Free Health Care Directive

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Do you live in Ohio?

Yes
No

Your Living Will and Medical Power of Attorney will be tailored to the laws of Ohio.



Who is this Health Care Directive being created for?




(e.g. Street, City, State, Zip Code)



Do you want to name a agent to make health
care decisions for you?

Yes
No


Where two or more agent have authority they
will make decisions:

Jointly
Successively


Where two or more agent are acting jointly
they will make decisions by:

Majority
Unanimous vote



Do you give your agent full authority to make all personal decisions your behalf?

Yes
No

Describe the limited areas of authority
that you wish to give to your agent:




Do you want to receive life support? Life support means any medical procedure, treatment, or intervention, which sustains, restores, or replaces a spontaneous vital function.

✔

✔

✔


Do you want to receive tube feeding? Tube feeding means the provision of nutrients or fluids by a tube inserted in vein, under the skin in the subcutaneous tissues, or in the stomach.

✔

✔

✔


Do you want to receive CPR? CPR - Cardiopulmonary Resuscitation - is the restoration of heartbeat and breathing following cardiac arrest, using artificial respiration and external cardiac massage.

✔

✔

✔


If you develop another illness, do you want that illness
to be treated? An Intervening Illness is a separate illness (e.g. pneumonia) that may be life threatening.

✔

✔

✔


Do you want to donate your organs and tissues
upon death?

Yes
Do not specify


Do you wish to designate the individuals who will
determine your incapacity?

Yes
No


Do you want your agent to sign and acknowledge
your Advance Directive? In Please select a governing law. it is not required that your Agent sign your Advance Directive. Your Agent's signature does not create a binding obligation and your Agent could never be forced to make a decision concerning your personal care that they are not comfortable with. However it is important that your Agent know that you have designated them as Agent and that your Agent be familiar with the contents of your Advance Directive as well as their obligations under the Please select a governing law. Please select a governing law.

Yes
No


Do you wish for anyone to be notified in case you
become incapacitated?

Yes
No

When it is determined that you are no longer capable to make decisions on your own behalf, a written copy of that declaration will be sent to you and to your Agent. If there are other individuals that you wish to be notified then list them here.


Do you wish to include a statement of your basic
values and beliefs?

Yes
No


Do you want to include additional instructions? 

Yes
No


Legal Consultation

British Columbia has special requirements concerning
Representation Agreements. In almost all circumstances
you will need to review your Representation Agreement
with a qualified lawyer and obtain a Consultation Certificate
to ensure that all terms of your Representation Agreement
are acceptable.


Legal Consultation

The Yukon has special requirements concerning an
Advance Directive. If you authorize your Proxy to give
consent to certain therapies or procedures then you will
need to review your Advance Directive with a qualified
lawyer and obtain a Certificate of Legal Consultation.


What will your Living Will cover?

My health treatment choices
Appoint health care agent
Both

You can set out which health care treatments that you want or don't want in various situations such as terminal condition and permanently unconscious.

You can also appoint a health care agent that will be able to make choices for you regarding various health care treatments.


When do you want to receive artificially administered
food and water?

✔

✔

✔


When do you want to receive artificial life support?

✔

✔

✔


When do you want to receive comfort care?

✔

✔

✔


When do you want to receive artificially administered
food and water?

✔

✔


When do you want to receive life sustaining treatment?

✔

✔


When do you want to receive artificially administered
food and water?

✔

✔


When do you want to receive artificial life support?

✔

✔


When do you want to receive comfort care?

✔

✔


If I have a terminal condition or am in a persistent
vegetative state I want:

(Please choose one)

✔

✔

✔


If I have a terminal condition, or am in a permanent coma, or a persistent vegetative state then:

(Please choose one)

✔

✔

✔


If I have a terminal condition, or am in a permanent coma, or a persistent vegetative state then:

(Please choose one)

✔

✔


If I have a terminal condition, or am in a permanent coma, or a persistent vegetative state then:

(Please choose one)

✔

✔


If I am in a terminal and irreversible condition:

✔

✔

✔


When do you want to receive artificially provided
nutrition (food)?

✔

✔


When do you want to receive artificially provided
hydration (water)?

✔

✔


When do you want to receive life prolonging treatment?

✔

✔


When do you want to receive artificially provided
food and water?

✔

✔


When do you want to receive life sustaining treatment?

✔

✔


When do you want to receive CPR?

✔

✔


When do you want to receive comfort care?

✔

✔


Do you want this Advance Directive to last for life?

Yes
No


When do you want to receive artificially administered
food and water?

✔

✔


When do you want to receive life sustaining treatment?

✔

✔


When do you want to receive comfort care?

✔

✔


When do you want to receive artificially administered
food and water?

✔

✔


When do you want to receive artificially administered
food and water?

✔

✔


When do you want to receive artificial life support?

✔

✔


When do you want to receive comfort care?

✔

✔


Do you want to add any additional instructions?

Yes
No
No additional instructions are needed for most people.


Are you pregnant now or may become pregnant in
the future?

Yes
No


Who will make health care decisions for you as your
health care agent?


(e.g. Street, City, State, Zip Code)


(e.g. brother, wife, friend, etc.)




Would you like to name an alternate health care agent in
case your first choice is unable/unwilling to make
decisions for you?

Yes
No


Do you want to be an organ or tissue donor after
you die?

Yes
No


When do you want your agent to discontinue your
artificial life support?


✔

✔



If you become terminally ill do you want your agent to
tell your health care providers to discontinue artificial
feeding?

Yes
No


I want my health care agent to

Only follow listed instructions
Follow instructions and make decisions not covered
Make final decision even if different from instructions


I want my health care agent to


✔

✔



Do you want to add any additional instructions for your
health care agent?

Yes
No
No additional instructions are needed for most people.


Do you want to add any additional instructions for your
health care agent?

Yes
No
No additional instructions are needed for most people.



Do you want to add any additional provisions
or limitations for your health care agent?

Yes
No
No additional instructions are needed for most people.


Do you want to add any additional provisions
or limitations for your health care agent?

Yes
No
No additional instructions are needed for most people.



Will you get someone to translate this document
for you?

(If English is not your first language)

Yes
No


Do you want your doctor to talk to anyone about ending life sustaining treatment/artificially administered food and water when the time comes?

Yes
No


This document will be signed in front of

Notary public only
Two witnesses


Are you a patient in a skilled nursing facility?

Yes
No



Do you want to give additional directions to your
health care agent?

Yes
No

In your final document you will authorize your health care representative to make decisions regarding life support and tube feeding. No additional instructions are needed for most people.



Do you want to give additional instructions to your health care
agent?

Yes
No
No additional instructions are needed for most people.


Do you want your health care agent's authority to last
indefinitely?

Yes
No


Do you want your health care agent to have the power
to cancel your Living Will?

Yes
No


Do you want your health care agent to have the power
enforce your Living Will?

Yes
No


What treatment do you want if you are in a terminal condition
or are permanently unconscious?


✔

✔

✔



Do you authorize your health care agent to donate your
tissue or organs for transplantation after you die?

Yes
No


When I die my health care agent will:

inform my family of my desire to be an organ donor
inform my family that I do NOT wish to be an organ donor
make no decisions regarding organ donation



When do you authorize your health care agent to withdraw you from artificially administered food
and water?

✔

✔


When do you authorize your health care agent to withdraw you from life-sustaining treatment?

✔

✔


When do you authorize your health care agent to withdraw you from comfort care?

✔

✔


Do you want to give your health care agent the authority to decide whether to donate parts of your body when
you die?

Yes
No


Do you want to donate all or part of your body for research, education or transplantation after you die?

Yes
No

✔

✔

✔

✔

✔

✔

✔


          


✔

✔

✔

✔

✔

✔

✔

Do you want your life prolonged to the greatest extent possible, without regard to your condition, the chances for recovery or long-term survival, or the cost of the procedures?

Yes
No


Do you want treatment to be provided or continued if the burdens of the treatment outweigh the expected benefits?

Yes
No


Do you want your health care agent to be able to see
your medical records?

Yes
No


Health Care Treatment Preferences

In your final document you will be asked to select
(by initialling) your health care treatment preferences.

READ YOUR FINAL DOCUMENT CAREFULLY. MAKE SURE
YOU HAVE IDENTIFIED ALL THE HEALTH CARE TREATMENT
PREFERENCES THAT ARE APPROPRIATE FOR YOU.



Do you want to set an expiration date for your
power of attorney for health care?

Yes
No
(A durable power of attorney for health care does not need to have
an expiration date under Ohio law. However, if you want to specify
an expiration date you may do so.)


Do you want to give your health care agent the authority
to admit you to a nursing home?

Yes
No


Do you want to give your health care agent the authority
to admit you to a community-based residential facility?

Yes
No


Do you authorize your health care agent to withhold or
withdraw your feeding tubes?

Yes
No


Do you want to add any additional instructions for your
health care agent?

Yes
No
No additional instructions are needed for most people.


Do you wish to donate your organs or make anatomical
gifts after you die?

Yes
No




Where will you keep this document after it has been
signed and witnessed?

(e.g. Street, City, State, Zip Code)


Do you want your health care agent's authority to last
indefinitely?

Yes
No


Unsure




BackContinueSkip this step for now

What Is a Living Will?

A Living Will, which is sometimes called a Health Care Directive or Medical Power of Attorney depending on the state, is a document that outlines your health care treatment preferences. A Living Will comes into effect in the event that you can't consent to medical treatment for yourself.

Depending on your state laws, there are a few things to consider about what documents may make up a Living Will:

  • Some states use the terms Living Will and Health Care Directive interchangeably. Other states may use one term, but not the other.
  • Some states recognize a Health Care Directive as being comprised of both a Living Will and Medical Power of Attorney, and some states recognize these as separate documents.
  • Some states have different requirements as to what documents make up a Health Care Directive or a Living Will.

LawDepot's Living Will is customized based on the state you select.

Person thinking
Person wanting details

What Is a Medical Power of Attorney?

A Medical Power of Attorney is generally used to assign someone you trust to make medical treatment decisions on your behalf. This document may be used on its own or in combination with other documents, depending on your needs and your state laws.

A Medical Power of Attorney can also be known as a:

  • Health Care Proxy
  • Power of Attorney for Health Care
  • Medical POA

What Is a Health Care Directive?

A Health Care Directive lets you plan out your medical treatment wishes in advance so if you become incapacitated (unable to make rational decisions yourself) your caregivers, family, and medical professionals will be aware of your preferences.

A Health Care Directive can also be known as a/an:

  • Advance Directive
  • Advance Care Directive
  • Medical Directive
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Person doing online research

What Decisions Can I Make with a Health Care Directive?

A Health Care Directive allows you to list your treatment preferences for a variety of medical situations. Keep in mind that every state has its own laws regarding what procedures or wishes professionals are permitted to carry out.

A Health Care Directive will generally allow you to list preferences with regards to:

  • Whether you want to receive medically administered food and water when you are, for example, terminally ill or permanently unconscious
  • Whether you want to receive life-sustaining treatment when you are, for example, terminally ill or permanently unconscious
  • Whether you want to appoint a health care agent to make medical decisions for you

Need More Health Care Planning Documents?

These forms may also be useful for planning your health care wishes:

  • Create a Power of Attorney to appoint an agent to make important decisions about property and financial matters on your behalf if you are unable to make them yourself.
  • A Last Will and Testament allows you to decide how your property and assets will be distributed after you pass away.
  • Create a Child Medical Consent to authorize a trusted person to make medical decisions for your child when they are being cared for by temporary guardians.
START MY HEALTH CARE DIRECTIVE
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