North Dakota Advance Health Care Directive (Living Will) Form

The North Dakota advance health care directive(living will) is a legal document that allows one to record in writing their wishes for their end of life medical decisions. The Principal will have the opportunity to name a health care agent to help in the decision-making process once the Principal is no longer able to make any decisions on their own, in this case, medical decisions. It is the obligation of the health care agent to ensure that all of the recorded wishes are honored to the best of their ability and in the best interest of the Principal. The Principal must complete the document while they are of sound mind. The form may be changed or revoked at any time.


Laws – 23-06.4-01, et seq. Uniform Rights of Terminally Ill Act

How to Write

Step 1 – After the document has been downloaded, the Principal may establish the ownership and responsibility of the document by entering their name into the first line of the form

  • The Principal must carefully review and understand the following three (3) paragraphs prior to application of signatures

Step 2 – Appointment of Health Care Agent – The Principal should begin this section by reading the information provided including the “Note,” then submit the following information:

  • The name of the selected Health Care Agent
  • Enter the relationship of the Agent to the Principal
  • Provide the best number(s) whereas the Agent may be contacted
  • Enter the Agent’s complete address
  • AND
  • In the event the Agent is unable to any longer carry out the responsibilities necessary to make decisions on behalf of the Principal, then an alternate may be assigned in advance to ensure someone will be available to assist the medical providers with decision making, enter, again, the following:
  • The name of the Alternate Health Care Agent
  • Enter the relationship of the alternate Agent to the Principal
  • Provide the best number(s) whereas the alternate Agent may be contacted
  • Enter the alternate Agent’s complete address
  • Once the information has been entered, continue to review the information provided including the A through D subsections
  • Should the Principal wish to limit or restrict portions of the care provided, enter the limits and/or restrictions in the lines provided
  • The Principal should then review the statements behind 1 and 2 and initial the statement that best indicates the powers that the Principal will allow either agent

Step 3 – Health Care Instructions – This section should be completed if the Principal would like to provide health care instructions: (Optional but beneficial)

  • Goals for health care
  • Fears about health care
  • Spiritual or religious beliefs and traditions
  • Beliefs as to when the Principal would believe that life would no longer be worth living
  • Principal’s thoughts about how their medical condition would affect family members

Step 4 – Principal’s views regarding their health care in the following situations:

  • Read each statement and respond by placing the answer into the lines provided

Step 5 – Making an Anatomical Gift – Should the Principal be interested in organ and tissue donation, read the paragraph and initial the preferred answer

Step 6 – Making the Document Legal – Understand that in signing this document, if there is any other “living will” documentation, this dated document will revoke anything prior. Be certain that the Principal signs before a notary public – Enter the following:

  • Enter the date  of the document in mm/dd/yyyy format
  • Enter the City of residence
  • State of residence
  • Principal’s signature

Step 7 – This section will require a Notary Public OR Statement of Witnesses –

  • Carefully review all of the information in this section before proceeding
  • Choose Option 1 OR Option 2
  • If selecting witnesses as an option, each witness must read the statement
  • Enter the date of signature in mm/dd/yyyy format
  • Enter the Principal’s name
  • Each witness must then provide their signature
  • Each witness must provide complete address

Step 8 – Acceptance of Appointment of Power of Attorney  – The Agent and alternate agent must carefully review and agree to the statement- Submit:

  • Signature of Agent
  • Date of signature mm/dd/yyyy format
  • AND
  • Signature of Alternate Agent
  • Date of signature mm/dd/yyyy format

Make copies for all signatories, medical providers and/or any others the Principal would be interested in providing copy

Comments

comments