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To be valid, an advance directive must be signed by you in the presence of two witnesses, who will also sign. The person you name as a health care agent may not also be a witness. Some states also require the advance directive to be notarized.

The primary outcome is completion of four key ACP behaviours: identification of a surrogate decision maker, communication about goals, completing advance directives and ensuring documents are in the medical record.

Creating advance directives Advance directives need to be in writing. Each state has different forms and requirements for creating legal documents. Depending on where you live, a form may need to be signed by a witness or notarized. You can ask a lawyer to help you with the process, but it is generally not necessary.

An advance directive encompasses all legal orders which concern your wishes surrounding future medical care. The document will come into play in the case of severe medical situations in which you're not able to communicate your wishes or make decisions. These may include such conditions as a coma, stroke or dementia.

A DNR says that if your heart stops or you stop breathing, medical professionals should not attempt to revive you. This is very different from a health care proxy, which only goes into effect if you are unable to communicate your wishes for care.

Get the living will and medical power of attorney forms for your state, or use a universal form that has been approved by many states. Choose your health care agent. Fill out the forms, and have them witnessed as your state requires.

What to include in your advance directive: The name and contact information of your healthcare agent or proxy. Answers to specific questions about your preferences for care if you become unable to speak for yourself. The forms and questions asked vary a bit from state to state.