"Advance Directive for Health Care" - Illinois

An Illinois Advance Directive is a revisable set of written instructions about future medical care that take effect in cases when a patient becomes unable to make decisions for themselves. The purpose of the form is to let an individual plan their medical treatment in advance.

Download a pre-made template through the link below or make your own Advance Directive with our online template.

The form lists decisions on life-sustaining medical procedures and about the specific kinds of treatment the individual may or may not wish to receive and can be used to elect a spouse, relative, friend or attorney as a decision-maker in case the individual is unable to make their own decisions because of an illness, accident or incapacity. The main difference between this form and an Illinois Living Will is that a Living Will - also called a "directive to physicians" - is one form of the Advance Health Care Directive. It's more limited in nature and only state a patient's wishes for end-of-life medical care.

An Illinois Advance Directive is regulated by the 755 ILCS 35/1 (Illinois Compiled Statutes) and defined by 755 ILCS 35/2(b). The document must be witnessed by two (2) individuals eighteen (18) years of age or older.

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Illinois Advance Directive for Health Care
Section I - Living Will
I, _______________________________ with a mailing address of ______________
____________________________________________________________________,
being of sound mind, memory, disposition, understanding, and at least eighteen years
of age, do willfully and intentionally, by this Living Will, direct my family,
physician(s), attorney, and any other individuals who may become responsible for my
health and well-being in the future, whether partly or fully, to take the following
actions in each of the circumstances described in the Living Will below.
1. In the event that I develop a condition considered “terminal” with my attending
physician and one other medical professional both agreeing that there is no
chance for improvement, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. In the event that I fall into a coma with my attending physician and one other
medical professional both agreeing that there is no chance for recovery, I direct
the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. In the event that I develop a persistent vegetative state with my attending
physician and one other medical professional both determining that there is no
chance for recovery, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Illinois Advance Directive for Health Care
Section I - Living Will
I, _______________________________ with a mailing address of ______________
____________________________________________________________________,
being of sound mind, memory, disposition, understanding, and at least eighteen years
of age, do willfully and intentionally, by this Living Will, direct my family,
physician(s), attorney, and any other individuals who may become responsible for my
health and well-being in the future, whether partly or fully, to take the following
actions in each of the circumstances described in the Living Will below.
1. In the event that I develop a condition considered “terminal” with my attending
physician and one other medical professional both agreeing that there is no
chance for improvement, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. In the event that I fall into a coma with my attending physician and one other
medical professional both agreeing that there is no chance for recovery, I direct
the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. In the event that I develop a persistent vegetative state with my attending
physician and one other medical professional both determining that there is no
chance for recovery, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
4. In addition to the directions I have listed above, I also request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Section II - Health Care Proxy
I would like to appoint __________________________________ with a mailing
address of ____________________________________________________________,
to act as my Health Care Proxy. I have talked with this person about my wishes.
They can be reached at ______________________________ during daytime hours or
at ______________________________​
a t night.
If this person is not able or not willing to serve as my Health Care Proxy, I would like
to appoint __________________________________ with a mailing address of
____________________________________________________________, to act as
my Health Care Proxy. I have talked with this person about my wishes.
They can be reached at ______________________________ during daytime hours or
at ______________________________​
a t night.
I want my Health Care Proxy:
❏ to follow only the directions as listed on this form.
❏ to follow my directions as listed on this form and to make any decisions about
things I have not covered in the form.
❏ to make the final decision, even though it could mean doing something
different from what I have listed on this form.
Section III - Acknowledgement
I understand the following:
If my doctor or hospital refuse to follow the directions I have listed, they must
see that I get to a doctor or hospital who will follow my wishes.
If I am pregnant, or if I become pregnant, the choices I have made on this form
will not be followed until after the birth of the child.
● If the time comes for me to stop receiving life-sustaining treatment or food and
water through a tube or an IV, I direct that my doctor talks about the good and
bad points of doing this, along with my wishes, with my health care proxy, if I
have one.
Section IV - Signatures
Principal
By signing this Advance Directive in front of the witnesses identified below, I hereby
administer and subscribe to the declarations made above both freely and voluntarily,
and wholeheartedly request that my family, physician(s), attorney, and any other
individuals who may in the future become responsible for my health and well-being,
whether partly or fully, all abide by my wishes as stated herein.
_________________________________
Name
_________________________________
Signature
_________________________________
Date of signing
Witnesses
This Advance Directive was signed by _________________________________ in the
presence of the following two witnesses, who by their signatures below, confirm that
_________________________________ was, at the time this document was signed,
at least eighteen years of age, of sound mind, memory, disposition, understanding, not
under any improper influence and able to understand the weight of this decision. The
undersigned have subscribed this document in the presence of each other and
_________________________________ and at their request.
First Witness: ​ _ ________________________________ ​ w ith a mailing address of
____________________________________________________________________.
_________________________________
Signature
_________________________________
Date of signing
Second Witness: ​ _ ________________________________ ​ w ith a mailing address of
____________________________________________________________________.
_________________________________
Signature
_________________________________
Date of signing
Health Care Proxy
I, _________________________________, am willing to serve as the health care
proxy.
_________________________________
Signature
_________________________________
Date of signing
I, _________________________________, am willing to serve as the health care
proxy if the other health care proxy will be unable to serve.
_________________________________
Signature
_________________________________
Date of signing
Notary Acknowledgement
STATE OF ILLINOIS
COUNTY OF _________________________________
I, _________________________________, a Notary Public of said County, do certify
that _________________________________, as Principal, and __________________
________________ and _________________________________, as witnesses,
whose names are signed to the writing above bearing date on the _______ day of
______________, ______, have this day acknowledged the same before me.
Given under my hand this _______ day of ______________, ______.
My commission expires: ___________________________________
______________________________________
Signature of Notary Public
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What Is an Illinois Advance Directive?

An Advance Directive is a legal document by which an individual appoints a proxy to make health care decisions for when they are no longer able to and to administer or withhold treatment and procedures based on their previously stated wishes. Advance Directives include two separate forms:

  • A Living Will (a written statement listing decisions about life-­sustaining procedures in the event of a terminal condition);
  • A durable power of attorney for health care (a document appointing an attorney-in-fact to make medical decisions for the individual).

The attorney-in-fact should meet the following criteria:

  1. The health care proxy - or agent - must meet the state's legal requirements.
  2. The individual's doctor or a member of their medical care team may not be selected as a proxy.
  3. The elected individual should be trusted to be the patient's advocate in any disagreements about their care.

How to Write an Advance Directive in Illinois?

Advance Care planning is a four-step process:

STEP 1 - Electing an agent to make health care decisions on the patient's behalf.

STEP 2 - Expressing wishes about any limitations in medical treatment - CPR, breathing machines, feeding tubes, and antibiotics.

STEP 3 - Making decisions related to organ and tissue donation and stating preferences regarding the funeral, burial and the disposition of remains.

STEP 4 - Signing, dating and witnessing the form according to the applicable Illinois law. Copies of the completed form should be handed out to the agent, the physician, the patient's family and to the health care facility.

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