A medical directive is a set of legal documents that spell out what medical treatment you want, and who speaks for you, if you’re ever too sick or injured to decide for yourself. Writing one doesn’t require a lawyer in most states, but it does require thinking carefully about your values, choosing the right person to advocate for you, and making sure the paperwork is properly signed and stored. Here’s how to do it step by step.
Understand the Two Main Parts
A medical directive typically has two components that work together. The first is a living will, a written document that details the specific medical treatments you would or wouldn’t want to keep you alive. It covers decisions like CPR, breathing machines, tube feeding, and pain management. It can also address choices like organ donation. A living will only takes effect when you can’t communicate your own decisions.
The second component is a healthcare power of attorney (sometimes called a healthcare proxy, healthcare surrogate, or durable power of attorney for healthcare, depending on your state). This is where you name a specific person to make medical decisions on your behalf. While a living will covers scenarios you’ve anticipated, a healthcare agent can respond to situations you didn’t predict. Together, the two documents give your care team both written instructions and a real person to consult.
Choose Your Healthcare Agent
Picking the right person to serve as your healthcare proxy is arguably the most important step. In most states, your proxy must be at least 18 (19 in Alabama and Nebraska) and of sound mind. The American Bar Association recommends against choosing your doctor or their spouse, anyone employed by your healthcare provider, or the owner or operator of your residential care facility. You should also avoid selecting someone who already serves as proxy for 10 or more other people, or a court-appointed guardian.
Beyond those restrictions, focus on fit. Ask yourself whether this person is comfortable having difficult conversations about death and medical care. Will they actually follow your wishes even under pressure from other family members or doctors who disagree? Do you trust them with your life? Can they travel to be with you if needed, or do they live close enough to respond quickly? The best proxy isn’t necessarily your closest relative. It’s the person most likely to honor what you want, even when that’s hard.
Talk to the person before naming them. Walk through specific scenarios so they understand not just what you want, but why. That context helps them make judgment calls in situations your documents don’t explicitly cover.
Decide What Treatments You Want or Don’t Want
Your living will should address the medical interventions most likely to come up in a serious illness or emergency. Common decisions include:
- CPR: Whether you want chest compressions, electric shocks, and emergency medications if your heart stops.
- Mechanical ventilation: Whether you want to be placed on a breathing machine if you can’t breathe on your own.
- Artificial nutrition and hydration: Whether you want feeding tubes or IV fluids if you can’t eat or drink.
- Dialysis: Whether you want a machine to filter your blood if your kidneys fail.
- Pain management: How aggressively you want pain treated, even if it means sedation.
- Organ and tissue donation: Whether you want to donate after death.
For each of these, think about the conditions under which your answer changes. You might want mechanical ventilation after a surgery you’re expected to recover from, but not if you’re in the final stages of a terminal illness. Be as specific as you can about the circumstances, not just the treatments.
DNR and DNI Are Not the Same Thing
One common point of confusion: a Do Not Resuscitate (DNR) order and a Do Not Intubate (DNI) order cover different situations, even though they’re often discussed together. A DNR means you don’t want CPR if your heart stops beating. A DNI means you don’t want a breathing tube inserted if your lungs are failing. Less than 2% of mechanical ventilation is used during cardiac arrest. The vast majority is used for conditions like pneumonia, heart failure, or complications after surgery. You might want one but not the other. Think about each decision separately, and make sure your directive reflects that distinction clearly.
Write a Values Statement
Beyond listing specific treatments, include a section that describes what quality of life means to you. This is the part of your directive that guides your healthcare agent through situations you couldn’t have predicted. Think about questions like: What makes life worth living for you? Is being able to recognize your family important? Would you want treatment continued if you were permanently unconscious? How do you weigh comfort against the chance of recovery?
Even a few sentences here can make an enormous difference. A treatment list tells your care team what to do in specific scenarios. A values statement tells them how to think on your behalf when the scenario is new.
Get the Right Form for Your State
Every state has its own advance directive form, and the legal requirements vary significantly. Some states require two witnesses to sign. Others require notarization. Some require both. CaringInfo, a program of the National Hospice and Palliative Care Organization, provides free, state-specific advance directive forms that you can download and complete. Your state’s bar association or department of health may also have forms available.
You don’t need a lawyer to fill out these forms in most states, but you do need to follow the signing requirements exactly. Read the instructions on your state’s form carefully. If you skip a required witness signature or notarization, the document may not be legally enforceable when it matters most.
POLST Forms Serve a Different Purpose
You may have heard of a POLST form (Portable Orders for Life-Sustaining Treatment, though names vary by state). This is not a replacement for an advance directive. A POLST is a medical order signed by a physician or other authorized provider. It’s designed primarily for people with serious illness or advanced frailty, and it travels with you between care settings. Emergency medical services (EMS) can act on a POLST immediately, whereas an advance directive may need interpretation. If you have a serious medical condition, ask your doctor whether a POLST makes sense in addition to your advance directive.
Store It Where People Can Find It
A directive that no one can locate is as useless as not having one. After your documents are complete and properly signed, make multiple copies and distribute them to your healthcare agent, your primary care doctor, your specialist if you have one, and your lawyer if applicable. If you’re admitted to a hospital, make sure a copy goes into your medical record.
Some states maintain registries where you can upload your advance directive for quick electronic access by healthcare providers and your proxy. If you use a registry, confirm that the most current version is on file. Some people also carry a wallet card noting that they have an advance directive and where it’s stored. Keep the original in a place that’s easy to access, not locked in a safe deposit box that no one can open in an emergency.
Review and Update Regularly
Your directive should be a living document, not something you fill out once and forget. A useful framework for knowing when to revisit it is the “5 Ds”: review your directive after a Death of a loved one, a Divorce, a new Diagnosis, a Decline in health, or when you reach a new Decade of life. At minimum, review it every five to ten years, though an annual check is better.
Your values and preferences can shift after a major life event or health change. When you update your directive, destroy old copies and redistribute the new version to everyone who had one. If your documents are in a state registry, upload the revised version and confirm it replaced the old one.