Health Care Advance Directives

The Patient’s Right to Decide

Every competent adult has the right to make decisions concerning his or her own health, including the
right to choose or refuse medical treatment.

When a person becomes unable to make decisions due to a physical or mental change, such as being in a
coma or developing dementia (like Alzheimer’s disease), they are considered incapacitated. To make
sure that an incapacitated person’s decisions about health care will still be respected, the Florida
legislature enacted legislation pertaining to health care advance directives (Chapter 765, Florida Statutes).
The law recognizes the right of a competent adult to make an advance directive instructing his or her
physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to
make treatment decisions if the person becomes unable to make his or her own decisions; and/or to
indicate the desire to make an anatomical donation after death.

By law hospitals, nursing homes, home health agencies, hospices, and health maintenance organizations
(HMOs) are required to provide their patients with written information, such as this pamphlet, concerning
health care advance directives. The state rules that require this include 58A-2.0232, 59A-3.254, 59A-
4.106, 59A-8.0245, and 59A-12.013, Florida Administrative Code.

Questions About Health Care Advance Directives

What is an advance directive?
It is a written or oral statement about how you want medical decisions made should you not be able to
make them yourself and/or it can express your wish to make an anatomical donation after death. Some
people make advance directives when they are diagnosed with a life-threatening illness. Others put their
wishes into writing while they are healthy, often as part of their estate planning.

Three types of advance directives are:

• A Living Will
• A Health Care Surrogate Designation
• An Anatomical Donation

You might choose to complete one, two, or all three of these forms. This pamphlet provides information
to help you decide what will best serve your needs.

What is a living will?

It is a written or oral statement of the kind of medical care you want or do not want if you become unable
to make your own decisions. It is called a living will because it takes effect while you are still living.
You may wish to speak to your health care provider or attorney to be certain you have completed the
living will in a way that your wishes will be understood.
What is a health care surrogate designation?
It is a document naming another person as your representative to make medical decisions for you if you
are unable to make them yourself. You can include instructions about any treatment you want or do not
want, similar to a living will. You can also designate an alternate surrogate.

Which is best?
Depending on your individual needs you may wish to complete any one or a combination of the three
types of advance directives.

What is an anatomical donation?

It is a document that indicates your wish to donate, at death, all or part of your body. This can be an
organ and tissue donation to persons in need, or donation of your body for training of health care workers.
You can indicate your choice to be an organ donor by designating it on your driver’s license or state
identification card (at your nearest driver’s license office), signing a uniform donor form (seen elsewhere
in this pamphlet), or expressing your wish in a living will.

Am I required to have an advance directive under Florida law?

No, there is no legal requirement to complete an advance directive. However, if you have not made an
advance directive, decisions about your health care or an anatomical donation may be made for you by a
court-appointed guardian, your wife or husband, your adult child, your parent, your adult sibling, an adult
relative, or a close friend.

The person making decisions for you may or may not be aware of your wishes. When you make an
advance directive, and discuss it with the significant people in your life, it will better assure that your
wishes will be carried out the way you want.

Must an attorney prepare the advance directive?

No, the procedures are simple and do not require an attorney, though you may choose to consult one.
However, an advance directive, whether it is a written document or an oral statement, needs to be
witnessed by two individuals. At least one of the witnesses cannot be a spouse or a blood relative.

Where can I find advance directive forms?

Florida law provides a sample of each of the following forms: a living will, a health care surrogate, and
an anatomical donation. Elsewhere in this pamphlet we have included sample forms as well as resources
where you can find more information and other types of advance directive forms.

Can I change my mind after I write an advance directive?

Yes, you may change or cancel an advance directive at any time. Any changes should be written, signed
and dated. However, you can also change an advance directive by oral statement; physical destruction of
the advance directive; or by writing a new advance directive.

If your driver’s license or state identification card indicates you are an organ donor, but you no longer
want this designation, contact the nearest driver’s license office to cancel the donor designation and a new
license or card will be issued to you.

What if I have filled out an advance directive in another state and need treatment in Florida?
An advance directive completed in another state, as described in that state's law, can be honored in
Florida.
What should I do with my advance directive if I choose to have one?
• If you designate a health care surrogate and an alternate surrogate be sure to ask them if they agree to
take this responsibility, discuss how you would like matters handled, and give them a copy of the
document.
• Make sure that your health care provider, attorney, and the significant persons in your life know that
you have an advance directive and where it is located. You also may want to give them a copy.
• Set up a file where you can keep a copy of your advance directive (and other important paperwork).
Some people keep original papers in a bank safety deposit box. If you do, you may want to keep
copies at your house or information concerning the location of your safety deposit box.
• Keep a card or note in your purse or wallet that states that you have an advance directive and where it
is located.
• If you change your advance directive, make sure your health care provider, attorney and the
significant persons in your life have the latest copy.

If you have questions about your advance directive you may want to discuss these with your health care
provider, attorney, or the significant persons in your life.

More Information On Health Care Advance Directives

Before making a decision about advance directives you might want to consider additional options and
other sources of information, including the following:

• As an alternative to a health care surrogate, or in addition to, you might want to designate a durable
power of attorney. Through a written document you can name another person to act on your behalf. It
is similar to a health care surrogate, but the person can be designated to perform a variety of activities
(financial, legal, medical, etc.). You can consult an attorney for further information or read Chapter
709, Florida Statutes.

If you choose someone as your durable power of attorney be sure to ask the person if he or she will
agree to take this responsibility, discuss how you would like matters handled, and give the person a
copy of the document.

• If you are terminally ill (or if you have a loved one who is in a persistent vegetative state) you may
want to consider having a pre-hospital Do Not Resuscitate Order (DNRO). A DNRO identifies
people who do not wish to be resuscitated from respiratory or cardiac arrest. The pre-hospital DNRO
is a specific yellow form available from the Florida Department of Health (DOH). Your attorney,
health care provider, or an ambulance service may also have copies available for your use. You, or
your legal representative, and your physician sign the DNRO form. More information is available on
the DOH website, www.doh.state.fl.us or www.MyFlorida.com (type DNRO in these website search
engines) or call (850) 245-4440.

When you are admitted to a hospital the pre-hospital DNRO may be used during your hospital stay or
the hospital may have its own form and procedure for documenting a Do Not Resuscitate Order.

• If a person chooses to donate, after death, his or her body for medical training and research the
donation will be coordinated by the Anatomical Board of the State of Florida. You, or your
survivors, must arrange with a local funeral home, and pay, for a preliminary embalming and
transportation of the body to the Anatomical Board located in Gainesville, Florida. After being used
for medical education or research, the body will ordinarily be cremated. The cremains will be
returned to the loved ones, if requested at the time of donation, or the Anatomical Board will spread
 the cremains over the Gulf of Mexico. For further information contact the Anatomical Board of the
State of Florida at (800) 628-2594 or www.med.ufl.edu/anatbd.

• If you would like to read more about organ and tissue donation to persons in need you can view the
Agency for Health Care Administration’s website http://ahca.MyFlorida.com (Click on “Site Map”
then scroll down to “Organ Donors”) or the federal government site www.OrganDonor.gov. If you
have further questions you may want to talk with your health care provider.

• Various organizations also make advance directive forms available. One such document is “Five
Wishes” that includes a living will and a health care surrogate designation. “Five Wishes” gives you
the opportunity to specify if you want tube feeding, assistance with breathing, pain medication, and
other details that might bring you comfort such as what kind of music you might like to hear, among
other things. You can find out more at:

Aging with Dignity

www.AgingWithDignity.org
(888) 594-7437

Other resources include:

American Association of Retired Persons (AARP)

www.aarp.org
(Type “advance directives” in the website’s search engine)

Your local hospital, nursing home, hospice, home health agency, and your attorney or health care
provider may be able to assist you with forms or further information.

Brochure: End of Life Issues

www.FloridaHealthStat.com (Under Reports and Guides)
(888) 419-3456
 Living Will
Declaration made this _____ day of ________________, 2____, I, ____________________________,
willfully and voluntarily make known my desire that my dying not be artificially prolonged under the
circumstances set forth below, and I do hereby declare that, if at any time I am mentally or physically
incapacitated and

_____(initial) I have a terminal condition,

or _____(initial) I have an end-stage condition,
or _____(initial) I am in a persistent vegetative state,

and if my attending or treating physician and another consulting physician have determined that there is
no reasonable medical probability of my recovery from such condition, I direct that life-prolonging
procedures be withheld or withdrawn when the application of such procedures would serve only to
prolong artificially the process of dying, and that I be permitted to die naturally with only the
administration of medication or the performance of any medical procedure deemed necessary to provide
me with comfort care or to alleviate pain.

I do ___, I do not ___ desire that nutrition and hydration (food and water) be withheld or withdrawn when
the application of such procedures would serve only to prolong artificially the process of dying.

It is my intention that this declaration be honored by my family and physician as the final expression of
my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event I have been determined to be unable to provide express and informed consent regarding the
withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my
surrogate to carry out the provisions of this declaration:

Name ________________________________________________________
Street Address _________________________________________________
City _______________________ State _____________ Phone ___________

I understand the full import of this declaration, and I am emotionally and mentally competent to make this
declaration.

Additional Instructions (optional): ______________________________________________________

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

(Signed) ___________________________________________________

Witness _____________________________ Witness _____________________________

Street Address ________________________ Street Address ________________________
City _____________________ State _______ City _____________________ State _______
Phone _________________ Phone ________________

At least one witness must not be a husband or wife or a blood relative of the principal.
Definitions for terms on the Living Will form:

“End-stage condition” means an irreversible condition that is caused by injury, disease, or illness
which has resulted in progressively severe and permanent deterioration, and which, to a
reasonable degree of medical probability, treatment of the condition would be ineffective.

“Persistent vegetative state” means a permanent and irreversible condition of unconsciousness in

which there is: The absence of voluntary action or cognitive behavior of any kind and an
inability to communicate or interact purposefully with the environment.

“Terminal condition” means a condition caused by injury, disease, or illness from which there is
no reasonable medical probability of recovery and which, without treatment, can be expected to
cause death.

These definitions come from section 765.101 of the Florida Statues. The Statutes can be found
in your local library or online at www.leg.state.fl.us.
 Designation of Health Care Surrogate
Name: ______________________________________________________

In the event that I have been determined to be incapacitated to provide informed consent for medical
treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care
decisions:

Name ________________________________________________________
Street Address _________________________________________________
City ________________________ State __________ Phone _____________
Phone: ______________

If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate
surrogate:

Name ________________________________________________________
Street Address _________________________________________________
City ________________________ State __________ Phone _____________

I fully understand that this designation will permit my designee to make health care decisions and to
provide, withhold, or withdraw consent on my behalf; or apply for public benefits to defray the cost of
health care; and to authorize my admission to or transfer from a health care facility.
Additional instructions (optional):
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

I further affirm that this designation is not being made as a condition of treatment or admission to a health
care facility. I will notify and send a copy of this document to the following persons other than my
surrogate, so they may know who my surrogate is.

Name ______________________________________________________
Name ______________________________________________________

Signed _____________________________________________________

Date _________________________

Witnesses 1. ________________________________________

2. ________________________________________

At least one witness must not be a husband or wife or a blood relative of the principal.
 Uniform Donor Form
The undersigned hereby makes this anatomical gift, if medically acceptable, to take effect on death. The
words and marks below indicate my desires:

I give:

(a) _____ any needed organs or parts

(b) _____ only the following organs or parts for the purpose of transplantation, therapy, medical
research, or education:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

(c) _____ my body for anatomical study if needed. Limitations or special wishes, if any:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Signed by the donor and the following witnesses in the presence of each other:

Donor’s Signature ___________________________________ Donor’s Date of Birth _____________

Date Signed ______________ City and State _____________________________________________

Witness _____________________________ Witness _____________________________

Street Address ________________________ Street Address ________________________
City _____________________ State ______ City _____________________ State ______

You can use this form to indicate your choice to be an organ donor. Or you can designate it on your
driver’s license or state identification card (at your nearest driver’s license office).
The card below may be used as a convenient method to inform others of your health care advance
directives. Complete the card and cut it out. Place in your wallet or purse. You can also make copies
and place another one on your refrigerator, in your car glove compartment, or other easy to find place.

Health Care Advance Directives

I, ___________________________________
have created the following Advance Directives:

___ Living Will

___ Health Care Surrogate Designation

___ Anatomical Donation

___ Other (specify) _____________________

----------------------- FOLD ----------------------------

Contact:
Name _____________________________

Address _____________________________
_____________________________
_____________________________

Phone _____________________________

Signature ____________________ Date _____

Produced and distributed by the Florida Agency for Health Care Administration. This publication can be
copied for public use or call our toll-free number 1-888-419-3456 for additional copies. To view or print
other publications from the Agency for Health Care Administration please visit
www.FloridaHealthStat.com.

SCHS-4-2006