An advance directive should include your choices about life-sustaining treatments like CPR, mechanical ventilation, and tube feeding, along with the name of a trusted person authorized to make medical decisions on your behalf. Those two components, a living will and a healthcare power of attorney, form the core of the document. But a thorough directive goes further, covering comfort care preferences, organ donation wishes, and the specific health scenarios that trigger your instructions.
Life-Sustaining Treatment Preferences
The heart of any advance directive is a clear statement about which emergency and long-term treatments you want, which you don’t, and under what circumstances. These are the decisions that come up most often when someone can no longer speak for themselves.
CPR. Cardiopulmonary resuscitation involves forceful, repeated chest compressions and air pushed into the lungs. It may also include electric shocks and medication. The procedure can break ribs, and for people who are already critically ill or near the end of life, survival rates after CPR are low. Your directive should state whether you want CPR attempted if your heart stops.
Mechanical ventilation. A ventilator is a machine that breathes for you through a tube inserted down your throat. The process is uncomfortable enough that patients are typically sedated. If ventilation is needed long-term, doctors may place the tube directly into the windpipe through a small hole in the neck, which is more comfortable but affects the ability to speak. You can specify whether you’d want to be placed on a ventilator, and if so, whether there’s a point at which you’d want it removed.
Tube feeding and IV hydration. When you can’t eat or drink, nutrients and fluids can be delivered through an IV or a feeding tube inserted through the nose or surgically placed into the stomach. For someone recovering from a temporary illness, this can be genuinely helpful. But studies show that artificial nutrition near the end of life does not meaningfully extend it. Hand-assisted feeding is an alternative that carries fewer risks, especially for people with dementia. Your directive can specify if, when, and for how long you’d accept artificial nutrition.
Antibiotics and dialysis. These are easy to overlook, but both come up frequently in serious illness. You may want antibiotics for a treatable infection but not for one that arises when you’re already dying. Similarly, dialysis keeps the kidneys functioning but requires regular sessions that can be physically draining. Stating your preferences for each gives your care team clear guidance.
Your Healthcare Agent
A healthcare power of attorney (sometimes called a healthcare proxy or surrogate) names the person who will make medical decisions for you if you’re unable to make them yourself. This covers a wide range: routine medical appointments, surgery decisions, choosing a care facility if you can no longer live at home, arranging rehab or caregiver services, and, in serious situations, end-of-life choices like whether to continue or stop treatment.
The legal standard your agent is held to is acting in your best interest. That sounds simple, but it requires the person to genuinely understand your values and preferences. Choose someone who can handle difficult conversations, stay calm under pressure, and advocate for your wishes even when family members may disagree. A spouse or adult child is common, but what matters more is whether the person will reliably follow through. If no one in your life fits that role, a professional care manager can serve as agent in some states.
Whoever you choose, have detailed conversations with them. Don’t just hand them a document. Talk through specific scenarios: What if you had a stroke and couldn’t communicate but were otherwise stable? What if you developed advanced dementia? The more your agent knows about your thinking, the better they’ll represent you.
Comfort Care and Pain Management
An advance directive isn’t only about what you want to refuse. It’s also about what you want to receive. Comfort care (also called palliative care) focuses on managing pain and keeping you comfortable rather than curing a disease. You can specify preferences like wanting adequate pain medication even if it causes drowsiness, choosing to die at home rather than in a hospital, receiving ice chips or mouth care for comfort, or avoiding invasive tests when they won’t change the outcome. If you’d want hospice care in a terminal situation, say so explicitly. These instructions help your medical team and your agent understand what “comfortable” means to you.
Organ and Tissue Donation
Your advance directive is a good place to record whether you want to donate organs, tissues, or your whole body after death. While many people register as donors through their state’s registry or driver’s license, including your wishes in the directive ensures your healthcare agent and family know your decision. You can be specific: donate any needed organs, donate only certain organs, or donate your body to medical research. Clarifying this in writing prevents confusion or disagreement among family members at an already difficult time.
Conditions That Trigger Your Instructions
A strong directive doesn’t just list treatments. It specifies the health scenarios under which your preferences apply. The most common triggers include terminal illness with no reasonable chance of recovery, a persistent vegetative state, permanent unconsciousness (such as an irreversible coma), and severe, progressive cognitive decline like advanced dementia. You might feel differently about ventilation after a car accident (temporary, with good odds of recovery) versus ventilation during end-stage cancer. Spelling out these distinctions prevents your directive from being applied too broadly or too narrowly.
For conditions like dementia, where decline happens gradually, consider adding specific instructions sometimes called a “dementia rider.” This might address at what stage you’d want to stop certain treatments, whether you’d want to be moved to a memory care facility, or how aggressively you’d want infections treated as the disease progresses.
Personal Values and Preferences
Many advance directive forms include a section for your overall values and goals. This is more useful than it might sound. Medical situations are unpredictable, and your agent will inevitably face a decision your directive doesn’t specifically cover. A values statement gives them a framework. You might write that quality of life matters more to you than length of life, that being able to recognize family is important to you, or that your faith shapes your views on end-of-life care. You can mention religious practices you’d want honored, such as specific prayers, rituals, or the presence of a clergy member. Keep these broad and clear rather than writing detailed theological instructions, which can create confusion when medical teams try to interpret them.
Making the Document Legally Valid
Every state requires your signature on the directive (or the signature of someone you direct to sign if you physically can’t). Beyond that, requirements vary. Most states require two witnesses who watch you sign and confirm in writing that you appeared to be of sound mind and weren’t being pressured. Some states accept notarization instead of witnesses, and others require both.
Witness rules matter. Many states prohibit your spouse, close relatives, anyone who would inherit from you, your attending physician, or employees of your healthcare facility from serving as witnesses. The goal is to ensure no one with a financial or personal conflict of interest validates the document. Colorado, for example, bars physicians, health facility employees, anyone with a claim against your estate, and fellow patients from witnessing. Montana, on the other hand, doesn’t require witnesses or a notary for a healthcare power of attorney at all. Check your state’s specific rules, as failing to follow them can make the document unenforceable.
When to Update Your Directive
An advance directive isn’t a one-time task. Your preferences will likely shift as your health and life circumstances change. Research on the timing of directives shows a real tension: completing one too early, when you’re healthy, often results in preferences for aggressive care that may not match what you’d actually want as your health declines. Completing one too late, during a medical crisis, leads to rushed decisions that may also miss the mark. The solution is to revisit the document regularly.
Good moments to review and update include after a new diagnosis, after a major health event like a hospitalization, after the death of a spouse or the person named as your agent, after a divorce, and after a significant change in your overall health or independence. It’s not uncommon for people to change their care preferences as an illness progresses, so treat the directive as a living document rather than a final answer.
Who Should Get a Copy
A directive that no one can find when it’s needed is essentially useless. Give copies to your healthcare agent, your primary care doctor, any specialists managing a chronic condition, and close family members who might be present in an emergency. If you’re admitted to a hospital or move into a care facility, provide a copy for your medical record. Keep the original in a place that’s easy to access, not locked in a safe deposit box that your agent can’t reach quickly. Some states offer online registries where you can upload the document, and certain organizations provide wallet cards with information about where your directive is stored.