Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
1
Pennsylvania Advance
Healthcare Directive
(which includes Living Will and Healthcare Power of Attorney)
This form lets you have a say about how you want to be cared for if you are
unable to speak for yourself. By completing Parts 1, 2 and 3 entirely, you will
have both Living Will and Healthcare Power of Attorney legal documents.
This form has 3 parts:
Choose a medical decision-maker — page 3
A medical decision-maker is a person who can make healthcare decisions for you if you
are unable to make them yourself. This person will be your advocate. They are also called
a healthcare agent, proxy representative, and/or surrogate or Healthcare Power of Attorney.
Make your own healthcare choices — page 7
This form lets you choose the kind of healthcare you want if you can no longer speak
for yourself. This way, those who care for you will not have to guess what you want
if you are not able to tell them yourself. This is also called a Living Will.
Sign the form — page 13
This form must be saved, printed, and signed before it can be used.*
*Pennsylvania law does not require this document to be notarized, but if the document is both
witnessed and notarized, it is more likely to be honored by the laws of some other states.
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
2
This is a legal form that lets you have a voice in your healthcare.
It will let your family, friends, and medical providers know how you want
to be cared for if you cannot speak for yourself.
Share this form and your choices with your family, friends, and medical providers.
What should I do with this form?
• Share this form with your family, friends, and medical providers.
• Make sure copies of this form are placed in your medical record at all the places
you get care.
What if I have questions about the form?
• Ask your doctors, nurses, social workers, family, or friends to help.
• Lawyers can help too. This form does not give legal advice.
• It is important to have your questions answered before you complete the form.
What if I want to make healthcare choices that are not on this form?
• On page 11, you can write down anything else that is important to you.
When should I fill out this form again?
• If you change your mind about your healthcare choices
• If your health changes
• If your medical decision-maker changes
If your spouse is your decision-maker, and you divorce, that person will no longer
be your decision-maker, unless you name them.
Give the new form to your medical decision-maker and medical providers.
Destroy old forms.
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
3
Part
Choose your medical decision-maker
(Heathcare Power of Attorney)
Your medical decision-maker can make healthcare decisions for you
if you’re unable to make them yourself, or if you haven’t already made
these decisions. For the purposes of this form, this person will be your
Healthcare Power of Attorney.
A good medical decision-maker is a family member or friend who:
• Is 18 years of age or older.
• Can talk to you about your wishes.
• Can be there for you when you need them.
• You trust to follow your wishes and do what’s best for you.
• You trust to know your medical information.
• Is not afraid to ask doctors questions and speak up about your wishes.
Legally, your decision-maker cannot be your doctor or someone who works at your hospital
or clinic, unless they are a family member.
What will happen if I don’t choose a medical decision-maker?
If you are unable to make your own decisions, a person will be chosen for you according
to Pennsylvania law. This person may not know what you want.
If you are not able, your medical decision-maker can choose these things for you:
• Who will care for you (doctors, nurses, social workers, or caregivers).
• Where you will receive care (hospitals, clinical, nursing homes).
• What treatments you will receive (medications, tests, or treatments).
• Who can look at your medical information, and who can visit you while you are hospitalized.
• What happens to your body and organs after you die.
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
4
Here are more decisions your medical decision-maker can make:
Start or stop life support or medical treatments, such as:
End-of-life decisions your medical decision-maker can make:
• Decide to call in a religious or spiritual leader
• Decide if you die at home or in the hospital
• Decide about autopsy or organ donation
• Decide about burial or cremation
CPR or cardiopulmonary resuscitation
cardio = heart pulmonary = lungs resuscitation = try to bring back
This may involve:
• Pressing hard on your chest to try to keep your blood pumping.
• Electrical shocks to try to jump start your heart.
• Putting medicine into your veins.
Breathing machine or ventilator
This machine pumps air into your lungs and tries to breathe
for you. You are not able to talk when you are on the machine.
Dialysis
This machine tries to clean your blood if your kidneys stop working.
Feeding tube
This is a tube used to try to feed you if you cannot swallow. The tube
can be placed through your nose down into your throat and stomach.
It can also be placed by surgery into your stomach.
Blood and water transfusions (IV)
To put blood and water into your body.
Surgery
Medicines
R
R
C
C
P
P
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
5
Flexibility allows your decision-maker to change your prior decisions if doctors think something
else is better for you at that time. Prior decisions may be wishes you wrote down or talked about
with your medical decision-maker. You can write your wishes in Part 2 of this form.
Check the one choice you most agree with:
Flexibility: It is OK for my decision-maker to change any of my medical decisions
if my doctors think it is best for me at that time.
No Flexibility: I want my decision-maker to follow my medical wishes exactly.
It is NOT OK to change my decisions, even if the doctors recommend it.
If you want, you can write why you feel this way.
To make your own healthcare choices, go to Part 2 on page 6.
When you are done, you must complete Part 3, which begins on page 12 and ends on page 14.
Please share your wishes with your family, friends, and medical providers.
Who is your decision-maker? (Must be same person listed on page 12, #1)
How strictly do you want your medical decision-maker to follow your wishes
if you are not able to speak for yourself?
If you want, you can write why you chose your medical decision-maker(s).
Write down anyone you would NOT want to help make medical decisions for you.
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
6
What matters most in life? Quality of life diers for each person.
What is most important in your life? Check as many as you want.
Part
Make your own healthcare choices
(Living Will)
Answer the questions that matter most to you. For purposes of this form,
this will serve as your Living Will.
Some people prefer to make their own medical decisions. Some people prefer input from others
(family, friends, and medical providers) before they make a decision. And, some people prefer other
people make decisions for them.
Note: Medical providers cannot make decisions for you. They can only give information to help
with decision-making.
How do you prefer to make medical decisions?
I prefer to make medical decisions on my own without input from others.
I prefer to make medical decisions only after input from others.
I prefer to have other people make medical decisions for me.
If you want, you can write why you feel this way, and who you want input from.
Your family or friends
Your pets
Hobbies, such as gardening, hiking,
and cooking
Working or volunteering
Caring for yourself and being independent
Not being a burden on your family
Religion or spirituality
Your religion:
Something else:
What brings joy to your life? What are you most looking forward to in life?
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
7
What matters most for your medical care? This diers for each person.
For some people, the main goal is to be kept alive as long as possible, even if:
• They have to be kept alive on machines and are suering.
• They are too sick to talk to their family and friends.
For other people, the main goal is to focus on quality of life and being comfortable.
• These people would prefer a natural death, and not be kept alive on machines.
Other people are somewhere in between. What is important to you?
Your goals may dier today in your current health than at the end of life.
AT THE END OF LIFE
Check one choice to show how you would feel if you were so sick
that you may die soon:
I prefer to make medical decisions on my own without input from others.
I prefer to make medical decisions only after input from others.
If you want, you can write why you feel this way.
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
8
Quality of life diers for each person at the end of life. What would be most
important to you? Write down your choices so those who care for you will
not have to guess.
AT THE END OF LIFE
Some people are willing to live through a lot for a chance of living longer. Other people know
that certain things would be very hard on their quality of life.
• Those things may make them want to focus on comfort rather than trying to live
as long as possible.
At the end of life, which of these things would be very hard on your quality of life?
Check as many as you want:
Being in a coma and not able to wake up or talk to my family and friends
Not being able to live without being hooked up to machines
Not being able to think for myself, such as severe dementia
Not being able to feed, bathe, or take care of myself
Not being able to live on my own, such as in a nursing home
Having constant, severe pain or discomfort
Something else:
OR, I am willing to live through all of these things for a chance of living longer.
If you want, you can write why you feel this way.
What experiences have you had with serious illness or with someone close to you who was very sick
or dying? If you want, you can write down what went well or did not go well.
If you were dying, where would you want to be?
At home In the hospital Either
What else would be important, such as food, music, pets, or people you want around you?
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
9
How do you balance quality of life with medical care?
Sometimes illness and the treatments used to try to help people live longer
can cause pain, side eects, and the inability to care for yourself.
Please read this whole page before making a choice.
AT THE END OF LIFE, some people are willing to live through a lot for a chance
of living longer. Other people know that certain things would be very hard
on their quality of life.
Life support treatment can be CPR, a breathing machine, feeding tubes, dialysis, or transfusions.
Check the one choice you most agree with.
If you were so sick that you may die soon, what would you prefer?
Try all life support treatments that my doctors think might help. I want to stay on life
support treatments even if there is little hope of getting better or living a life I value.
Do a trial of life support treatments that my doctors think might help. But, I DO NOT
want to stay on life support treatments if the treatments do not work and there is little
hope of getting better or living a life I value.
I do not want life support treatments, and I want to focus on being comfortable.
I prefer to have a natural death.
I want my medical decision-maker to decide for me.
If you are pregnant and become unable to make decisions: Pennsylvania law may require your
doctor to give you life support treatments even if you have an advance directive.
What else should your medical providers and decision-maker know about this choice?
Or, why did you choose this option?
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
10
Your decision-maker may be asked about organ donation and autopsy
after you die. Please tell us your wishes.
ORGAN DONATION
Some people decide to donate their organs
or body parts. What do you prefer?
I want to donate my organs or body parts.
Which organ or body part do you want to donate?
Liver, kidneys, heart, lung, etc.:
Other body parts: face, limbs, facial tissue, other vascularized allografts (this requires
separate consent that is not supplied here; checking this box is not sucient legal consent)
Only:
I do not want to donate my organs or body parts.
What else should your medical providers and medical decision-maker know about donating
your organs or body parts?
AUTOPSY
An autopsy can be done after death to find out why someone died.
It is done by surgery. It can take a few days.
I want an autopsy.
I do not want an autopsy.
I only want an autopsy if there are questions about my death.
I want my medical decision-maker to decide for me.
Pennsylvania law may override your choice.
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
11
What else would you like to share about you and your medical choices?
CONSIDER how much of your medical information you wish to know:
Some people may want to know all of their medical information. Other people may not.
If you had a serious illness, would you want your doctors and medical
providers to tell you how sick you are?
Yes, I would want to know this information.
No, I would not want to know. Please talk with my decision-maker instead.
Talk to your medical providers so they know whether you want to get
information about your condition(s), diagnosis, and/or prognosis.
FUNERAL OR BURIAL WISHES
What should your medical providers and decision-maker know about how you
want your body to be treated after you die, and your funeral or burial wishes?
Do you have religious or spiritual wishes?
Do you have funeral or burial wishes?
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
12
Part
I want this person to make my medical decisions if I am not able to make my own:
(This must be the same person listed on page 5 of this form.)
First name Last name
Phone #1 Phone #2 Relationship
Address City State ZIP code
If the first person cannot do it, then I want this person to make my medical decisions:
First name Last name
Phone #1 Phone #2 Relationship
Address City State ZIP code
By signing this form, you allow your medical decision-maker to:
• Agree to, refuse, or withdraw any life support or medical treatment if you are not able
to speak for yourself.
• Decide what happens to your body after you die, such as funeral plans and organ donation.
If there are decisions you do not want them to make, write them here:
When can my medical decision-maker make decisions for me?
ONLY after I am not able to make my own decisions
NOW, right after I sign this form
Choose your medical decision-maker:
Write the name of your medical decision-maker (Healthcare Power of Attorney).
Sign the form
(Remember to complete Parts 1 and 2)
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
13
Before this form can be used, you must:
Witnesses
• Sign this form if you are 18 years of age or older.
• Have two witnesses who can watch you sign this form.
Sign your name and write the date:
Sign your name Today’s date
Print your first name Print your last name Date of birth
Address City State ZIP code
Before this form can be used, you must have two (2) witnesses sign the form.
Your witnesses must:
• Be 18 years of age or older.
• See you sign the form.
Your witnesses cannot:
• Be the person that signed this form for you.
• Be your medical decision-maker.
• Be your healthcare provider (your doctor, nurse, physician’s assistant, etc.).
It is recommended that your witnesses NOT:
• Work for your healthcare provider; or
• Work at the place where you live.
Witnesses need to sign their names on page 14.
Your name
Date of birth (MM/DD/YYYY)
Pennsylvania Advance Healthcare Directive
14
Have your witnesses sign their names and write the date.
By signing, I promise that signed this form while I watched.
They were thinking clearly and were not forced to sign it. I also promise that:
• I am 18 years of age or older.
• I am not a medical decision-maker for this person.
Witness
Sign your name Date
Print your first name Print your last name
Address City State ZIP code
Witness
Sign your name Date
Print your first name Print your last name
Address City State ZIP code
The person named on page 13
Notarization (Optional)
On this day of , 20 , before me personally appeared the aforesaid declarant
and principal, to me known to be the person described in and who executed the foregoing instrument
and acknowledged that he/she executed the same as his/her free act and deed. IN WITNESS WHEREOF,
I have hereunto set my hand and axed my ocial seal in the County of ,
State of the day and year first above written.
You are now done with this form.
Share this form with your family, friends, and medical providers.
Talk with them about your medical wishes.
Copyright © The Regents of the University of California, 2016. All rights reserved. Revised 2021. No one may reproduce this form by any means
for commercial purposes or add to or modify this form in any way without a licensing agreement and written permission from the Regents.
The Regents makes no warranties about this form. To learn more about this and the terms of use, go to www.prepareforyourcare.org.
Adapted with permission from the PREPARE for Your Care PA Advance Directive in English.
Copyright (c) 2012-2022 The Regents of the University of California. All rights reserved.
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