Step by Step Guide

Completing an Advance Directive

This section helps you navigate through an Advance Directive and offers some basic education as to what choices are available on each page and section. Feel free to use the Contact Form to ask any questions you may have or if you would like personal help working through the document.

Step 1: Download the Advance Directive document

To start, you will want to print out a copy of the Advance Directive for Healthcare here and then work through the steps below to complete each section of the document.

Step 2: Complete the Advance Directive document
Page 1: Cover Sheet
Advance Care Planning Document - Page 1
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This is the Cover Sheet. The MOST important part – PRINT Your Name and Date of Birth

Page 2: Explanation & Directions
Advance Care Planning Document - Page 2
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This is an Explanation and Directions page. There is no information for you to fill out here. However, this page does provide good directions to:

  • the parts of the document,
  • what to do after you complete it,
  • what to do with your old Advance Directive,
  • when you should consider updating your documents, and
  • contact info to reach out to if you need help

Page 3: Naming Your Healthcare Agent

This is Part OneNaming Your Healthcare Agent. This section is for naming who would speak for you if you couldn’t speak for yourself or if you choose not to speak for yourself

Advance Care Planning Document - Page 3
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  • The top of the page highlights the characteristics important for who you choose as a healthcare agent or who you cannot choose to be your agent. 
  • One of the most important characteristics: choosing a person who will follow your instructions even if he/she may not agree with them. We so often see families disagree on treatment options – you want to be sure that whoever you choose will be a good advocate and follow your wishes.
  • Naming your Healthcare Agent: You name your first choice for your Healthcare Agent.  It is one person, not multiple people. Then if that person cannot be reached, you should have a 2nd choice named and then if that person cannot be reached, then you should have a 3rd choice named.
  • Some people choose to ONLY complete Part One and do not choose to complete Part Two. They have a conversation with those they have named and feel comfortable that they will be able to advocate for the treatment preferences you would want.
  • Others choose NOT to complete Part One. In that case, there is a box at the bottom of the page to notify healthcare teams that you are not naming a person to speak for you, instead you are only going to complete Part Two to name treatment choices you want followed.
Page 4: Authority Given to Your Healthcare Agent
Advance Care Planning Document - Page 4
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This section highlights what power your Healthcare Agent has in making decisions for you.

It also has Georgia statutory language around authority you may NOT want your Healthcare Agent to have after your death – in which case you would initial next to those powers you do not want your agent to have. 

Pages 5 & 6: Naming Treatment Preferences

This section allows you to name treatment you do or do not want.

If you have named a Healthcare Agent in Part One, then these choices only become a guide. However, if you did not name a Healthcare Agent then these choices direct your care.

This section is only activated when you are unable to communicate from a terminal illness or a state of permanent unconsciousness documented by two physicians.

Being kept comfortable and clean are overriding choices that all patients receive. It is NOT a choice that has to be made.

These choices refer to life sustaining treatments.

Often the difference in Choice 1 and Choice 2 is the difference in choices around an illness that worsens over time such as cancer or dementia versus a sudden event such as a stroke or car accident. Sometimes your choices may be different in different circumstances.

Advance Care Planning Document - Page 5
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Advance Care Planning Document - Page 6
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  • Choice 1: If you have a terminal illness, then your choices are a) extend your life as long as possible with all treatment options or  b) allow your natural death with only comfort measures or i), ii) and iii) allow you to choose certain treatments you WOULD want even in allowing natural death. 
  • Choice 2: If you have a state of permanent unconsciousness, then your choices for a), b) and i), ii), and iii) are all the same as above.

    There are extra blank lines below each choice to further identify specifics you would want followed such as timeframe for treatments or more specific treatments you would not want (i.e., antibiotics).
  • Choice 3: Do you want CPR (cardiopulmonary resuscitation)? There are 3 choices that allow you to choose the one that fits your desired treatment.

    This is NOT a Code Status for DNR. If you become an inpatient in a hospital, then your wishes for CPR or no CPR are turned into a physician order for your code status.

    If you wish to have your choice in CPR be a code status when you are outside of the hospital, then you would need to complete a POLST (Physician Order for Life Sustaining Treatment) with your physician.
  • Choice 4: Your choice in case of pregnancy. Under GA law, your treatment preferences will not be followed in the case of a viable fetus.  However, by initialing this choice your treatment preferences will be followed if you are pregnant, but the fetus is not viable.
  • Choices for Comfort Measures: This is such an IMPORTANT part to fill out for your family! This is where you get to name people you would want around, music or reading you would like, and personalize other things that would allow your family to provide you comfort.
  • Choices for Preferences After Death: This is where you can share with your family your wishes for funeral arrangements. Be specific. Share those things that will help them give you the goodbye you would want.
Page 7: Making Your Advance Directive Legal
Advance Care Planning Document - Page 7
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This is the page for signatures to make this document legally binding.

You must be of sound mind to sign and date this document. You do NOT need to have this document notarized.

You do need to have two witnesses. The top of the page describes who are eligible to witness.

The two witness need to sign in front of you, though you do not have to sign in front of them. You only have to acknowledge your signature.

Step 3: Make Your Advance Directive Known

Once you have completed your Advance Directive for Healthcare (AD), any previous versions will automatically be revoked so destroy old copies. Copies are as good as the original so make copies of your AD. You may want to give those to the people you have named as your healthcare agent (and backups) and your hospital of choice through any registration desk to be uploaded to your electronic medical record. If you have not provided it to your hospital, bring a copy if you ever come to the hospital for a procedure, because you will be asked if you have an AD by our registration desk.

MyChart is another option to scan your AD from your home computer to your electronic medical record. And of course keeping a copy in your Plan in a Can ensures that it always comes with you in case you had to call 911 in an emergency.