A guide to creating an advance healthcare directive (living will), covering end-of-life preferences, medical treatment decisions, healthcare agent designation, and legal execution requirements.
Learn the difference between a living will and a healthcare proxy (healthcare power of attorney)
A living will states your treatment preferences for specific scenarios. A healthcare proxy names a person to make decisions for you. Most states combine both into a single 'advance healthcare directive' form. About 40 states offer a statutory form.
Check your state's specific advance directive requirements and available forms
Each state has its own advance directive statute. Some states like California use a standardized form (the AHCD form). Others like Texas combine the directive of physicians with an out-of-hospital DNR. Free state-specific forms are available from your state attorney general's office.
Determine if a POLST or MOLST form is also appropriate for your situation
POLST (Physician Orders for Life-Sustaining Treatment) is a medical order signed by your doctor, not a legal document you create alone. It's typically for people with serious illness or advanced age. POLST forms are recognized in 46 states as of 2024.
Choose Your Healthcare Agent
Select a healthcare agent (proxy) who understands and will honor your medical wishes
Choose someone who can remain calm under pressure and advocate for your wishes even under family disagreement. Your agent does not need to live locally but should be reachable by phone 24/7. Do not name your physician — most states prohibit this.
Name at least one alternate healthcare agent
If your primary agent is unreachable when a decision must be made, doctors will turn to your state's default surrogate hierarchy (usually spouse, then adult children, then parents). An alternate agent ensures your chosen person makes decisions, not a default list.
Have a detailed conversation with your agent about your values and treatment preferences
Cover specific scenarios: long-term ventilator use, feeding tubes, dialysis, and experimental treatments. The Five Wishes document ($5 online) provides structured conversation prompts. Studies show that 70% of patients cannot speak for themselves at the end of life.
Clarify the scope of authority — can the agent override the written directive if circumstances change?
Some states allow the agent to override your written wishes if medical circumstances differ from what you anticipated. Decide if you want strict adherence to your directive or flexibility for your agent. State this preference explicitly in the document.
Document Your Medical Treatment Preferences
State your wishes regarding CPR and mechanical ventilation
CPR survival rates for out-of-hospital cardiac arrest average 10-12%. For hospitalized patients over 70, the survival-to-discharge rate is approximately 15%. Specify whether you want CPR attempted and for how long ventilator support should continue.
Address artificial nutrition and hydration (feeding tubes and IV fluids)
A PEG feeding tube insertion costs $5,000-$15,000 and requires ongoing care. For patients with advanced dementia, studies show feeding tubes do not extend life or prevent aspiration pneumonia. Specify your preference for temporary versus long-term use.
Indicate preferences for pain management and comfort care
Palliative sedation (continuous deep sedation for intractable suffering) is legal in all 50 states but is not the same as aid in dying. Specify whether you prioritize consciousness over pain relief or vice versa. Hospice care is covered by Medicare Part A with zero copay.
State your wishes regarding dialysis, blood transfusions, and antibiotics in terminal conditions
Dialysis costs $90,000-$100,000 per year. For patients with terminal illness, stopping dialysis typically results in death within 7-14 days. Specify whether you want these treatments continued if they will not cure the underlying condition.
Address organ and tissue donation preferences
Register your decision with your state's donor registry in addition to stating it in the directive. Over 100,000 people are on the U.S. transplant waiting list. One donor can save up to 8 lives through organ donation and improve 75 more through tissue donation.
Document any religious, spiritual, or personal values that should guide medical decisions
Some religious traditions have specific positions on life support, blood products, or autopsy. Include these in writing so your agent and medical team can honor them. A hospital chaplain or ethics committee can help resolve conflicts between medical recommendations and personal beliefs.
Execute the Directive Legally
Sign the directive in front of the required number of witnesses (typically 2)
Most states require 2 adult witnesses who are not your healthcare agent, not related to you, and not your healthcare provider. In about 10 states, at least one witness must be unrelated and have no financial interest in your estate.
Have the directive notarized if your state requires or recommends it
About 10 states require notarization for advance directives. Even where not required, notarization adds legitimacy and prevents challenges. Notarization costs $5-$15. Some states accept either notarization or witnesses — not both.
Complete a HIPAA authorization form granting your agent access to medical records
HIPAA privacy rules prevent doctors from sharing your medical information without written authorization — even with your healthcare agent. A HIPAA release costs nothing to prepare but without one, your agent may be unable to make informed decisions.
Distribute and Keep Current
Give copies to your healthcare agent, alternate agent, primary care physician, and local hospital
Ask each doctor's office to scan the directive into your electronic health record. Most EHR systems have a dedicated section for advance directives. Upload a copy to your state's advance directive registry if one exists — 10 states maintain an online registry.
Keep a wallet card listing your agent's contact information and the existence of the directive
Emergency responders follow standard protocols unless a valid DNR or POLST form is physically present. A wallet card alone will not stop CPR, but it alerts hospital staff to locate your directive once you're admitted.
Give copies to close family members even if they are not your healthcare agent
Family disagreements are the leading cause of advance directive disputes. Sharing the document now — and explaining your reasoning — reduces conflict later. A family meeting to discuss the directive takes 30-60 minutes and prevents months of legal battles.
Review and update the directive every 2-3 years or after any major health change
Many states specify that a directive signed more than 7 years ago may be given less weight. After a new diagnosis, hospitalization, or change in family circumstances, review your preferences. Revocation is simple — a signed, dated written statement is sufficient in all states.
Frequently Asked Questions
What is the difference between an advance directive and a living will?
A living will is one component of a broader advance directive. The living will specifically states your treatment preferences for end-of-life scenarios (such as ventilator use, tube feeding, and resuscitation), while the full advance directive also includes a healthcare power of attorney that names a trusted person to make medical decisions if you become incapacitated. Most states allow you to combine both into a single document, though some require them filed separately. This is not legal advice — consult an attorney for your specific situation.
How much does it cost to create an advance healthcare directive?
Costs range from $0 to $500 depending on your approach. Free templates are available from state health departments and organizations like AARP and Five Wishes ($5 for their guided form). If you work with an estate planning attorney, expect to pay $150-$500 for a directive as part of a broader document package. Many hospitals and hospice organizations offer free assistance completing the forms, and some states like California provide a statutory form at no cost.
Do advance directives expire or need to be renewed?
In most states, advance directives remain valid indefinitely once properly executed. However, a few states (such as South Carolina) set expiration periods of five years, after which the document must be re-signed. Even in states without expiration rules, medical professionals recommend reviewing and re-signing your directive every 3-5 years or after any major life event like marriage, divorce, a new diagnosis, or a change in your healthcare agent. An outdated directive can create confusion or conflict among family members and providers. This is not legal advice — consult an attorney for your specific situation.
Will my advance directive be honored in a different state?
Most states have laws recognizing out-of-state advance directives, but enforcement is inconsistent. The Uniform Health-Care Decisions Act, adopted by about 20 states, specifically validates directives from other jurisdictions. If you split time between two states or travel frequently, the safest approach is to execute directives that comply with each state where you spend significant time. Carry a wallet card noting you have a directive on file, and register it with a national registry like the U.S. Living Will Registry for quick electronic access by healthcare providers.
Can I change or revoke my advance directive after signing it?
Yes, you can revoke or amend your advance directive at any time while you are mentally competent. Revocation can usually be done verbally, in writing, or by physically destroying the document — though written revocation is strongly preferred for clear documentation. After revoking, notify your healthcare agent, all doctors who have a copy, any hospitals where it is on file, and family members. Create and distribute the updated version promptly, and ask recipients to destroy the old copies to prevent conflicting instructions from surfacing during a medical emergency. This is not legal advice — consult an attorney for your specific situation.