve already provided a list of what you should include in your advance directive. Below, you’ll find examples of these items and what they contain.

Living will

First, you should plan to include a living will. Every state provides different information on what you should have in your living will and how it should be worded. You’ll need to research living will requirements in your state or speak with an estate attorney to meet your state’s requirements.

Here’s an example of part of a living will to give you an idea of what it might look like (this example is from the State of California): 

“END-OF-LIFE DECISIONS: I direct that my healthcare 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 (1) I have an incurable and irreversible condition that will result in my death

within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain

consciousness, or (3) 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.” 

POLST form

A POLST form is generally a one- or two-page document that includes the following language:

IV fluids and feeding tubes. On most forms, you can indicate whether you want these interventions short-term to determine chances of recovery. Or a specified length of time or no IV fluids or feeding tube under any circumstances.

Comfort measures only, limited additional interventions, or full interventions. Most POLST forms give you one choice ONLY. 

Resuscitation. If you have no pulse, do you want CPR or DNR?

Healthcare Power of Attorney

Some healthcare power of attorney forms allow you to write a narrative that helps you be very specific about exclusions.

Limitations of Authority. If your state’s healthcare power of attorney form permits a narrative, you can state limitations. For example, you may not want your healthcare power of attorney to be your legal guardian.

Duration of Powers. Some states allow you to terminate the healthcare power of attorney’s authority on a specific date which you can indicate on the form. 

HIPPA Form

Most HIPPA release forms give you wide latitude on how and when you want your private healthcare information shared. 

Which Medical Records You Want to be Shared. You can exclude mental health, substance abuse, communicable diseases, and genetic information.

Which Healthcare Entities You Want the Information Shared With. You can designate specific healthcare providers to receive information and exclude others.

Duration of Authorization. You can be as specific as you want. Choose either indefinite authorization, a specific date, or a date “from and to.”

Financial Power of Attorney

A financial power of attorney has lots of flexibility, and working with an estate planning attorney can help you choose which one best suits your needs.

General Durable Power of Attorney. A general durable power of attorney authorizes someone to act and take effect even if you’re incapacitated. A general durable power of attorney can be effective immediately or only upon your incapacity. 

Limited Power of Attorney. You can use a limited power of attorney for specific financial transactions that you cannot perform, such as signing real estate documents. You can designate a limited time period for the authority.

What to Include in Advance Directives

Although complicated at times, advance directives are your opportunity to make your healthcare and financial wishes known. Keep in mind that your situation, healthcare, and family status may change over time. Don’t hesitate to revisit your advance directive documents and amend or change them. 

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