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Living Will Form
Making Your Wishes Known
Living Wills and Advance Directives outline prearranged actions that should be taken in regards to your health if you are no longer able to make
decisions for yourself due to incapacity or illness. These legally binding documents outline your wishes regarding life support, resuscitation and other
interventions for both your health care team and your family members.
There are two different types of directives: A Living Will and a Designation of Health Care Surrogate. Both can be changed anytime, and you’ll want to
update them periodically.
Provides your physician instructions regarding procedures that are meant to prolong your life. Your physician and your health care surrogate are
required to follow all the directives in a Living Will.
Designation of Health Care Surrogate or Durable Power of Attorney for Health Care: Allows you to appoint another adult to make
decisions on your behalf when you are unable to do so. It is recommended that you appoint someone who knows your wishes and is willing to carry
them out, especially regarding your personal, religious, moral and cultural beliefs. If you are incapacitated, your health care surrogate will have the
authority to make all the medical decisions regarding your health care, including decisions about when to withhold or withdraw life-prolonging
If you establish Advance Directives, make sure members of your immediate family know about them and where they are located. You’ll also want to
share a copy with your TFHC physician to include as part of your medical records, and provide a new copy if your directives change. Be sure to also
bring a copy with you when you are admitted to the hospital.
FAQs About Advance Directives
Why is it important for me to complete Advance Directives?
There may be a time, due to an accident, injury or illness; you may not be able to make sound decisions about your health care. However, decisions will
need to be made regarding your treatment and care. You will need a directive outline and a designated person who can legally speak on your behalf
and see that your wishes are carried out.
Who can be assigned to fulfill a directive?
Any person who is 18-years of age and older (or an emancipated minor), can serve as a surrogate for your Advance Directives.
When are they valid?
You will need two witnesses present when you sign your directives. Only one can be a spouse, family member or relative; your health care surrogate
cannot be a witness. These documents do not need to be notarized to be legal, though some prefer to have them notarized along with any other legal
documents, such as a will.
When do Advance Directives take effect?
The Designation of Health Care Surrogate takes effect as soon as your physician deems that you are unable to make your own health care decisions. A
Living Will be will be enacted only when your attending physician along with a consulting physician determine you are:
1) Unable to make your own medical decisions and are unlikely to regain this ability.
2) In a terminal persistent vegetative state, an end-stage condition, or in any other condition that you specified in your Living Will.
How long are Advance Directives valid?
These documents are valid indefinitely, unless you have specified an expiration date on the document. They become void at the time of your death or
when you have rescinded them or declared them void.
If I did not designate a health care surrogate, who would make the decisions on my behalf if I were unable to make them
According to Florida law, the following individuals must be reasonably available for consultation (in person or by phone) and willing to make the medical
decisions. They are, in the order of priority:
Spouse (Please note: Florida law does not recognize common law marriages as a legal marriage contract)
Relative who has exhibited special care and concern for the patient and who has maintained regular contact with the patient and who is familiar
with the patient's activities, health and religious or moral beliefs.
Close Personal Friend - must exhibit special care and concern for the patient and has signed a Close Personal Friend affidavit stating he/she is a
friend of the patient and is willing and able to become involved in the patient's healthcare. This person must have maintained regular contact with
the patient so as to be familiar with the patient's activities, health and religious or moral beliefs.
When should a person make sure that a Designated Health Care Surrogate has been appointed?
Prior to your medical procedure, you should appoint a designated health care surrogate. If you already have one designated, life changes may require
changes to your surrogate appointment as well:
Divorced, or contemplating divorce
Living with a significant other
Wanting to designate one person from the proxy category where there are several people.
As a patient with TFHC, will I be asked about Advance Directives?
Yes, if you are an adult or emancipated minor, during your appointment, you will be asked about an Advance Directives form.
If you have completed the Living Will and Advance Directive, please bring a copy with you to your appointment. If you would like to complete one,
please let our medical staff know. If you have questions after reading the instructions on the back of the Advance Directives form, you may request to
speak to your physician.
Does a Living Will mean the person is not to be resuscitated in the event of a cardiac and/or respiratory arrest?
No, but if you do not wish to be resuscitated in the event of cardiac or respiratory arrest, you must discuss this with your physician so that a Do Not
Resuscitate (DNR) order can be entered into your medical records. This form must be completed by you and your physician in order to be valid and take
Download Florida's Designation
of Health Care Surrogate Form
Tampa Family Health Centers is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C.
233(g)-(n). It is an FTCA Deemed facility, covered by professional liability insurance through our enrollment in Federal Tort Claims Act program.
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