Advance Directive Support Forms

There are numerous forms that can be particularly helpful in supporting advance planning and in ensuring that an individuals wishes are known and honored. Several are provided for FREE download here.

Advance Directive Activation

It is not uncommon for an advance directive agent to learn only belatedly that the patient they represent had lost decisional capacity. Typically, this is because no one thought to make specific contact -- waiting, instead, until the final moment wherein an decision had to be made. In truth, an advance directive agent or proxy is likely to follow an evolving medical situation much more closely if he or she has been made aware in advance that medical decisions will need to be determined and/or ratified by him or her personally. Earlier family consultations are more likely to occur, and more complete deliberations are likely to result. Further, having the Activation form present in the advance planning section of the chart ensures that all are aware of exactly who is to be contacted when decisions must be made, and affirms that he or she is aware, available, and currently willing to be involved. Waiting until the last moment, one may discover an out-of-date (even deceased) primary agent, and/or others unavailable or unwilling to act. Ensure proper planning in this area by downloading and completing the Advance Directive Activation form by clicking here.

Advance Directive Revocation

Circumstances can arise wherein an individual wishes to void his or her advance directive. Normally this is done by destroying the advance directive or by writing "revoked" across the face of the document. However, in situations where the document has already been disseminated widely (perhaps faxed to nursing homes considering admission, distributed to various departments or staff, etc) it can be advantageous to also complete a Revocation form. In this way the form can be duplicated, faxed, or otherwise transmitted and distributed as needed. Further, the Revocation form can remain in the advance planning section of the medical record, where it can serve as a continuing reminder that the identified advance directive was indeed revoked. This can be particularly important if a revoked document later surfaces, leaving medical staff uncertain about its validity. Obtain a copy of the Advance Directive Revocation form by clicking here.

Agent/Proxy Resignation

If a patient-appointed advance directive agent/proxy is no longer able to serve (i.e., whether unavailable, no longer able, or unwilling), it is important to indicate this formally. In this way, any alternate agent can be contacted and begin to assume his or her representative role. As with a Revocation form, this document can be filed in the medical record (ideally attached to the advance directive) and faxed or otherwise transmitted to other involved parties, as needed. To download a copy of the Resignation form, click here.

Clinical Surrogate Designation

Long before advance directives existed, physicians have been identifying family members to serve in the role of surrogate decision maker and consultant. Some states specifically allow this. Virtually all recognize that urgent/emergent situations may arise where there is insufficient time to pursue a mislaid advance directive document, or where no such document exists, or where securing court orders is not possible. In such situations, an available, willing, and appropriately presenting family member/significant other may need to be identified for decision-making. Legal reviewers have often referred to this as a "clinical surrogate designation." Where such a designation has been made, it is helpful to record this in the advance planning section of the medical record. Use of a formal Designation form can aid in notifying others that a designation has been made for purposes of consistency, and as a means of recording other recommendations by which to more formally determine a proper long-term agent/proxy or other such representative appointment. Download this form by clicking here.

Peri-Operative DNR Suspension

For many years the problem of a patient-requested Do-Not-Resuscitate order in the peri-operative setting has been repeatedly examined. Perhaps two researchers put it best when they advocated for a "policy of ‘required reconsideration' by which patients and the responsible care givers would re-examine DNR orders before surgery, whenever possible" (see: Cohen, CB; Cohen, P. Do-not-resuscitate orders in the operating room. New England Journal of Medicine. 1991;325(26) (26 December):1879-1882). They felt that an appropriate discussion would typically "result in a negotiated suspension of the orders, with their reinstatement when the orders again became appropriate." In keeping with this recommendation, the Peri-Operative DNR Suspension form was created. It can be a valuable tool to ensure continuity in advance planning, including in the peri-operative setting. Download a copy by clicking here.

Peri-Operative DNR Confirmation

Not all patients and/or surrogates will want to suspend existing DNR orders during the peri-operative period. If, after thorough discussion, the patient still seems appropriate for surgical intervention but standing DNR orders are not to be suspended, this can be formally documented and confirmed -- including the securing of a patient/agent signature. Download a copy of this form by clicking here.

Procedure-Specific DNR Suspension

There are many medical procedures and interventions that may be performed which can increase the risk of cardiopulmonary arrest. For example, procedures such as cardiac imaging studies that use injected contrasts, dyes, or other substances may result in anaphylactic reactions and/or other untoward cardiopulmonary and events. Specifically addressing DNR orders in advance of these procedures will likely result in the suspension of any existing DNR orders. If so, this should be documented using the Procedure-Specific DNR Suspension form. Download a copy of this form by clicking here.

Procedure-Specific DNR Confirmation

Where discussion prior to a specific medical procedure does not result in suspension of a standing DNR order, this should be carefully recorded. The Procedure-Specific DNR Confirmation form can be used to formally document and confirm patient or agent/proxy wishes in this regard -- including the securing of their signature to this end. You may download a copy of this form by clicking here.


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