Advanced Care Directive

Kind Path Guide — Advance Care Directive Tool

Kind Path Guide

Compassionate Planning

Advance Care Directive

Health Care Directive & Durable POA for Health Care

Fill in as much as feels right — you can leave anything blank and complete it by hand later. When you are ready, choose Create my directive. You can then print or save it as a PDF. In Washington, this directive must be signed before two qualified witnesses or acknowledged before a notary public.

Your state

Choose the state where you live and will sign. This sets the signing, witness, and notary requirements throughout your directive.

State

About you Your full name

Date of birth

Home address

1. My health care agent

The person you trust to make health care decisions for you when you cannot.

Agent's full name

Relationship to me

Phone

Alternate phone

Address

2. Alternate agent

Serves if your first agent is unable, unwilling, or unavailable.

Alternate's full name

Relationship to me

Phone

Address

3. Life-sustaining treatment

If I have a terminal condition, am permanently unconscious, or am in an end-stage condition, my wishes are:

I do not want life-sustaining treatment. Keep me comfortable and allow a natural death. I am willing to undergo a time-limited trial of treatment; if it will not lead to meaningful recovery, withdraw it and keep me comfortable. I want all life-sustaining treatment that could prolong my life, regardless of my condition. I want my health care agent to decide, guided by my values below.

In my own words (optional)

4. Specific treatment preferences

For each treatment, choose the option that reflects your wishes.

5. Comfort & pain management

I direct that I be kept as free of pain and discomfort as possible, and that medication be given to relieve my suffering even if it may make me drowsy or unintentionally hasten my death.

If possible and consistent with my care, I would prefer to be cared for:

6. Organ & tissue donation

Upon my death, I wish to donate any needed organs and tissues. Upon my death, I wish to donate only certain organs or tissues (note below). I do not wish to donate.

If only certain organs or tissues, list them:

7. My values & personal wishes What matters most to me: Religious, spiritual, or cultural wishes:

8. My primary physician

Physician's name

Physician's phone

Signing City where you will sign (optional)

Preview — this is exactly what will print. Website headers are not included.