Healthcare Directive worksheet
Organize your medical wishes and healthcare proxy designation. Take to your attorney for a state-valid living will.
Healthcare directives (living will + healthcare proxy/POA) tell doctors and family what you want if you can't speak for yourself — life support, resuscitation, feeding tubes, organ donation, mental health treatment. Without one, family may make choices you wouldn't have made, or face devastating disagreements. Forms are state-specific.
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The person who makes medical decisions if you can't. Choose someone who knows you, will follow your wishes, and can handle hospital pressure. Have the conversation in advance.
Choices: yes if there's reasonable hope of recovery; no under any circumstance; trial period (specify days); per proxy's judgment.
If your heart stops, do you want CPR attempted? In end-stage illness, CPR success is very low. Many seniors choose 'no CPR if terminal' but 'yes if otherwise healthy.' Your call.
Yes always; no in terminal/persistent vegetative state; trial period; per proxy.
Some choose to allow infection to take its course in end-stage illness. Discuss with your doctor what 'end-stage' means in your medical context.
Most people want maximum pain relief even if it shortens life. Make this explicit so doctors aren't conservative.
Yes (all organs/tissues), yes (specific only), no, decided by family.
- ·Have an in-person conversation with your healthcare proxy. Tell them WHY you've made these choices, not just what.
- ·Give copies to: your doctor, your hospital (when admitted), each family member, your healthcare proxy, your safe-deposit box.
- ·Update if your situation changes (new diagnosis, divorce, death of proxy).
- ·States have specific forms (POLST, MOLST, advance directive) — your attorney knows yours.
SmartSeniorX is not a law firm and does not provide legal advice. This worksheet is an educational organizer to help you gather your information BEFORE meeting with a licensed attorney in your state. Worksheets are NOT legal documents. To create a valid will, power of attorney, or healthcare directive, work with a licensed attorney in your state. State-specific signing, witness, and notarization requirements apply.