"Advance Directive for Health Care" - Louisiana

A Louisiana Advance Directive for Health Care is a set of instructions about preferred medical care that takes effect when a patient becomes unable to make decisions. In addition to listing preferences for medical care, the form provides individuals with the option of appointing a health care proxy. A health care proxy - otherwise known as a health care agent or surrogate - is a person who has the authority to make health-related decisions on another person's behalf.

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

If an individual has never had an Advance Directive made, any health care decisions may be made for them by a court-appointed guardian (a spouse, an adult child, an adult sibling, an adult relative or a professional). In Louisiana, this document is regulated by Title 40 (Public Health and Safety), RS 40:1151.2. The declaration may be written, oral or nonverbal and be must be witnessed by two (2) adult witnesses.

There is a difference between this form and a Living Will in Louisiana. A Living Will is a specific type of an Advance Directive for Health Care that becomes effective only in the event of a terminal illness.

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Louisiana 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:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Louisiana 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 LOUISIANA
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 a Louisiana Advance Directive?

An Advance Directive is a legal document by which an individual appoints a proxy to make medical 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 Louisiana?

Creating an Advance Care Directive in Louisiana usually features the following steps:

  1. Learn the necessary components of the document. Consider including a Living Will to express end-of-life medical preferences. Designate a health care proxy - or agent - using a health care power of attorney.
  2. Get the required paperwork and begin filling out your form.
  3. Determine your wishes on CPR, breathing tubes, feeding tubes, surgeries, kidney dialysis, and organ donation.
  4. Discuss your wishes with your partner, family, friends and health care providers to make sure your plans are known to them ahead of time.
  5. Hand copies of the certified and signed form to your health care proxy and doctors. Keep the original in an obvious easy-to-find place with your other paperwork and keep more copies handy.
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