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Missouri Living Will Form

If you want to pre-determine the kinds of medical treatment you want to receive of have another person decide this for you in case of you not being able to make this decision in the State of Missouri, the Missouri Living Will Form has to be completed and submitted.

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6 MISSOURI ADVANCE DIRECTIVE – PAGE 1 OF 6 
 
Part I. Durable Power of Attorney for Health Care Choices 
 
I, _____________________________________________, appoint 
 
Name: ______________________________________________________ 
 
Address: ____________________________________________________ 
 
as my agent for health care choices when I am unable to make decisions or 
communicate my wishes. In the case the person above cannot serve as my 
agent, or if I am divorced from or legally separated from the agent above, I 
appoint the person below:  
 
Name: ______________________________________________________ 
 
Address: ____________________________________________________ 
 
This alternate agent may make health care decisions for me when I am 
unable to do so or to communicate my wishes.  
 
This durable power of attorney becomes effective when two physicians 
certify that I am incapacitated and unable to make and communicate 
health care choices. 
 
You may choose to have one physician, instead of two, determine whether 
you are incapacitated. If you want to exercise this option — allowing one 
physician to determine whether you are incapacitated — initial here. _____ 
 	
 
 
 
 
 
 
 
PRINT YOUR NAME 
 
PRINT YOUR 
AGENT'S NAME AND 
ADDRESS 
 
 
 
 
 
 
 
PRINT YOUR 
ALTERNATE 
AGENT'S NAME AND 
ADDRESS 
 
 
 
 
 
 
 
 
 
 
INITIAL HERE IF 
YOU WANT TO 
ALLOW ONLY ONE 
PHYSICIAN TO 
DETERMINE 
WHETHER YOU ARE 
INCAPACITATED 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization 
2011 Revised.

7 MISSOURI ADVANCE DIRECTIVE – PAGE 2 OF 6 
 
By completing this durable power of attorney, I authorize my agent to 
make all decisions for me regarding my health care. This includes the 
power to:  
 
 Consent, refuse or withdraw consent to artificially supplied nutrition 
and hydration. 
 Make all necessary arrangements for health care on my behalf. This 
includes admitting me to any hospital, psychiatric treatment facility, 
hospice, nursing home or other health care facility. 
 Hire or fire health care personnel on my behalf. 
 Request, receive and review my medical and hospital records. 
 Take legal action if necessary to do what I have directed. 
 Carry out my wishes regarding autopsy and organ donation, and 
decide what should be done with my body. 
 
 
My agent under this durable power of attorney will not incur any personal 
financial liability. The agent also should not be compensated for services 
performed for me. However, the agent shall be reimbursed for reasonable 
expenses that are part of my care. 
 
 
 
 
 
 
 
 
 
 
 
THIS IS A DURABLE POWER OF ATTORNEY AND THE AUTHORITY OF MY 
ATTORNEY IN FACT, WHEN EFFECTIVE, SHALL NOT TERMINATE OR BE 
VOID OR VOIDABLE IF I AM OR BECOME DISABLED OR INCAPACITATED 
OR IN THE EVENT OF LATER UNCERTAINTY AS TO WHETHER I AM DEAD 
OR ALIVE. 
 
 
 	
 
 
 
 
 
 
 
 
 
IF YOU DON'T 
WANT YOUR AGENT 
TO HAVE ANY OF 
THESE POWERS 
DRAW A LINE 
THROUGH THE 
PROVISION AND 
INITIAL NEXT TO IT 
 
 
 
 
 
 
 
 
 
 
YOUR AGENT MAY 
HAVE A CLAIM 
AGAINST YOUR 
ESTATE FOR 
REASONABLE 
EXPENSES THAT 
ARE PART OF YOUR 
CARE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization 
2011 Revised.

8 MISSOURI ADVANCE DIRECTIVE – PAGE 3 OF 6 
 
Part II. Health Care Choices Directive 
 
I want those involved in my health care to understand my wishes if I 
cannot communicate or make decisions on my own. I make this directive 
to provide clear and convincing proof of my wishes and instructions about 
my health care and treatment. If my doctor believes medical treatment will 
lead to my recovery, I want to have the treatment. I also want to have 
care and treatment for pain or discomfort even if this treatment might 
shorten my life, affect my appetite, slow my breathing or be habit-forming.  
 
If I have a terminal illness or condition and there is no reasonable hope I 
will recover, or if I am persistently unconscious, I direct all of the life-
prolonging procedures I have initialed below to be withheld or withdrawn. 
I direct the following treatments to be withheld or withdrawn: (initial all 
that apply) 
 
_____ Surgery or other invasive procedures 
_____ Cardiopulmonary resuscitation (CPR) to restart my heart or 
 breathing 
_____ Antibiotics 
_____ Dialysis 
_____ Mechanical ventilator (respirator) 
_____ Artificially supplied nutrition and hydration (including tube feeding) 
_____ Chemotherapy 
_____ Radiation therapy 
_____ All other “life-prolonging” medical treatments or surgeries that are 
  merely intended to keep me alive without reasonable hope of 
  making me better or curing my illness or injury. 
 
Organ Donation Choices (initial only one) 
_____ I consent to the donation of my organs or tissues. I realize my 
  body may need to be maintained artificially after my death until my 
  organs can be removed.  
_____ I refuse to make anatomical gifts of part or all of my body. I 
  prohibit my agent from consenting to such gifts before or after my 
 death. 
 	
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
INITIAL ALL 
TREATMENTS THAT 
YOU WANT TO BE 
WITHHELD OR 
WITHDRAWN IN 
THE EVENT YOU 
ARE TERMINALLY 
ILL OR 
PERMANENTLY 
UNCONSCIOUS 
 
 
 
 
 
 
 
 
 
 
 
INITIAL YOUR 
ORGAN DONATION 
PREFERENCE 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization 
2011 Revised.

9 MISSOURI ADVANCE DIRECTIVE – PAGE 4 OF 6 
 
 
I also give the following directions regarding my health care: 
 
____________________________________________________________ 
 
____________________________________________________________ 
 
____________________________________________________________ 
 
____________________________________________________________ 
 
____________________________________________________________ 
 
____________________________________________________________ 
Attach extra pages if necessary.  Sign and date the attached pages.   
 
 
Optional: Describe what you consider an acceptable quality of life. For 
example, being able to recognize my loved ones, make decisions, 
communicate or feed yourself. 
 
____________________________________________________________ 
 
____________________________________________________________ 
 
____________________________________________________________ 
 
____________________________________________________________ 
 
____________________________________________________________ 
 
____________________________________________________________ 
Attach extra pages if necessary.  Sign and date the attached pages.   
 
 
 
 
Make sure to talk about this directive and your wishes with your agent, 
your doctors, family, friends and clergy. Give each of them a copy of the 
directive. Bring a copy with you when you go to a hospital or other health 
care facility. Keep the original with your important papers. 	
 
 
 
 
ADD OTHER 
INSTRUCTIONS, IF 
ANY, REGARDING 
YOUR ADVANCE 
CARE PLANS 
 
THESE 
INSTRUCTIONS CAN 
FURTHER ADDRESS 
YOUR HEALTH CARE 
PLANS, SUCH AS 
YOUR WISHES 
REGARDING 
HOSPICE 
TREATMENT, BUT 
CAN ALSO ADDRESS 
OTHER ADVANCE 
PLANNING ISSUES, 
SUCH AS YOUR 
BURIAL WISHES 
 
ATTACH 
ADDITIONAL PAGES 
IF NEEDED 
 
 
 
OPTIONAL 
DESCRIBE YOUR 
IDEA OF AN 
ACCEPTABLE 
QUALITY OF LIFE 
 
 
 
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization 
2011 Revised.

10 MISSOURI ADVANCE DIRECTIVE – PAGE 5 OF 6 
 
 
Part III. Relationship Between Health Care Choices Directive and 
Durable Power of Attorney for Health Care Choices 
 
This Part is effective only if I have completed Part I and Part II. 
 
As I have executed the health care choices directive and durable power of 
attorney for health care choices, I trust and encourage my agent to: 
 
 First, follow my wishes as expressed in the directive or otherwise 
from knowledge about me or having had discussions with me about 
making choices regarding life-prolonging medical treatment. 
 
 Second, if my agent does not know my wishes for a specific 
decision, but my agent has evidence of what I might want, my 
agent can try to figure out how I would decide. This is called 
substituted judgment and requires my agent imagining himself or 
herself in my position. My agent should consider my values, 
religious beliefs, past choices and past statements I have made. 
The aim is to choose as I probably would choose, even if it is not 
what my agent would choose for himself or herself. 
 
 Third, if my agent has very little or no knowledge of what I would 
want, then my agent and the doctors will have to make a decision 
based on what a reasonable person in the same situation would 
decide. This is called making decisions in my best interest. I have 
confidence in my agent’s ability to make decisions in my best 
interest if my agent does not have enough information to follow my 
preferences or use substituted judgment, and if this is the case, I 
authorize my agent to make decisions that might even be contrary 
to my directive in his or her best judgment. 
 
 Finally, if the durable power of attorney for health care choices is 
determined to be ineffective, or if my agent is unable to serve, the 
health care choices directive is intended to be used on its own as 
firm instructions to my health care providers regarding life-
prolonging procedures. 	
 
 
 
 
 
 
 
 
 
 
 
 
THIS PART 
DESCRIBES THE 
RELATIONSHIP 
BETWEEN PARTS I 
AND II IN THE 
EVENT YOU FILL 
OUT BOTH PARTS 
 
 
 
 
 
 
 
IF YOU DISAGREE 
WITH THIS 
RELATIONSHIP, 
YOU MAY WANT TO 
ONLY FILL OUT ONE 
PART OR TALK TO 
AN ATTORNEY 
ABOUT AN 
ADVANCE 
DIRECTIVE 
TAILORED TO YOUR 
NEEDS 
 
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization 
2011 Revised.

11 MISSOURI ADVANCE DIRECTIVE – PAGE 6 OF 6 
 
Part IV.  Execution 	
 
IN WITNESS THEREOF, I have executed this document on this ____ day of 
____________________, in the year of ________. 
 
Signature: ___________________________________________________ 
Print name: __________________________________________________ 
Address: ____________________________________________________ 
 
If you filled out Part II, you must have your signature witnessed by two people 
who are at least 18 years of age. 
 
The person who signed this document is of sound mind and voluntarily signed 
this document in our presence. Each of the undersigned witnesses is at least 18 
years of age. 
 
Witness #1 
Signature: ___________________________________________________ 
Print name: __________________________________________________ 
Address: ____________________________________________________ 
 
Witness #2  
Signature: ___________________________________________________ 
Print name: __________________________________________________ 
Address: ____________________________________________________ 
 
If you filled out Part I, you must have your advance directive notarized.  
 
STATE OF MISSOURI         )   
      ) SS 
COUNTY OF ______________________  ) 
 
On this ____ day of ____________________, in the year of ________, 
personally appeared before me the person signing, known by me to be the 
person who completed this document and acknowledged it as his/her free act 
and deed. 
 
IN WITNESS WHEREOF, I have set my hand and affixed my official seal in the 
County  
 
of________________________, State of Missouri, the day and year first above 
written. 
 
________________________________   _____________________ 
Notary public’s signature    Notary seal 
 	
Courtesy of Caring Connections 
1731 King St., Suite 100, Alexandria, VA  22314 
www.caringinfo.org, 800/658-8898	
 	
 
 
 
 
DATE YOUR 
DOCUMENT 
 
SIGN HERE AND 
PRINT YOUR NAME 
AND ADDRESS 
 
 
 
 
 
 
 
 
 
IF YOU FILLED OUT 
PART II, YOUR 
WITNESSES MUST 
SIGN AND PRINT 
THEIR NAMES AND 
ADDRESSES HERE 
 
 
 
 
 
 
 
 
A NOTARY MUST 
FILL OUT THIS 
SECTION IF YOU 
FILLED OUT PART I 
 
 
NOTE: YOU MUST 
HAVE YOUR 
DOCUMENT BOTH 
NOTARIZED AND 
SIGNED BY TWO 
WITNESSES IF YOU 
FILLED OUT PARTS 
I AND II 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization 
2011 Revised.

12 You Have Filled Out Your Health Care Directive, Now What? 
 
1. Your Missouri Advance Directive is an important legal document.  Keep the original 
signed document in a secure but accessible place.  Do not put the original document in 
a safe deposit box or any other security box that would keep others from having access 
to it. 
 
2. Give photocopies of the signed original to your agent and alternate agent, doctor(s), 
family, close friends, clergy, and anyone else who might become involved in your 
healthcare. If you enter a nursing home or hospital, have photocopies of your 
document placed in your medical records. 
 
3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes 
concerning medical treatment. Discuss your wishes with them often, particularly if your 
medical condition changes. 
 
4. You may also want to save a copy of your form in an online personal health records 
application, program, or service that allows you to share your medical documents with 
your physicians, family, and others who you want to take an active role in your advance 
care planning.  
 
5. If you want to make changes to your documents after they have been signed and 
witnessed, you must complete a new document. 
 
6. Remember, you can always revoke your Missouri document. 
 
7. Be aware that your Missouri document will not be effective in the event of a medical 
emergency.  Ambulance and hospital emergency department personnel are required to 
provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive 
that states otherwise. These directives called “prehospital medical care directives” or 
“do not resuscitate orders” are designed for people whose poor health gives them little 
chance of benefiting from CPR. These directives instruct ambulance and hospital 
emergency personnel not to attempt CPR if your heart or breathing should stop.   
 
Currently not all states have laws authorizing these orders. We suggest you speak to 
your physician if you are interested in obtaining one. Caring Connections does not 
distribute these forms.
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