Missouri Living Will Declaration and Durable Power of Attorney for Health Care

MISSOURI LIVING WILL DECLARATION

DECLARATION

I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.

Signed this _________ day of __________________, __________.

Signature ________________________________

City, County and State of residence ________________________________

The declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence.

Witness ________________________________

Address ________________________________

Witness ________________________________

Address ________________________________

REVOCATION PROVISION

I hereby revoke the above declaration.

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IMPORTANT MISSOURI-LAW NOTES

Execution requirements. The declaration must be in writing, dated, and signed by the declarant, or by another person in the declarant’s presence and at the declarant’s express direction. If it is not wholly in the declarant’s handwriting, it must be signed in the presence of TWO witnesses age eighteen or older; neither witness may be the person who signed at the declarant’s direction. (§ 459.015.1 RSMo.)

Physician and facility records. The declarant is responsible for notifying the attending physician. At the declarant’s request, the declaration must be made part of the physician’s records and the records of the health care facility. (§ 459.015.2.)

When operative. The declaration operates only when the declarant has a terminal condition and cannot participate in treatment decisions. The declarant’s current directions supersede the declaration. (§ 459.025.)

PREGNANCY. A declaration to withhold or withdraw death-prolonging procedures has no effect during the declarant’s pregnancy. (§ 459.025.)

Nutrition and hydration. “Death-prolonging procedure” excludes any procedure to provide nutrition or hydration. (§ 459.010(3).) Decisions about artificially supplied nutrition and hydration belong in the companion Durable Power of Attorney for Health Care.

Optional specific directions. A declaration may include other specific directions. If one direction is invalid, the remaining directions are severable and may still be given effect. (§ 459.015.3.)

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Section 459.016 (2023) directs the Missouri Department of Health and Senior Services to make an advance-directive form available; it does not make that form mandatory.

MISSOURI DURABLE POWER OF ATTORNEY FOR HEALTH 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

Appointment of Attorney in Fact

Principal’s full legal name: ________________________________

Attorney in fact’s full legal name: ________________________________

Address: ________________________________

Telephone: ________________________________

Successor attorney in fact’s full legal name: ________________________________

Address: ________________________________

Telephone: ________________________________

I appoint the person named above as my attorney in fact for health care decisions. If that person is unable or unwilling to act, I appoint the successor. I expressly grant my attorney in fact authority to give or withhold consent to health care on my behalf, including authority described in § 404.710.6(10) RSMo, when this power becomes effective.

Artificially Supplied Nutrition and Hydration

Initial ONE option. Missouri law requires a specific grant before an attorney in fact may direct a provider to withhold or withdraw artificially supplied nutrition and hydration. (§ 404.820.1.)

I SPECIFICALLY GRANT my attorney in fact authority to direct a health care provider to withhold or withdraw artificially supplied nutrition and hydration.

I DO NOT grant my attorney in fact authority to direct a health care provider to withhold or withdraw artificially supplied nutrition and hydration.

When Authority Begins and Duties

Before my attorney in fact acts, TWO physicians must determine that I am unable to make health care decisions. (§ 404.825.) At least one physician’s certification is always required by Missouri law.

My attorney in fact shall seek and consider information about my diagnosis and prognosis and the benefits and burdens of the proposed health care. (§ 404.822.)

Eligibility notice. My attending physician, an employee of that physician, or an owner, operator, or employee of the health care facility where I reside may not serve unless related to me within the second degree by affinity or consanguinity or a member of my same vowed religious community. (§ 404.815.)

Marriage dissolution. Filing a petition for dissolution of marriage terminates a spouse-attorney-in-fact’s authority unless this instrument provides otherwise. (§§ 404.717.1(6), 404.810.)

Principal’s Execution

The principal must subscribe and date this instrument and acknowledge it before a notary public in the manner prescribed for conveyances of real estate. Witnesses are not required by Missouri law. (§ 404.705.1(3).)

Date: __________________________

Principal’s printed name: ________________________________

Principal’s signature: ________________________________

NOTARY ACKNOWLEDGMENT

State of Missouri

County of _______________________________

On this ________ day of _________________, 20________, before me personally appeared ________________________,

to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed.

Notary public’s signature: ________________________________

Notary public’s printed name: ________________________________

My commission expires: ________________________________

OPTIONAL SUPPLEMENTAL TWO-WITNESS BLOCK

Not required by Missouri law; may aid acceptance in other states.

We witnessed the principal sign this instrument voluntarily.

Witness 1 printed name: ________________________________

Witness 1 address: ________________________________

Witness 1 signature: ________________________________

Witness 2 printed name: ________________________________

Witness 2 address: ________________________________

Witness 2 signature: ________________________________