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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.

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.

Advance directives do not expire. An advance directive remains in effect until you change it. If you complete a new advance directive, it invalidates the previous one. You should review your advance directives periodically to ensure that they still reflect your wishes.

In most states, advance directives must be signed in the presence of two people who then sign the document as witnesses.Many states also prohibit health care practitioners, including the person's doctor, attending nurses, and other professionals involved in health care, from being witnesses.

Some states combine a declaration and a durable power of attorney into a single form, called an "advance health care directive."You may change or revoke your health care directive at any time. If someone disputes the validity of your health care directive, it may be challenged in court.

Advance directives do not expire. An advance directive remains in effect until you change it. If you complete a new advance directive, it invalidates the previous one. You should review your advance directives periodically to ensure that they still reflect your wishes.

Checklist: Creating An Advance Health Care Directive200bMedical devices to aid breathing (ventilator)Medical devices to aid nutrition and hydration (tube feeding)Blood transfusions.Dialysis.Antibiotics.Surgery.

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.

Validity of advance care directives it is consistent with the person's preferences. the person has expressed these preferences previously. the person appoints a substitute decision-maker who has a clear understanding of their preferences and is willing to be a strong advocate for them. it is a written document.

An advance directive, alone, may not be sufficient to stop all forms of life-saving treatment.You retain the right to override the decisions or your representative, change the terms of your living will or POA, or completely revoke an advance directive.