What Is an Advance Directive?

An advance directive is a type of health care directive—that is, a document in which you set out instructions or wishes for your medical care in case you can’t speak for yourself. For many years, there were two separate documents for this purpose:

• Durable power of attorney for health care. This document names someone you trust to oversee your health care and make medical decisions should you become unable to do so.
• Living will. In this document, you state what types of care you want or do not want if you cannot speak for yourself. Your doctors and the person you choose as your agent must do their best to follow your instructions.

An advance health care directive combines these two documents into a single form. The documents you’ll need depend on your state, but the basics are the same no matter where you live. This article answers common questions about advance directives, using the terms “advance directive,” “advance medical directive,” and “health care directive” interchangeably.

How Does an Advance Directive Work?

An advance directive lets you state your medical treatment preferences if you cannot communicate or make decisions yourself. You can also name a health care agent to work with your doctors and make other medical decisions for you.

To set up an advance directive, you need to complete the correct forms for your state. (You can find your state’s forms at the end of this article.) When your forms are complete, you’ll give copies to your health care agent, your doctors, and any family or friends who may be involved in your care.

Your forms take effect only if you cannot make your own decisions. For a health care power of attorney, you can also choose when your agent should start making decisions for you. Health care providers usually must follow your wishes or, if needed, transfer you to another provider who will.

You can change or cancel a health care directive at any time, as long as you are mentally able to do so. If you do not make changes, your health care directives won’t expire; they will stay in effect until the end of your life.

Your Legal Right to Direct Your Own Health Care

Today, the law clearly recognizes your right to control your own medical care. But this right is fairly new. Just a few decades ago, families endured painful legal battles to decide whether life-sustaining treatments should be stopped or continued when someone was near death.

Key legal cases involving Karen Ann Quinlan and Nancy Cruzan, both young women who suffered brain damage and could not share their medical wishes, led to laws that recognize health care directives.

The 1990 Cruzan decision by the U.S. Supreme Court affirmed that patients have a constitutional right to refuse life-sustaining treatment when their intentions are clearly documented. Following this ruling, the federal Patient Self-Determination Act (PSDA) became law in 1991, mandating that all Medicare and Medicaid facilities inquire whether patients have created an advance medical directive and educate them about their rights to make health care decisions.

Now, every state has laws that let people document their health care preferences. Medical professionals must follow these instructions or help transfer you to another provider who will.

If Hospitals Don’t Agree With Your Wishes for Medical Treatment

Even though the law protects your right to control your medical care, hospitals and care facilities, including nursing homes, have their own rules for end-of-life treatment. Many prioritize patient wishes, but adhere firmly to their own values.

For example, Catholic hospitals and care facilities may require artificial nutrition and hydration for all end-of-life patients, even if an advance directive says otherwise. In these places, patients must follow these rules or move to a facility that will respect their wishes.

If you’re concerned, look into the policies of any facilities where you might get care. This helps you and your health care agent know which places to choose in an emergency. When planning for long-term care, this information helps you pick providers whose policies align with your values.

Who Should Make Health Care Directives?

It’s clear that older and seriously ill people need health care directives for end-of-life decisions. But young, healthy adults need them too, because accidents or sudden illnesses can happen at any time. High-profile cases show that the hardest end-of-life conflicts often happen when a younger person is suddenly unable to share their wishes and has not documented their preferences.

The main point is clear: Advance directives are not just for older or sick people. Every adult should have one. Writing down your wishes now, while you are healthy, is a caring gift to your loved ones.

What Happens If You Don't Make Health Care Directives?

Without health care documents, state law determines who makes medical decisions for you. Some states allow providers to decide your treatment, but most require consultation with your spouse or close family member, often called your "surrogate." A few states permit a close friend to serve as surrogate. Disputes may require court intervention.

Health care providers typically consult close relatives, usually spouses, parents, or children, for major medical decisions. Friends and unmarried partners, even those most familiar with your wishes, are often excluded from the process.

When family members disagree about treatment, disputes can escalate into costly, time-consuming court battles in which a judge with no medical expertise or knowledge of the patient decides your care. Properly made health care directives prevent these painful conflicts.

What Can You Include in an Advance Directive?

Health care directives are flexible and let you plan for many parts of your medical care. They help you stay in control and make sure your wishes are followed, even if you cannot speak for yourself. Here are the main things you can include:

• Choose someone you trust to be your "health care agent" (the name varies by state) who will make medical decisions on your behalf if you’re unable to do so. You can also name backup agents in case your first choice isn’t available.
• Select a preferred doctor or health care professional to oversee your treatment.
• State whether you want life-prolonging treatments, such as resuscitation, intubation, or artificial nutrition and hydration.
• List any other specific medical treatments or procedures you do or don’t want to receive.
• Explain how you’d like to be treated in different scenarios—for example, your preferences might differ depending on whether you’re terminally ill, permanently unconscious, or need mental health care.
• If pregnancy is possible for you, specify your wishes should you become incapacitated while pregnant.
• Include your wishes about organ, tissue, or body donation after death.

Beyond these specifics, you can share general preferences about your care. For example, you might express where you’d prefer to receive care (at home or in a particular hospice facility) or how you feel about pain management, such as whether you’d want full pain medication even if it affects your awareness of loved ones around you.

What Does a Health Care Agent Do?

If you cannot make your own medical decisions, your health care agent steps in to follow your wishes and make choices about things you didn’t mention. You can decide how much power your agent has, granting them broad authority or limiting it to specific areas.

Your agent typically has the power to:

• access and review your medical records
• approve or decline medical treatments
• visit you in any hospital or care facility, and
• choose or change your medical providers.

Your agent can take legal action if needed to enforce your wishes. These powers ensure your health care preferences are respected. If a doctor or facility refuses to follow your directives, your agent can transfer you to one that will.

To learn more about a health care agent’s role, see Naming a Health Care Agent and Primary Physician.

How to Make Your Health Care Directives

Making an advance health care directive can feel overwhelming, but it is easier if you take it step by step. Here is a simple guide to help you:

Step 1. Consider your values and wishes. Think about what quality of life means to you and what medical interventions you would or wouldn't want in different scenarios.

Step 2. Choose a health care agent and primary physician. Consider alternate agents and doctors as well.

Step 3. Get the right forms for your state. You can usually find state-specific health care power of attorney, living will, or advance directive forms at your hospital, on your state health department website, or through online legal resources. Check the list at the end of this article to see what these documents are called in your state.

Step 4. Complete your forms. Name your agent and physician, document your treatment preferences, and describe any special instructions or wishes.

Step 5. Finalize your documents. Follow your state’s rules for signatures, witnesses, or notarization to make your document legal.

Step 6. Distribute copies. Give copies to your health care agent, alternate agents, doctor, hospital, and close family members.

Step 7. Store the original in a safe place. Make sure it can be found quickly in an emergency.

Step 8. Update your directive as needed. You can change or cancel your advance directive at any time, as long as you are mentally able.

How to Finalize Your Health Care Directives

To finalize your advance health care directive, you must follow certain legal steps to make sure your document is valid. Every state requires your signature, or someone else can sign for you if you cannot. You should sign the document only when the required witnesses, a notary public, or both are present, depending on your state’s laws.

Witnessing and notarization. Most states require two witnesses to observe your signing and confirm in writing that you appeared mentally sound and were not under pressure or undue influence. States impose restrictions on who can serve as witnesses to prevent conflicts of interest. These rules typically exclude spouses, close relatives, anyone who stands to inherit from you, your attending physician, and owners or employees of a health care facility that is treating you, unless they’re a close relative. Some states allow you to have your document notarized instead of witnessed, while others require both witnesses and notarization. A notary public will watch you sign, verify your identity with photo ID, and add their official signature to your document. You can find notaries through online searches, at banks, or at hospitals, where the service is often provided free of charge to patients.

Storing and sharing your documents. After your directives are properly signed, witnessed, and notarized, make copies to distribute to your health care agent, family members, doctors, and any hospitals or care facilities where you receive treatment. Store the original in a safe, accessible location and ensure your agent and family know where to find it. Copies are just as legally valid as the original, so distributing them widely helps ensure your wishes will be known and honored when needed.

To learn the specific finalization requirements for your state, see Witness and Notarization Requirements for Advance Directives.

Can You Help Another Person Make Health Care Directives?

If the person you want to help is mentally able and wants to write down their health care wishes, your job is simple. You can explain the process, answer questions, and help them prepare and finish the documents. But if you are worried about their mental or physical ability, or think they may not want your help, you should approach the topic with care.

Begin by explaining the benefits. Some people like knowing it will ease stress for family caregivers, while others want to stay in control of their medical care. If you are talking to someone with mental challenges, be sensitive to feelings of frustration or loss. Remind them that planning ahead is smart for everyone, no matter their age or health.

Helping someone who is becoming forgetful or has intellectual disabilities. Never force someone to fill out health care documents just because you think it is best. If you pressure someone whose mental ability is unclear and the documents are later questioned in court, you could get into legal trouble. A person can only make a valid advance directive if they fully understand it. If you are unsure about someone’s ability, talk to an estate planning attorney.

Helping someone finalize their documents. If the person you are helping is too sick or weak to sign the documents, you or someone else can sign on their behalf if they ask. Both the person making the document and the signer should be together in front of witnesses or a notary public, depending on state rules. This way, someone can watch the signing and confirm it reflects what the person wanted.

Names for Health Care Directives in Your State

More Information About Advance Health Care Planning

Whether you are making your own advance directive or helping someone else, doing it now can prevent confusion and conflict later. Your written wishes will guide your loved ones and doctors, making sure your voice is heard even if you cannot speak for yourself.

For more information, see the following articles:

• Naming a Health Care Agent and Primary Physician
• Advance Health Care Planning: Specifying Your Wishes
• Advance Care Planning for Different Medical Conditions
• Power of Attorney for Health Care: What Powers Can You Grant?
• Expressing Organ Donation Wishes in Your Health Care Directive
• Witness and Notarization Requirements for Advance Directives
• Storing, Sharing, or Revoking Your Advance Directive

You can learn more about making health care directives valid in your state in WillMaker’s Legal Manual.