End-of-life Wishes: How to Document Your Preferences

If you're reading this, you're likely facing one of life's most stressful moments. You've just lost someone, you're helping a family member navigate care decisions, or you're trying to get your own affairs in order. You know roughly what you want, but the paperwork feels overwhelming.

You're not alone. Only about five percent of Americans have a formal advance care plan, and roughly half are unfamiliar with the concept entirely. Even among adults over 55, one-third lack any documented wishes. The gap between concern and action is wide—not because people don't care, but because clear, practical guidance is hard to find when you need it most.

This guide closes that gap. You'll learn what documentation you actually need, where to find free state-specific forms, and how to make sure your wishes are accessible when it matters.

What "End-of-Life Wishes" Usually Includes

Before diving into forms, let's map the territory. When people talk about documenting end-of-life wishes, they usually mean one or more of these items:

• Medical treatment preferences: CPR, ventilation, tube feeding, comfort-focused care
• Health care agent: The person you appoint to make decisions if you cannot
• POLST or MOLST: Clinician-signed medical orders for seriously ill patients
• Out-of-hospital DNR: Separate documents for emergency medical services
• Practical preferences: Funeral plans, organ donation, digital account access
• Financial and legal documents: Wills, trusts, financial power of attorney (distinct from medical documents)

Understanding these categories helps you grab the right paperwork instead of drowning in the wrong forms.

The Core Documents: What They Do and When They Apply

Advance Directives (The Foundation)

Think of advance directives as your baseline. Most adults should complete these, regardless of current health. They typically include two parts:

Living will: Details your preferences for life-sustaining treatments if you're unable to communicate. This might cover mechanical ventilation, artificial nutrition and hydration (tube feeding or IV fluids), dialysis, or comfort care only.

Durable power of attorney for health care: Names your health care agent (sometimes called a health care proxy or surrogate) who can make medical decisions on your behalf if you're incapacitated.

These documents only activate when you lack decision-making capacity. You must sign them while you're fully capable, and you can update them as long as you remain capable.

POLST/MOLST (For Serious Illness or Frailty)

A Portable Medical Order (called POLST in many states, MOLST in others) is not an advance directive. It's a clinician-signed medical order for people with serious illness or frailty—generally those for whom death within a year would not be surprising.

Key differences:

• It's a medical order, not just a preference document
• It's designed to be portable across care settings (home, hospital, nursing facility, EMS)
• It translates your advance directives into actionable medical orders

Availability and procedures vary by state. If you or your loved one has advanced illness, ask your clinician about POLST/MOLST forms and whether your state maintains a registry.

Out-of-Hospital DNR (Often Separate)

Many states require a separate out-of-hospital Do Not Resuscitate order for emergency medical services. Standard advance directives or living wills may not prevent EMS from performing CPR. Check your state's specific EMS procedures and forms, which often involve wallet cards, bracelets, or special orders that must be presented to first responders.

Other Documents People Ask About

Will versus living will: A will distributes property after death; a living will guides medical decisions before death. They're completely separate.

Financial power of attorney versus health care power of attorney: Financial POA handles money and property; health care POA handles medical decisions. Don't confuse them.

HIPAA authorization: Some state forms include privacy waivers that help your agent access medical information. This can prevent delays during emergencies.

Step-by-Step: How to Document Your Preferences

Step 1: Get the Right State Form(s)

There is no universal federal advance directive form. Each state governs its own validity requirements, and an out-of-state document may not be honored unless it's substantially similar to local law.

Use these reputable, free sources:

• CaringInfo (National Hospice and Palliative Care Organization): Free, state-specific advance directive PDFs for all U.S. states and territories at caringinfo.org
• AARP: Free printable state-by-state forms and guidance at aarp.org
• National Institute on Aging: Links to free tools and state resources at nia.nih.gov

If you spend significant time in more than one state, complete forms for each state. Print them, as many states require physical signatures.

Step 2: Choose a Health Care Agent and Backup

This is one of the most important decisions you'll make. Your agent should:

• Be willing to serve and able to advocate under pressure
• Understand your values and priorities, not just your medical preferences
• Be available and able to communicate with your medical team
• Handle family conflict if disagreements arise

Choose at least one backup in case your primary choice is unavailable. Have a direct conversation with each person about what you value, not just which boxes you checked.

Step 3: Clarify Your Values

Forms ask about specific treatments, but your answers should reflect deeper values. Consider:

• What outcomes would be unacceptable? (e.g., permanent inability to recognize loved ones)
• How do you balance length of life versus quality of life?
• Are there spiritual, cultural, or religious practices that should guide care?
• Where would you prefer to receive care if possible? (home, hospice, hospital)

Writing a short values statement helps your agent interpret your preferences when medical situations don't match the form's exact scenarios.

Step 4: Make Specific Medical Choices

State forms vary, but most ask about these categories:

• CPR/Resuscitation: Remember that EMS DNR orders are often separate
• Mechanical ventilation: Preferences if you cannot breathe on your own
• Artificial nutrition and hydration: Tube feeding or IV fluids
• Hospital transfer: Whether to move to a hospital or remain in current setting
• Pain control and comfort measures: You can request aggressive comfort care even while declining other interventions

Discuss these categories with your clinician if you're unsure what they mean for your specific health situation.

Step 5: Execute Correctly (State Requirements Vary)

Execution rules differ significantly:

• Most states require your signature plus either one or two qualified witnesses or notarization
• Witnesses typically cannot be beneficiaries, your agent, or your health care providers
• Some states prohibit relatives from serving as witnesses
• A few states require notarization or allow it as an alternative to witnesses
• Electronic completion and online notarization are permitted in some states, but verify local acceptance before relying on digital-only versions

Follow the instructions printed on your state's official form exactly. Requirements are not interchangeable between states.

Example: California requires signing and dating your document, then either having two qualified witnesses sign (one of whom cannot be related to you by blood, marriage, or adoption and cannot be entitled to any part of your estate) or having it notarized. If you're in a skilled nursing facility, a patient advocate or ombudsman must also witness the document.

Step 6: Distribute and Store for Emergency Access

A signed document that no one can find is useless. Complete this checklist:

• Give signed copies to your agent and backup
• Provide copies to close family members who might be involved in decision-making
• Share with your primary care physician and any relevant specialists
• Send a copy to your local hospital system (many can scan it into your electronic medical record)
• Keep an accessible copy at home and note its location clearly
• Consider a wallet card or emergency contact note indicating you have advance directives and who your agent is

Step 7: Review and Update

Life changes, and your documents should too. Review your advance directives:

• After any new diagnosis or significant health change
• Following a hospitalization
• When you move to a different state
• If your marital status changes
• If your relationship with your agent changes
• If your preferences evolve

Re-execution requirements vary by state; follow current guidance for your jurisdiction when updating.

Templates and Examples You Can Use

Starting the Conversation

Use this script to talk with your agent or family:

"I'm working on my advance directive to make things easier for you if I ever can't speak for myself. If that happens, I want you to know that what matters most to me is [quality of life/being comfortable/being able to recognize you]. If doctors say recovery isn't likely, I prefer [comfort-focused care at home/a trial of treatment for X days/aggressive treatment unless I'm permanently unconscious]. I've named you as my agent because I trust you to make decisions that honor my values. Here's where I'm keeping the documents..."

Quick Reference Summary

Create a simple summary sheet to keep with your forms:

My Health Care Agent

• Primary: [Name, phone, relationship]
• Backup: [Name, phone, relationship]

Document Locations

• [Location at home, e.g., "fireproof box in office closet"]
• [Who has copies, e.g., "son has electronic copy, primary doctor has scanned version"]

Key Medical Preferences

• CPR: [Yes/No/Only if likely to recover]
• Ventilation: [Yes for reversible condition/No after X days]
• Artificial feeding: [Yes/No/Time-limited trial]
• Pain control: [Always prioritize comfort]

Faith/Cultural Notes

• [Any specific practices or restrictions]

Funeral/Memorial Preferences

• [Brief notes; note that state law may govern who has authority]

This summary is a companion to, not a substitute for, your legal forms.

Example Scenarios

Comfort-Focused if No Meaningful Recovery
"If I have a severe stroke with no reasonable chance of returning to a life where I can recognize my family and communicate, I want comfort care only. This means no feeding tubes, ventilators, or ICU transfers. Prioritize pain control and keeping me comfortable at home or in hospice."

Trial Period of Treatment
"If I develop a serious infection or pneumonia, I'm willing to try antibiotics and short-term hospital care for up to two weeks. If there's no meaningful improvement after that trial, switch to comfort measures and do not escalate to ventilators or ICU."

Aggressive Treatment Unless Permanently Unconscious
"I want all life-sustaining treatments (ventilation, feeding tubes, dialysis) unless I am in a persistent vegetative state or brain death. In those cases, I want care withdrawn and do not resuscitate."

Discuss these specifics with your clinician to ensure they align with realistic medical scenarios.

Getting Professional Help

Using Your Clinician Appointment

Your doctor can help you complete and document your preferences. Since 2016, Medicare has covered voluntary advance care planning visits using CPT codes 99497 (16 to 30 minutes) and 99498 (each additional 30 minutes). These conversations can take place during a separate appointment or as part of your annual wellness visit.

Ask your clinician to:

• Review your forms with you
• Document your preferences in your medical record
• Confirm what formats your health system accepts
• Discuss POLST/MOLST if you have serious illness

CMS updated guidance in March 2025 on documentation and billing requirements, so most providers are familiar with the process.

When to Consult an Attorney or Financial Professional

Consider professional legal advice if:

• You live in multiple states and need help coordinating documents
• You have a blended family and anticipate potential disputes
• You own complex assets or a business
• You have a dependent with special needs
• Your family dynamics are likely to create conflict

An attorney can ensure your documents comply with current state law and coordinate with your broader estate plan. For financial questions, consult a qualified financial advisor.

Common Mistakes to Avoid

• Using the wrong state form or not following witness/notary rules, which can invalidate your documents
• Naming an agent who isn't willing or able to serve when needed
• Keeping documents locked in a safe deposit box that no one can access in an emergency
• Assuming a will covers medical decisions (it doesn't)
• Failing to update documents after moving to a new state or experiencing major health changes
• Relying on verbal wishes alone, which often lead to family conflict and may not be honored

What Varies by State

• Validity and execution: Witnessing and notarization requirements differ; follow your state's official form instructions
• Out-of-state recognition: A directive from one state may not be honored in another. If you live in multiple states, complete forms for each
• POLST/MOLST availability: Not all states have programs, and procedures vary where they exist
• Out-of-hospital DNR: State EMS procedures differ; verify local acceptance of forms, bracelets, or orders
• Default decision-makers: Some states have laws designating who makes decisions if you haven't named an agent; others do not

Always verify current requirements with your state's Attorney General office or Health Department.

Your Next Steps

1. Download your state's official advance directive form from CaringInfo, AARP, or your state Attorney General's website
2. Identify your agent and at least one backup; have an initial conversation about your values
3. Complete your forms, focusing on the treatment categories that matter most to you
4. Execute correctly per your state's witness or notary requirements
5. Distribute signed copies to your agent, family, and health care providers
6. Store an accessible copy at home and note its location
7. Review every few years and after any major life or health change

The paperwork may feel daunting, but documenting your wishes now prevents confusion and conflict later. You're giving your family and medical team the guidance they need to honor your preferences when you can't speak for yourself.