{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/54.1-2984.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/54.1-2984.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/54.1-2984.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/54.1-2984.html"}],"law_id":62832,"edition_id":1,"section_id":62832,"structure_id":14683,"section_number":"54.1-2984","catch_line":"Suggested form of written advance directives","history":"1983, c. 532, \u00a7 54-325.8:4; 1988, c. 765; 1989, c. 592; 1991, c. 583; 1992, cc. 748, 772; 1997, c. 609; 1999, c. 814; 2000, c. 810; 2005, c. 186; 2007, cc. 92, 907; 2009, cc. 211, 268; 2010, c. 792; 2015, c. 109.","full_text":"An advance directive executed pursuant to this article may, but need not, be in the following form:\n\t\tADVANCE MEDICAL DIRECTIVE\n\t\tI, __________, willingly and voluntarily make known my wishes in the event that I am incapable of making an informed decision, as follows:\n\t\tI understand that my advance directive may include the selection of an agent as well as set forth my choices regarding health care. The term “health care” means the furnishing of services to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical disability, including but not limited to, medications; surgery; blood transfusions; chemotherapy; radiation therapy; admission to a hospital, nursing home, assisted living facility, or other health care facility; psychiatric or other mental health treatment; and life-prolonging procedures and palliative care.\n\t\tThe phrase “incapable of making an informed decision” means unable to understand the nature, extent and probable consequences of a proposed health care decision or unable to make a rational evaluation of the risks and benefits of a proposed health care decision as compared with the risks and benefits of alternatives to that decision, or unable to communicate such understanding in any way.\n\t\tThe determination that I am incapable of making an informed decision shall be made by my attending physician and a capacity reviewer, if certification by a capacity reviewer is required by law, after a personal examination of me and shall be certified in writing. Such certification shall be required before health care is provided, continued, withheld or withdrawn, before any named agent shall be granted authority to make health care decisions on my behalf, and before, or as soon as reasonably practicable after, health care is provided, continued, withheld or withdrawn and every 180 days thereafter while the need for health care continues.\n\t\tIf, at any time, I am determined to be incapable of making an informed decision, I shall be notified, to the extent I am capable of receiving such notice, that such determination has been made before health care is provided, continued, withheld, or withdrawn. Such notice shall also be provided, as soon as practical, to my named agent or person authorized by \u00a7 54.1-2986 to make health care decisions on my behalf. If I am later determined to be capable of making an informed decision by a physician, in writing, upon personal examination, any further health care decisions will require my informed consent.\n\t\t(SELECT ANY OR ALL OF THE OPTIONS BELOW.)\n\t\tOPTION I: APPOINTMENT OF AGENT (CROSS THROUGH OPTIONS I AND II BELOW IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE HEALTH CARE DECISIONS FOR YOU.)\n\t\tI hereby appoint __________ (primary agent), of __________ (address and telephone number), as my agent to make health care decisions on my behalf as authorized in this document. If __________ (primary agent) is not reasonably available or is unable or unwilling to act as my agent, then I appoint __________ (successor agent), of __________ (address and telephone number), to serve in that capacity.\n\t\tI hereby grant to my agent, named above, full power and authority to make health care decisions on my behalf as described below whenever I have been determined to be incapable of making an informed decision. My agent’s authority hereunder is effective as long as I am incapable of making an informed decision.\n\t\tIn exercising the power to make health care decisions on my behalf, my agent shall follow my desires and preferences as stated in this document or as otherwise known to my agent. My agent shall be guided by my medical diagnosis and prognosis and any information provided by my physicians as to the intrusiveness, pain, risks, and side effects associated with treatment or nontreatment. My agent shall not make any decision regarding my health care which he knows, or upon reasonable inquiry ought to know, is contrary to my religious beliefs or my basic values, whether expressed orally or in writing. If my agent cannot determine what health care choice I would have made on my own behalf, then my agent shall make a choice for me based upon what he believes to be in my best interests.\n\t\tOPTION II: POWERS OF MY AGENT (CROSS THROUGH ANY LANGUAGE YOU DO NOT WANT AND ADD ANY LANGUAGE YOU DO WANT.)\n\t\tThe powers of my agent shall include the following:\n\nA\n\nTo consent to or refuse or withdraw consent to any type of health care, treatment, surgical procedure, diagnostic procedure, medication and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, artificially administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the power to consent to the administration of dosages of pain-relieving medication in excess of recommended dosages in an amount sufficient to relieve pain, even if such medication carries the risk of addiction or of inadvertently hastening my death;B\n\nTo request, receive, and review any information, verbal or written, regarding my physical or mental health, including but not limited to, medical and hospital records, and to consent to the disclosure of this information;C\n\nTo employ and discharge my health care providers;D\n\nTo authorize my admission to or discharge (including transfer to another facility) from any hospital, hospice, nursing home, assisted living facility or other medical care facility. If I have authorized admission to a health care facility for treatment of mental illness, that authority is stated elsewhere in this advance directive;E\n\nTo authorize my admission to a health care facility for the treatment of mental illness for no more than 10 calendar days provided I do not protest the admission and a physician on the staff of or designated by the proposed admitting facility examines me and states in writing that I have a mental illness and I am incapable of making an informed decision about my admission, and that I need treatment in the facility; and to authorize my discharge (including transfer to another facility) from the facility;F\n\nTo authorize my admission to a health care facility for the treatment of mental illness for no more than 10 calendar days, even over my protest, if a physician on the staff of or designated by the proposed admitting facility examines me and states in writing that I have a mental illness and I am incapable of making an informed decision about my admission, and that I need treatment in the facility; and to authorize my discharge (including transfer to another facility) from the facility. [My physician or licensed clinical psychologist hereby attests that I am capable of making an informed decision and that I understand the consequences of this provision of my advance directive: ____________________];G\n\nTo authorize the specific types of health care identified in this advance directive [specify cross-reference to other sections of directive] even over my protest. [My physician or licensed clinical psychologist hereby attests that I am capable of making an informed decision and that I understand the consequences of this provision of my advance directive: ____________________];H\n\nTo continue to serve as my agent even in the event that I protest the agent’s authority after I have been determined to be incapable of making an informed decision;I\n\nTo authorize my participation in any health care study approved by an institutional review board or research review committee according to applicable federal or state law that offers the prospect of direct therapeutic benefit to me;J\n\nTo authorize my participation in any health care study approved by an institutional review board or research review committee pursuant to applicable federal or state law that aims to increase scientific understanding of any condition that I may have or otherwise to promote human well-being, even though it offers no prospect of direct benefit to me;K\n\nTo make decisions regarding visitation during any time that I am admitted to any health care facility, consistent with the following directions: __________; andL\n\nTo take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers. Further, my agent shall not be liable for the costs of health care pursuant to his authorization, based solely on that authorization.\n\t\t\tOPTION III: HEALTH CARE INSTRUCTIONS\n\t\t\t(CROSS THROUGH PARAGRAPHS A AND\/OR B IF YOU DO NOT WANT TO GIVE ADDITIONAL SPECIFIC INSTRUCTIONS ABOUT YOUR HEALTH CARE.)A\n\nI specifically direct that I receive the following health care if it is medically appropriate under the circumstances as determined by my attending physician: __________.B\n\nI specifically direct that the following health care not be provided to me under the following circumstances (you may specify that certain health care not be provided under any circumstances): __________.\n\t\t\tOPTION IV: END OF LIFE INSTRUCTIONS\n\t\t\t(CROSS THROUGH THIS OPTION IF YOU DO NOT WANT TO GIVE INSTRUCTIONS ABOUT YOUR HEALTH CARE IF YOU HAVE A TERMINAL CONDITION.)\n\t\t\tIf at any time my attending physician should determine that I have a terminal condition where the application of life-prolonging procedures \u2014 including artificial respiration, cardiopulmonary resuscitation, artificially administered nutrition, and artificially administered hydration \u2014 would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.\n\t\t\tOPTION: LIFE-PROLONGING PROCEDURES DURING PREGNANCY. (If you wish to provide additional instructions or modifications to instructions you have already given regarding life-prolonging procedures that will apply if you are pregnant at the time your attending physician determines that you have a terminal condition, you may do so here.)\n\t\t\tIf I am pregnant when my attending physician determines that I have a terminal condition, my decision concerning life-prolonging procedures shall be modified as follows:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________:\n\t\t\tOPTION: OTHER DIRECTIONS ABOUT LIFE-PROLONGING PROCEDURES. (If you wish to provide your own directions, or if you wish to add to the directions you have given above, you may do so here. If you wish to give specific instructions regarding certain life-prolonging procedures, such as artificial respiration, cardiopulmonary resuscitation, artificially administered nutrition, and artificially administered hydration, this is where you should write them.) I direct that:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________;\n\t\t\tOPTION: My other instructions regarding my care if I have a terminal condition are as follows:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________;\n\t\t\tIn the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this advance directive shall be honored by my family and physician as the final expression of my legal right to refuse health care and acceptance of the consequences of such refusal.\n\t\t\tOPTION V: APPOINTMENT OF AN AGENT TO MAKE AN ANATOMICAL GIFT OR ORGAN, TISSUE OR EYE DONATION (CROSS THROUGH IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE AN ANATOMICAL GIFT OR ANY ORGAN, TISSUE OR EYE DONATION FOR YOU.)\n\t\t\tUpon my death, I direct that an anatomical gift of all of my body or certain organ, tissue or eye donations may be made pursuant to Article 2 (\u00a7 32.1-291.1 et seq.) of Chapter 8 of Title 32.1 and in accordance with my directions, if any. I hereby appoint __________ as my agent, of __________ (address and telephone number), to make any such anatomical gift or organ, tissue or eye donation following my death. I further direct that: __________ (declarant’s directions concerning anatomical gift or organ, tissue or eye donation).\n\t\t\tThis advance directive shall not terminate in the event of my disability.\n\t\t\tAFFIRMATION AND RIGHT TO REVOKE: By signing below, I indicate that I am emotionally and mentally capable of making this advance directive and that I understand the purpose and effect of this document. I understand I may revoke all or any part of this document at any time (i) with a signed, dated writing; (ii) by physical cancellation or destruction of this advance directive by myself or by directing someone else to destroy it in my presence; or (iii) by my oral expression of intent to revoke.\n\t\t\t________ ____________________Date\n\n(Signature of Declarant)\n\t\t\t\tThe declarant signed the foregoing advance directive in my presence.Witness\n\n_________________________Witness\n\n_________________________","order_by":null,"text":{"0":{"id":229039,"text":"An advance directive executed pursuant to this article may, but need not, be in the following form:\n\t\tADVANCE MEDICAL DIRECTIVE\n\t\tI, __________, willingly and voluntarily make known my wishes in the event that I am incapable of making an informed decision, as follows:\n\t\tI understand that my advance directive may include the selection of an agent as well as set forth my choices regarding health care. The term “health care” means the furnishing of services to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical disability, including but not limited to, medications; surgery; blood transfusions; chemotherapy; radiation therapy; admission to a hospital, nursing home, assisted living facility, or other health care facility; psychiatric or other mental health treatment; and life-prolonging procedures and palliative care.\n\t\tThe phrase “incapable of making an informed decision” means unable to understand the nature, extent and probable consequences of a proposed health care decision or unable to make a rational evaluation of the risks and benefits of a proposed health care decision as compared with the risks and benefits of alternatives to that decision, or unable to communicate such understanding in any way.\n\t\tThe determination that I am incapable of making an informed decision shall be made by my attending physician and a capacity reviewer, if certification by a capacity reviewer is required by law, after a personal examination of me and shall be certified in writing. Such certification shall be required before health care is provided, continued, withheld or withdrawn, before any named agent shall be granted authority to make health care decisions on my behalf, and before, or as soon as reasonably practicable after, health care is provided, continued, withheld or withdrawn and every 180 days thereafter while the need for health care continues.\n\t\tIf, at any time, I am determined to be incapable of making an informed decision, I shall be notified, to the extent I am capable of receiving such notice, that such determination has been made before health care is provided, continued, withheld, or withdrawn. Such notice shall also be provided, as soon as practical, to my named agent or person authorized by \u00a7 54.1-2986 to make health care decisions on my behalf. If I am later determined to be capable of making an informed decision by a physician, in writing, upon personal examination, any further health care decisions will require my informed consent.\n\t\t(SELECT ANY OR ALL OF THE OPTIONS BELOW.)\n\t\tOPTION I: APPOINTMENT OF AGENT (CROSS THROUGH OPTIONS I AND II BELOW IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE HEALTH CARE DECISIONS FOR YOU.)\n\t\tI hereby appoint __________ (primary agent), of __________ (address and telephone number), as my agent to make health care decisions on my behalf as authorized in this document. If __________ (primary agent) is not reasonably available or is unable or unwilling to act as my agent, then I appoint __________ (successor agent), of __________ (address and telephone number), to serve in that capacity.\n\t\tI hereby grant to my agent, named above, full power and authority to make health care decisions on my behalf as described below whenever I have been determined to be incapable of making an informed decision. My agent’s authority hereunder is effective as long as I am incapable of making an informed decision.\n\t\tIn exercising the power to make health care decisions on my behalf, my agent shall follow my desires and preferences as stated in this document or as otherwise known to my agent. My agent shall be guided by my medical diagnosis and prognosis and any information provided by my physicians as to the intrusiveness, pain, risks, and side effects associated with treatment or nontreatment. My agent shall not make any decision regarding my health care which he knows, or upon reasonable inquiry ought to know, is contrary to my religious beliefs or my basic values, whether expressed orally or in writing. If my agent cannot determine what health care choice I would have made on my own behalf, then my agent shall make a choice for me based upon what he believes to be in my best interests.\n\t\tOPTION II: POWERS OF MY AGENT (CROSS THROUGH ANY LANGUAGE YOU DO NOT WANT AND ADD ANY LANGUAGE YOU DO WANT.)\n\t\tThe powers of my agent shall include the following:","type":"section","prefixes":[""],"prefix":"","entire_prefix":"","prefix_anchor":"","level":1,"next_prefix":"A"},"1":{"id":229040,"text":"To consent to or refuse or withdraw consent to any type of health care, treatment, surgical procedure, diagnostic procedure, medication and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, artificially administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the power to consent to the administration of dosages of pain-relieving medication in excess of recommended dosages in an amount sufficient to relieve pain, even if such medication carries the risk of addiction or of inadvertently hastening my death;","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"prior_prefix":"","next_prefix":"B"},"2":{"id":229041,"text":"To request, receive, and review any information, verbal or written, regarding my physical or mental health, including but not limited to, medical and hospital records, and to consent to the disclosure of this information;","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"3":{"id":229042,"text":"To employ and discharge my health care providers;","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"4":{"id":229043,"text":"To authorize my admission to or discharge (including transfer to another facility) from any hospital, hospice, nursing home, assisted living facility or other medical care facility. If I have authorized admission to a health care facility for treatment of mental illness, that authority is stated elsewhere in this advance directive;","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"5":{"id":229044,"text":"To authorize my admission to a health care facility for the treatment of mental illness for no more than 10 calendar days provided I do not protest the admission and a physician on the staff of or designated by the proposed admitting facility examines me and states in writing that I have a mental illness and I am incapable of making an informed decision about my admission, and that I need treatment in the facility; and to authorize my discharge (including transfer to another facility) from the facility;","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"6":{"id":229045,"text":"To authorize my admission to a health care facility for the treatment of mental illness for no more than 10 calendar days, even over my protest, if a physician on the staff of or designated by the proposed admitting facility examines me and states in writing that I have a mental illness and I am incapable of making an informed decision about my admission, and that I need treatment in the facility; and to authorize my discharge (including transfer to another facility) from the facility. [My physician or licensed clinical psychologist hereby attests that I am capable of making an informed decision and that I understand the consequences of this provision of my advance directive: ____________________];","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"7":{"id":229046,"text":"To authorize the specific types of health care identified in this advance directive [specify cross-reference to other sections of directive] even over my protest. [My physician or licensed clinical psychologist hereby attests that I am capable of making an informed decision and that I understand the consequences of this provision of my advance directive: ____________________];","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"8":{"id":229047,"text":"To continue to serve as my agent even in the event that I protest the agent’s authority after I have been determined to be incapable of making an informed decision;","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"I"},"9":{"id":229048,"text":"To authorize my participation in any health care study approved by an institutional review board or research review committee according to applicable federal or state law that offers the prospect of direct therapeutic benefit to me;","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H","next_prefix":"J"},"10":{"id":229049,"text":"To authorize my participation in any health care study approved by an institutional review board or research review committee pursuant to applicable federal or state law that aims to increase scientific understanding of any condition that I may have or otherwise to promote human well-being, even though it offers no prospect of direct benefit to me;","type":"section","prefixes":["J"],"prefix":"J","entire_prefix":"J","prefix_anchor":"J","level":1,"prior_prefix":"I","next_prefix":"K"},"11":{"id":229050,"text":"To make decisions regarding visitation during any time that I am admitted to any health care facility, consistent with the following directions: __________; and","type":"section","prefixes":["K"],"prefix":"K","entire_prefix":"K","prefix_anchor":"K","level":1,"prior_prefix":"J","next_prefix":"L"},"12":{"id":229051,"text":"To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers. Further, my agent shall not be liable for the costs of health care pursuant to his authorization, based solely on that authorization.\n\t\t\tOPTION III: HEALTH CARE INSTRUCTIONS\n\t\t\t(CROSS THROUGH PARAGRAPHS A AND\/OR B IF YOU DO NOT WANT TO GIVE ADDITIONAL SPECIFIC INSTRUCTIONS ABOUT YOUR HEALTH CARE.)","type":"section","prefixes":["L"],"prefix":"L","entire_prefix":"L","prefix_anchor":"L","level":1,"prior_prefix":"K","next_prefix":"A"},"13":{"id":229052,"text":"I specifically direct that I receive the following health care if it is medically appropriate under the circumstances as determined by my attending physician: __________.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"prior_prefix":"L","next_prefix":"B"},"14":{"id":229053,"text":"I specifically direct that the following health care not be provided to me under the following circumstances (you may specify that certain health care not be provided under any circumstances): __________.\n\t\t\tOPTION IV: END OF LIFE INSTRUCTIONS\n\t\t\t(CROSS THROUGH THIS OPTION IF YOU DO NOT WANT TO GIVE INSTRUCTIONS ABOUT YOUR HEALTH CARE IF YOU HAVE A TERMINAL CONDITION.)\n\t\t\tIf at any time my attending physician should determine that I have a terminal condition where the application of life-prolonging procedures \u2014 including artificial respiration, cardiopulmonary resuscitation, artificially administered nutrition, and artificially administered hydration \u2014 would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.\n\t\t\tOPTION: LIFE-PROLONGING PROCEDURES DURING PREGNANCY. (If you wish to provide additional instructions or modifications to instructions you have already given regarding life-prolonging procedures that will apply if you are pregnant at the time your attending physician determines that you have a terminal condition, you may do so here.)\n\t\t\tIf I am pregnant when my attending physician determines that I have a terminal condition, my decision concerning life-prolonging procedures shall be modified as follows:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________:\n\t\t\tOPTION: OTHER DIRECTIONS ABOUT LIFE-PROLONGING PROCEDURES. (If you wish to provide your own directions, or if you wish to add to the directions you have given above, you may do so here. If you wish to give specific instructions regarding certain life-prolonging procedures, such as artificial respiration, cardiopulmonary resuscitation, artificially administered nutrition, and artificially administered hydration, this is where you should write them.) I direct that:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________;\n\t\t\tOPTION: My other instructions regarding my care if I have a terminal condition are as follows:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________;\n\t\t\tIn the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this advance directive shall be honored by my family and physician as the final expression of my legal right to refuse health care and acceptance of the consequences of such refusal.\n\t\t\tOPTION V: APPOINTMENT OF AN AGENT TO MAKE AN ANATOMICAL GIFT OR ORGAN, TISSUE OR EYE DONATION (CROSS THROUGH IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE AN ANATOMICAL GIFT OR ANY ORGAN, TISSUE OR EYE DONATION FOR YOU.)\n\t\t\tUpon my death, I direct that an anatomical gift of all of my body or certain organ, tissue or eye donations may be made pursuant to Article 2 (\u00a7 32.1-291.1 et seq.) of Chapter 8 of Title 32.1 and in accordance with my directions, if any. I hereby appoint __________ as my agent, of __________ (address and telephone number), to make any such anatomical gift or organ, tissue or eye donation following my death. I further direct that: __________ (declarant’s directions concerning anatomical gift or organ, tissue or eye donation).\n\t\t\tThis advance directive shall not terminate in the event of my disability.\n\t\t\tAFFIRMATION AND RIGHT TO REVOKE: By signing below, I indicate that I am emotionally and mentally capable of making this advance directive and that I understand the purpose and effect of this document. I understand I may revoke all or any part of this document at any time (i) with a signed, dated writing; (ii) by physical cancellation or destruction of this advance directive by myself or by directing someone else to destroy it in my presence; or (iii) by my oral expression of intent to revoke.\n\t\t\t________ ____________________","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"BDate"},"15":{"id":229054,"text":"(Signature of Declarant)\n\t\t\t\tThe declarant signed the foregoing advance directive in my presence.","type":"section","prefixes":["B","Date"],"prefix":"Date","entire_prefix":"BDate","prefix_anchor":"BDate","level":2,"prior_prefix":"B","next_prefix":"BWitness"},"16":{"id":229055,"text":"_________________________","type":"section","prefixes":["B","Witness"],"prefix":"Witness","entire_prefix":"BWitness","prefix_anchor":"BWitness","level":2,"prior_prefix":"BDate","next_prefix":"BWitness"},"17":{"id":229056,"text":"_________________________","type":"section","prefixes":["B","Witness"],"prefix":"Witness","entire_prefix":"BWitness","prefix_anchor":"BWitness","level":2,"prior_prefix":"BWitness"}},"ancestry":[{"id":14683,"edition_id":1,"name":"Health Care Decisions Act","identifier":"8","label":"article","depth":4,"order_by":1,"parent_id":12759,"metadata":{},"date_created":"2026-06-26 03:49:19","date_modified":"2026-06-26 03:49:19","permalink":{"id":242579,"object_type":"structure","relational_id":14683,"identifier":"8","token":"54.1\/III\/29\/8","url":"\/54.1\/III\/29\/8\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12759,"edition_id":1,"name":"Medicine and Other Healing Arts","identifier":"29","label":"chapter","depth":3,"order_by":1,"parent_id":12758,"metadata":{},"date_created":"2026-06-26 03:43:51","date_modified":"2026-06-26 03:43:51","permalink":{"id":241933,"object_type":"structure","relational_id":12759,"identifier":"29","token":"54.1\/III\/29","url":"\/54.1\/III\/29\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12758,"edition_id":1,"name":"Professions and Occupations Regulated by Boards Within the Department of Health Professions","identifier":"III","label":"subtitle","depth":2,"order_by":1,"parent_id":12754,"metadata":{},"date_created":"2026-06-26 03:43:51","date_modified":"2026-06-26 03:43:51","permalink":{"id":241105,"object_type":"structure","relational_id":12758,"identifier":"III","token":"54.1\/III","url":"\/54.1\/III\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12754,"edition_id":1,"name":"Professions and Occupations","identifier":"54.1","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:51","date_modified":"2026-06-26 03:43:51","permalink":{"id":239313,"object_type":"structure","relational_id":12754,"identifier":"54.1","token":"54.1","url":"\/54.1\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":77307,"structure_id":14683,"section_number":"54.1-2981","catch_line":"Short title","url":"\/54.1-2981\/","token":"54.1\/III\/29\/8\/54.1-2981","metadata":false},{"id":56308,"structure_id":14683,"section_number":"54.1-2982","catch_line":"Definitions","url":"\/54.1-2982\/","token":"54.1\/III\/29\/8\/54.1-2982","metadata":false},{"id":57295,"structure_id":14683,"section_number":"54.1-2983","catch_line":"Procedure for making advance directive; notice to physician","url":"\/54.1-2983\/","token":"54.1\/III\/29\/8\/54.1-2983","metadata":false},{"id":61815,"structure_id":14683,"section_number":"54.1-2983.1","catch_line":"Participation in health care research","url":"\/54.1-2983.1\/","token":"54.1\/III\/29\/8\/54.1-2983.1","metadata":false},{"id":67924,"structure_id":14683,"section_number":"54.1-2983.2","catch_line":"Capacity; required determinations","url":"\/54.1-2983.2\/","token":"54.1\/III\/29\/8\/54.1-2983.2","metadata":false},{"id":56394,"structure_id":14683,"section_number":"54.1-2983.3","catch_line":"Exclusions and limitations of advance directives","url":"\/54.1-2983.3\/","token":"54.1\/III\/29\/8\/54.1-2983.3","metadata":false},{"id":62832,"structure_id":14683,"section_number":"54.1-2984","catch_line":"Suggested form of written advance directives","url":"\/54.1-2984\/","token":"54.1\/III\/29\/8\/54.1-2984","metadata":false},{"id":58882,"structure_id":14683,"section_number":"54.1-2985","catch_line":"Revocation of an advance directive","url":"\/54.1-2985\/","token":"54.1\/III\/29\/8\/54.1-2985","metadata":false},{"id":61746,"structure_id":14683,"section_number":"54.1-2985.1","catch_line":"Injunction; court-ordered health care","url":"\/54.1-2985.1\/","token":"54.1\/III\/29\/8\/54.1-2985.1","metadata":false},{"id":65220,"structure_id":14683,"section_number":"54.1-2986","catch_line":"Procedure in absence of an advance directive; procedure for advance directive without agent; no presumption; persons who may authorize health care for patients incapable of informed decisions","url":"\/54.1-2986\/","token":"54.1\/III\/29\/8\/54.1-2986","metadata":false},{"id":79852,"structure_id":14683,"section_number":"54.1-2986.1","catch_line":"Duties and authority of agent or person identified in \u00a7 54.1-2986","url":"\/54.1-2986.1\/","token":"54.1\/III\/29\/8\/54.1-2986.1","metadata":false},{"id":73438,"structure_id":14683,"section_number":"54.1-2986.2","catch_line":"Health care decisions in the event of patient protest","url":"\/54.1-2986.2\/","token":"54.1\/III\/29\/8\/54.1-2986.2","metadata":false},{"id":70254,"structure_id":14683,"section_number":"54.1-2987","catch_line":"Transfer of patient by physician who refuses to comply with advance directive or health care decision","url":"\/54.1-2987\/","token":"54.1\/III\/29\/8\/54.1-2987","metadata":false},{"id":61456,"structure_id":14683,"section_number":"54.1-2987.1","catch_line":"Durable Do Not Resuscitate Orders","url":"\/54.1-2987.1\/","token":"54.1\/III\/29\/8\/54.1-2987.1","metadata":false},{"id":78436,"structure_id":14683,"section_number":"54.1-2988","catch_line":"Immunity from liability; burden of proof; presumption","url":"\/54.1-2988\/","token":"54.1\/III\/29\/8\/54.1-2988","metadata":false},{"id":76186,"structure_id":14683,"section_number":"54.1-2988.1","catch_line":"Assistance with completing and executing advance directives","url":"\/54.1-2988.1\/","token":"54.1\/III\/29\/8\/54.1-2988.1","metadata":false},{"id":75997,"structure_id":14683,"section_number":"54.1-2989","catch_line":"Willful destruction, concealment, etc., of declaration or revocation; penalties","url":"\/54.1-2989\/","token":"54.1\/III\/29\/8\/54.1-2989","metadata":false},{"id":63401,"structure_id":14683,"section_number":"54.1-2989.1","catch_line":"Failure to deliver advance directive","url":"\/54.1-2989.1\/","token":"54.1\/III\/29\/8\/54.1-2989.1","metadata":false},{"id":83098,"structure_id":14683,"section_number":"54.1-2990","catch_line":"Medically unnecessary health care not required; procedure when physician refuses to comply with an advance directive or a designated person's health care decision; mercy killing or euthanasia prohibited","url":"\/54.1-2990\/","token":"54.1\/III\/29\/8\/54.1-2990","metadata":false},{"id":78993,"structure_id":14683,"section_number":"54.1-2991","catch_line":"Effect of declaration; suicide; insurance; declarations executed prior to effective date","url":"\/54.1-2991\/","token":"54.1\/III\/29\/8\/54.1-2991","metadata":false},{"id":74741,"structure_id":14683,"section_number":"54.1-2992","catch_line":"Preservation of existing rights","url":"\/54.1-2992\/","token":"54.1\/III\/29\/8\/54.1-2992","metadata":false},{"id":58521,"structure_id":14683,"section_number":"54.1-2993","catch_line":"Reciprocity","url":"\/54.1-2993\/","token":"54.1\/III\/29\/8\/54.1-2993","metadata":false},{"id":76420,"structure_id":14683,"section_number":"54.1-2993.1","catch_line":"Qualified advance directive facilitators; requirements for training programs","url":"\/54.1-2993.1\/","token":"54.1\/III\/29\/8\/54.1-2993.1","metadata":false}],"previous_section":{"id":56394,"structure_id":14683,"section_number":"54.1-2983.3","catch_line":"Exclusions and limitations of advance directives","url":"\/54.1-2983.3\/","token":"54.1\/III\/29\/8\/54.1-2983.3","metadata":false},"next_section":{"id":58882,"structure_id":14683,"section_number":"54.1-2985","catch_line":"Revocation of an advance directive","url":"\/54.1-2985\/","token":"54.1\/III\/29\/8\/54.1-2985","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/54.1-2984\/","history_text":"

This law was first created in 1983. The record of its establishment is cataloged in chapter 532 of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. Unfortunately, the 1983 \u201cActs\u201d aren\u2019t available online. It has been modified 12 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 1988, chapter 765; in 1989, chapter 592; in 1991, chapter 583; in 1992, chapters 748 and 772; in 1997, chapter 609<\/a>; in 1999, chapter 814<\/a>; in 2000, chapter 810<\/a>; in 2005, chapter 186<\/a>; in 2007, chapters 92<\/a> and 907<\/a>; in 2009, chapters 211<\/a> and 268<\/a>; in 2010, chapter 792<\/a>; in 2015, chapter 109<\/a>.<\/p>","references":[{"id":60700,"section_number":"32.1-309.1","catch_line":"Identification of decedent, next of kin; disposition of claimed dead body","order_by":null,"url":"\/32.1-309.1\/"},{"id":56627,"section_number":"37.2-838","catch_line":"Discharge of individuals from a licensed hospital","order_by":null,"url":"\/37.2-838\/"},{"id":75008,"section_number":"54.1-2807.02","catch_line":"Absence of next of kin","order_by":null,"url":"\/54.1-2807.02\/"},{"id":84765,"section_number":"54.1-2818.1","catch_line":"Prerequisites for cremation","order_by":null,"url":"\/54.1-2818.1\/"},{"id":79569,"section_number":"54.1-2818.5","catch_line":"Request for life insurance information; notification of beneficiaries","order_by":null,"url":"\/54.1-2818.5\/"},{"id":76186,"section_number":"54.1-2988.1","catch_line":"Assistance with completing and executing advance directives","order_by":null,"url":"\/54.1-2988.1\/"},{"id":76420,"section_number":"54.1-2993.1","catch_line":"Qualified advance directive facilitators; requirements for training programs","order_by":null,"url":"\/54.1-2993.1\/"}],"refers_to":[{"id":72836,"section_number":"32.1-291.1","catch_line":"Revised Uniform Anatomical Gift Act; short title","order_by":null,"url":"\/32.1-291.1\/"},{"id":65220,"section_number":"54.1-2986","catch_line":"Procedure in absence of an advance directive; procedure for advance directive without agent; no presumption; persons who may authorize health care for patients incapable of informed decisions","order_by":null,"url":"\/54.1-2986\/"}],"permalink":{"id":242605,"object_type":"law","relational_id":62832,"identifier":"54.1-2984","token":"54.1\/III\/29\/8\/54.1-2984","url":"\/54.1-2984\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/54.1-2984\/","token":"54.1\/III\/29\/8\/54.1-2984","dublin_core":{"Title":"Suggested form of written advance directives","Type":"Text","Format":"text\/html","Identifier":"\u00a7 54.1-2984","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

An advance directive<\/span> executed pursuant to this article may, but need not, be in the following form:\n\t\tADVANCE MEDICAL DIRECTIVE\n\t\tI, __________, willingly and voluntarily make known my wishes in the event that I am incapable of making an informed decision<\/span>, as follows:\n\t\tI understand that my advance directive<\/span> may include the selection of an agent<\/span> as well as set forth my choices regarding health care<\/span>. The term “health care<\/span>” means the furnishing of services to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical disability, including but not limited to, medications; surgery; blood transfusions; chemotherapy; radiation therapy; admission to a hospital, nursing home, assisted living facility, or other health care<\/span> facility; psychiatric or other mental health treatment<\/span>; and life-prolonging procedures<\/span> and palliative care.\n\t\tThe phrase “incapable of making an informed decision<\/span>” means unable to understand the nature, extent and probable consequences of a proposed health care<\/span> decision or unable to make a rational evaluation of the risks and benefits of a proposed health care<\/span> decision as compared with the risks and benefits of alternatives to that decision, or unable to communicate such understanding in any way.\n\t\tThe determination that I am incapable of making an informed decision<\/span> shall be made by my attending physician<\/span> and a capacity reviewer<\/span>, if certification by a capacity reviewer<\/span> is required by law<\/span>, after a personal examination of me and shall be certified in writing. Such certification shall be required before health care<\/span> is provided, continued, withheld or withdrawn, before any named agent<\/span> shall be granted authority to make health care<\/span> decisions on my behalf, and before, or as soon as reasonably practicable after, health care<\/span> is provided, continued, withheld or withdrawn and every 180 days thereafter while the need for health care<\/span> continues.\n\t\tIf, at any time, I am determined to be incapable of making an informed decision<\/span>, I shall be notified, to the extent I am capable of receiving such notice, that such determination has been made before health care<\/span> is provided, continued, withheld, or withdrawn. Such notice shall also be provided, as soon as practical, to my named agent<\/span> or person authorized by \u00a7 54.1-2986<\/a> to make health care<\/span> decisions on my behalf. If I am later determined to be capable of making an informed decision by a physician, in writing, upon personal examination, any further health care<\/span> decisions will require my informed consent.\n\t\t(SELECT ANY OR ALL OF THE OPTIONS BELOW.)\n\t\tOPTION I: APPOINTMENT OF AGENT<\/span> (CROSS THROUGH OPTIONS I AND II BELOW IF YOU DO NOT WANT TO APPOINT AN AGENT<\/span> TO MAKE HEALTH CARE<\/span> DECISIONS FOR YOU.)\n\t\tI hereby appoint __________ (primary agent<\/span>), of __________ (address and telephone number), as my agent<\/span> to make health care<\/span> decisions on my behalf as authorized in this document. If __________ (primary agent<\/span>) is not reasonably available or is unable or unwilling to act as my agent<\/span>, then I appoint __________ (successor agent<\/span>), of __________ (address and telephone number), to serve in that capacity.\n\t\tI hereby grant to my agent<\/span>, named above, full power and authority to make health care<\/span> decisions on my behalf as described below whenever I have been determined to be incapable of making an informed decision<\/span>. My agent<\/span>’s authority hereunder is effective as long as I am incapable of making an informed decision<\/span>.\n\t\tIn exercising the power to make health care<\/span> decisions on my behalf, my agent<\/span> shall follow my desires and preferences as stated in this document or as otherwise known to my agent<\/span>. My agent<\/span> shall be guided by my medical diagnosis and prognosis and any information provided by my physicians<\/span> as to the intrusiveness, pain, risks, and side effects associated with treatment or nontreatment. My agent<\/span> shall not make any decision regarding my health care<\/span> which he knows, or upon reasonable inquiry ought to know, is contrary to my religious beliefs or my basic values, whether expressed orally or in writing. If my agent<\/span> cannot determine what health care<\/span> choice I would have made on my own behalf, then my agent<\/span> shall make a choice for me based upon what he believes to be in my best interests.\n\t\tOPTION II: POWERS OF MY AGENT<\/span> (CROSS THROUGH ANY LANGUAGE YOU DO NOT WANT AND ADD ANY LANGUAGE YOU DO WANT.)\n\t\tThe powers of my agent<\/span> shall include the following:<\/p><\/section>\n\t\t\t\t\t\t

A.<\/span> To consent to or refuse or withdraw consent to any type of health care<\/span>, treatment, surgical procedure, diagnostic procedure, medication and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, artificially administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the power to consent to the administration of dosages of pain-relieving medication in excess of recommended dosages in an amount sufficient to relieve pain, even if such medication carries the risk of addiction or of inadvertently hastening my death; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> To request, receive, and review any information, verbal or written, regarding my physical or mental health, including but not limited to, medical and hospital records, and to consent to the disclosure of this information; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> To employ and discharge my health care<\/span> providers; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> To authorize my admission to or discharge (including transfer to another facility) from any hospital, hospice, nursing home, assisted living facility or other medical care facility. If I have authorized admission to a health care<\/span> facility for treatment of mental illness, that authority is stated elsewhere in this advance directive<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> To authorize my admission to a health care<\/span> facility for the treatment of mental illness for no more than 10 calendar days provided I do not protest the admission and a physician on the staff of or designated by the proposed admitting facility examines me and states in writing that I have a mental illness and I am incapable of making an informed decision<\/span> about my admission, and that I need treatment in the facility; and to authorize my discharge (including transfer to another facility) from the facility; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> To authorize my admission to a health care<\/span> facility for the treatment of mental illness for no more than 10 calendar days, even over my protest, if a physician on the staff of or designated by the proposed admitting facility examines me and states in writing that I have a mental illness and I am incapable of making an informed decision<\/span> about my admission, and that I need treatment in the facility; and to authorize my discharge (including transfer to another facility) from the facility. [My physician or licensed clinical psychologist hereby attests that I am capable of making an informed decision and that I understand the consequences of this provision of my advance directive<\/span>: ____________________]; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> To authorize the specific types of health care<\/span> identified in this advance directive<\/span> [specify cross-reference to other sections of directive] even over my protest. [My physician or licensed clinical psychologist hereby attests that I am capable of making an informed decision and that I understand the consequences of this provision of my advance directive<\/span>: ____________________]; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> To continue to serve as my agent<\/span> even in the event that I protest the agent<\/span>’s authority after I have been determined to be incapable of making an informed decision<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> To authorize my participation in any health care<\/span> study approved by an institutional review board<\/span> or research review committee according to applicable federal or state law<\/span> that offers the prospect of direct therapeutic benefit to me; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

J.<\/span> To authorize my participation in any health care<\/span> study approved by an institutional review board<\/span> or research review committee pursuant to applicable federal or state law<\/span> that aims to increase scientific understanding of any condition that I may have or otherwise to promote human well-being, even though it offers no prospect of direct benefit to me; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

K.<\/span> To make decisions regarding visitation during any time that I am admitted to any health care<\/span> facility, consistent with the following directions: __________; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

L.<\/span> To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers. Further, my agent<\/span> shall not be liable for the costs of health care<\/span> pursuant to his authorization, based solely on that authorization.\n\t\t\tOPTION III: HEALTH CARE<\/span> INSTRUCTIONS\n\t\t\t(CROSS THROUGH PARAGRAPHS A AND\/OR B IF YOU DO NOT WANT TO GIVE ADDITIONAL SPECIFIC INSTRUCTIONS ABOUT YOUR HEALTH CARE<\/span>.) <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

A.<\/span> I specifically direct that I receive the following health care<\/span> if it is medically appropriate under the circumstances as determined by my attending physician<\/span>: __________. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> I specifically direct that the following health care<\/span> not be provided to me under the following circumstances (you may specify that certain health care<\/span> not be provided under any circumstances): __________.\n\t\t\tOPTION IV: END OF LIFE INSTRUCTIONS\n\t\t\t(CROSS THROUGH THIS OPTION IF YOU DO NOT WANT TO GIVE INSTRUCTIONS ABOUT YOUR HEALTH CARE<\/span> IF YOU HAVE A TERMINAL CONDITION<\/span>.)\n\t\t\tIf at any time my attending physician<\/span> should determine that I have a terminal condition<\/span> where the application of life-prolonging procedures<\/span> \u2014 including artificial respiration, cardiopulmonary resuscitation, artificially administered nutrition, and artificially administered hydration \u2014 would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.\n\t\t\tOPTION: LIFE-PROLONGING PROCEDURES<\/span> DURING PREGNANCY. (If you wish to provide additional instructions or modifications to instructions you have already given regarding life-prolonging procedures<\/span> that will apply if you are pregnant at the time your attending physician<\/span> determines that you have a terminal condition<\/span>, you may do so here.)\n\t\t\tIf I am pregnant when my attending physician<\/span> determines that I have a terminal condition<\/span>, my decision concerning life-prolonging procedures<\/span> shall be modified as follows:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________:\n\t\t\tOPTION: OTHER DIRECTIONS ABOUT LIFE-PROLONGING PROCEDURES<\/span>. (If you wish to provide your own directions, or if you wish to add to the directions you have given above, you may do so here. If you wish to give specific instructions regarding certain life-prolonging procedures<\/span>, such as artificial respiration, cardiopulmonary resuscitation, artificially administered nutrition, and artificially administered hydration, this is where you should write them.) I direct that:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________;\n\t\t\tOPTION: My other instructions regarding my care if I have a terminal condition<\/span> are as follows:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________;\n\t\t\tIn the absence of my ability to give directions regarding the use of such life-prolonging procedures<\/span>, it is my intention that this advance directive<\/span> shall be honored by my family and physician as the final expression of my legal right to refuse health care<\/span> and acceptance of the consequences of such refusal.\n\t\t\tOPTION V: APPOINTMENT OF AN AGENT<\/span> TO MAKE AN ANATOMICAL GIFT OR ORGAN, TISSUE OR EYE DONATION (CROSS THROUGH IF YOU DO NOT WANT TO APPOINT AN AGENT<\/span> TO MAKE AN ANATOMICAL GIFT OR ANY ORGAN, TISSUE OR EYE DONATION FOR YOU.)\n\t\t\tUpon my death, I direct that an anatomical gift of all of my body or certain organ, tissue or eye donations may be made pursuant to Article 2 (\u00a7 32.1-291.1<\/a> et seq.) of Chapter 8 of Title 32.1 and in accordance with my directions, if any. I hereby appoint __________ as my agent<\/span>, of __________ (address and telephone number), to make any such anatomical gift or organ, tissue or eye donation following my death. I further direct that: __________ (declarant<\/span>’s directions concerning anatomical gift or organ, tissue or eye donation).\n\t\t\tThis advance directive<\/span> shall not terminate in the event of my disability.\n\t\t\tAFFIRMATION AND RIGHT TO REVOKE: By signing below, I indicate that I am emotionally and mentally capable of making this advance directive<\/span> and that I understand the purpose and effect of this document. I understand I may revoke all or any part of this document at any time (i) with a signed, dated writing; (ii) by physical cancellation or destruction of this advance directive<\/span> by myself or by directing someone else to destroy it in my presence; or (iii) by my oral expression of intent<\/span> to revoke.\n\t\t\t________ ____________________ <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

Date.<\/span> (Signature of Declarant<\/span>)\n\t\t\t\tThe declarant<\/span> signed the foregoing advance directive<\/span> in my presence. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

Witness.<\/span> _________________________ <\/i><\/a><\/p>

_________________________ <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nSUGGESTED FORM OF WRITTEN ADVANCE DIRECTIVES (\u00a7 54.1-2984)\n\nAn advance directive executed pursuant to this article may, but need not, be in\nthe following form:\n\t\tADVANCE MEDICAL DIRECTIVE\n\t\tI, __________, willingly and voluntarily make known my wishes in the event\nthat I am incapable of making an informed decision, as follows:\n\t\tI understand that my advance directive may include the selection of an agent\nas well as set forth my choices regarding health care. The term “health\ncare” means the furnishing of services to any individual for the purpose\nof preventing, alleviating, curing, or healing human illness, injury or physical\ndisability, including but not limited to, medications; surgery; blood\ntransfusions; chemotherapy; radiation therapy; admission to a hospital, nursing\nhome, assisted living facility, or other health care facility; psychiatric or\nother mental health treatment; and life-prolonging procedures and palliative\ncare.\n\t\tThe phrase “incapable of making an informed decision” means unable\nto understand the nature, extent and probable consequences of a proposed health\ncare decision or unable to make a rational evaluation of the risks and benefits\nof a proposed health care decision as compared with the risks and benefits of\nalternatives to that decision, or unable to communicate such understanding in\nany way.\n\t\tThe determination that I am incapable of making an informed decision shall be\nmade by my attending physician and a capacity reviewer, if certification by a\ncapacity reviewer is required by law, after a personal examination of me and\nshall be certified in writing. Such certification shall be required before\nhealth care is provided, continued, withheld or withdrawn, before any named\nagent shall be granted authority to make health care decisions on my behalf, and\nbefore, or as soon as reasonably practicable after, health care is provided,\ncontinued, withheld or withdrawn and every 180 days thereafter while the need\nfor health care continues.\n\t\tIf, at any time, I am determined to be incapable of making an informed\ndecision, I shall be notified, to the extent I am capable of receiving such\nnotice, that such determination has been made before health care is provided,\ncontinued, withheld, or withdrawn. Such notice shall also be provided, as soon\nas practical, to my named agent or person authorized by \u00a7 54.1-2986 to make\nhealth care decisions on my behalf. If I am later determined to be capable of\nmaking an informed decision by a physician, in writing, upon personal\nexamination, any further health care decisions will require my informed consent.\n\t\t(SELECT ANY OR ALL OF THE OPTIONS BELOW.)\n\t\tOPTION I: APPOINTMENT OF AGENT (CROSS THROUGH OPTIONS I AND II BELOW IF YOU DO\nNOT WANT TO APPOINT AN AGENT TO MAKE HEALTH CARE DECISIONS FOR YOU.)\n\t\tI hereby appoint __________ (primary agent), of __________ (address and\ntelephone number), as my agent to make health care decisions on my behalf as\nauthorized in this document. If __________ (primary agent) is not reasonably\navailable or is unable or unwilling to act as my agent, then I appoint\n__________ (successor agent), of __________ (address and telephone number), to\nserve in that capacity.\n\t\tI hereby grant to my agent, named above, full power and authority to make\nhealth care decisions on my behalf as described below whenever I have been\ndetermined to be incapable of making an informed decision. My agent’s\nauthority hereunder is effective as long as I am incapable of making an informed\ndecision.\n\t\tIn exercising the power to make health care decisions on my behalf, my agent\nshall follow my desires and preferences as stated in this document or as\notherwise known to my agent. My agent shall be guided by my medical diagnosis\nand prognosis and any information provided by my physicians as to the\nintrusiveness, pain, risks, and side effects associated with treatment or\nnontreatment. My agent shall not make any decision regarding my health care\nwhich he knows, or upon reasonable inquiry ought to know, is contrary to my\nreligious beliefs or my basic values, whether expressed orally or in writing. If\nmy agent cannot determine what health care choice I would have made on my own\nbehalf, then my agent shall make a choice for me based upon what he believes to\nbe in my best interests.\n\t\tOPTION II: POWERS OF MY AGENT (CROSS THROUGH ANY LANGUAGE YOU DO NOT WANT AND\nADD ANY LANGUAGE YOU DO WANT.)\n\t\tThe powers of my agent shall include the following:\n\nA. To consent to or refuse or withdraw consent to any type of health care,\ntreatment, surgical procedure, diagnostic procedure, medication and the use of\nmechanical or other procedures that affect any bodily function, including, but\nnot limited to, artificial respiration, artificially administered nutrition and\nhydration, and cardiopulmonary resuscitation. This authorization specifically\nincludes the power to consent to the administration of dosages of pain-relieving\nmedication in excess of recommended dosages in an amount sufficient to relieve\npain, even if such medication carries the risk of addiction or of inadvertently\nhastening my death;\n\nB. To request, receive, and review any information, verbal or written, regarding\nmy physical or mental health, including but not limited to, medical and hospital\nrecords, and to consent to the disclosure of this information;\n\nC. To employ and discharge my health care providers;\n\nD. To authorize my admission to or discharge (including transfer to another\nfacility) from any hospital, hospice, nursing home, assisted living facility or\nother medical care facility. If I have authorized admission to a health care\nfacility for treatment of mental illness, that authority is stated elsewhere in\nthis advance directive;\n\nE. To authorize my admission to a health care facility for the treatment of\nmental illness for no more than 10 calendar days provided I do not protest the\nadmission and a physician on the staff of or designated by the proposed\nadmitting facility examines me and states in writing that I have a mental\nillness and I am incapable of making an informed decision about my admission,\nand that I need treatment in the facility; and to authorize my discharge\n(including transfer to another facility) from the facility;\n\nF. To authorize my admission to a health care facility for the treatment of\nmental illness for no more than 10 calendar days, even over my protest, if a\nphysician on the staff of or designated by the proposed admitting facility\nexamines me and states in writing that I have a mental illness and I am\nincapable of making an informed decision about my admission, and that I need\ntreatment in the facility; and to authorize my discharge (including transfer to\nanother facility) from the facility. [My physician or licensed clinical\npsychologist hereby attests that I am capable of making an informed decision and\nthat I understand the consequences of this provision of my advance directive:\n____________________];\n\nG. To authorize the specific types of health care identified in this advance\ndirective [specify cross-reference to other sections of directive] even over my\nprotest. [My physician or licensed clinical psychologist hereby attests that I\nam capable of making an informed decision and that I understand the consequences\nof this provision of my advance directive: ____________________];\n\nH. To continue to serve as my agent even in the event that I protest the\nagent’s authority after I have been determined to be incapable of making\nan informed decision;\n\nI. To authorize my participation in any health care study approved by an\ninstitutional review board or research review committee according to applicable\nfederal or state law that offers the prospect of direct therapeutic benefit to\nme;\n\nJ. To authorize my participation in any health care study approved by an\ninstitutional review board or research review committee pursuant to applicable\nfederal or state law that aims to increase scientific understanding of any\ncondition that I may have or otherwise to promote human well-being, even though\nit offers no prospect of direct benefit to me;\n\nK. To make decisions regarding visitation during any time that I am admitted to\nany health care facility, consistent with the following directions: __________;\nand\n\nL. To take any lawful actions that may be necessary to carry out these\ndecisions, including the granting of releases of liability to medical providers.\nFurther, my agent shall not be liable for the costs of health care pursuant to\nhis authorization, based solely on that authorization.\n\t\t\tOPTION III: HEALTH CARE INSTRUCTIONS\n\t\t\t(CROSS THROUGH PARAGRAPHS A AND\/OR B IF YOU DO NOT WANT TO GIVE ADDITIONAL\nSPECIFIC INSTRUCTIONS ABOUT YOUR HEALTH CARE.)\n\nA. I specifically direct that I receive the following health care if it is\nmedically appropriate under the circumstances as determined by my attending\nphysician: __________.\n\nB. I specifically direct that the following health care not be provided to me\nunder the following circumstances (you may specify that certain health care not\nbe provided under any circumstances): __________.\n\t\t\tOPTION IV: END OF LIFE INSTRUCTIONS\n\t\t\t(CROSS THROUGH THIS OPTION IF YOU DO NOT WANT TO GIVE INSTRUCTIONS ABOUT YOUR\nHEALTH CARE IF YOU HAVE A TERMINAL CONDITION.)\n\t\t\tIf at any time my attending physician should determine that I have a terminal\ncondition where the application of life-prolonging procedures \u2014 including\nartificial respiration, cardiopulmonary resuscitation, artificially administered\nnutrition, and artificially administered hydration \u2014 would serve only to\nartificially prolong the dying process, I direct that such procedures be\nwithheld or withdrawn, and that I be permitted to die naturally with only the\nadministration of medication or the performance of any medical procedure deemed\nnecessary to provide me with comfort care or to alleviate pain.\n\t\t\tOPTION: LIFE-PROLONGING PROCEDURES DURING PREGNANCY. (If you wish to provide\nadditional instructions or modifications to instructions you have already given\nregarding life-prolonging procedures that will apply if you are pregnant at the\ntime your attending physician determines that you have a terminal condition, you\nmay do so here.)\n\t\t\tIf I am pregnant when my attending physician determines that I have a\nterminal condition, my decision concerning life-prolonging procedures shall be\nmodified as follows:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________:\n\t\t\tOPTION: OTHER DIRECTIONS ABOUT LIFE-PROLONGING PROCEDURES. (If you wish to\nprovide your own directions, or if you wish to add to the directions you have\ngiven above, you may do so here. If you wish to give specific instructions\nregarding certain life-prolonging procedures, such as artificial respiration,\ncardiopulmonary resuscitation, artificially administered nutrition, and\nartificially administered hydration, this is where you should write them.) I\ndirect that:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________;\n\t\t\tOPTION: My other instructions regarding my care if I have a terminal\ncondition are as follows:\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________\n\t\t\t____________________________________________________________;\n\t\t\tIn the absence of my ability to give directions regarding the use of such\nlife-prolonging procedures, it is my intention that this advance directive shall\nbe honored by my family and physician as the final expression of my legal right\nto refuse health care and acceptance of the consequences of such refusal.\n\t\t\tOPTION V: APPOINTMENT OF AN AGENT TO MAKE AN ANATOMICAL GIFT OR ORGAN, TISSUE\nOR EYE DONATION (CROSS THROUGH IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE AN\nANATOMICAL GIFT OR ANY ORGAN, TISSUE OR EYE DONATION FOR YOU.)\n\t\t\tUpon my death, I direct that an anatomical gift of all of my body or certain\norgan, tissue or eye donations may be made pursuant to Article 2 (\u00a7 32.1-291.1\net seq.) of Chapter 8 of Title 32.1 and in accordance with my directions, if\nany. I hereby appoint __________ as my agent, of __________ (address and\ntelephone number), to make any such anatomical gift or organ, tissue or eye\ndonation following my death. I further direct that: __________\n(declarant’s directions concerning anatomical gift or organ, tissue or eye\ndonation).\n\t\t\tThis advance directive shall not terminate in the event of my disability.\n\t\t\tAFFIRMATION AND RIGHT TO REVOKE: By signing below, I indicate that I am\nemotionally and mentally capable of making this advance directive and that I\nunderstand the purpose and effect of this document. I understand I may revoke\nall or any part of this document at any time (i) with a signed, dated writing;\n(ii) by physical cancellation or destruction of this advance directive by myself\nor by directing someone else to destroy it in my presence; or (iii) by my oral\nexpression of intent to revoke.\n\t\t\t________ ____________________\n\n Date. (Signature of Declarant)\n \t\t\t\tThe declarant signed the foregoing advance directive in my presence.\n\n Witness. _________________________\n\n _________________________\n\nHISTORY: 1983, c. 532, \u00a7 54-325.8:4; 1988, c. 765; 1989, c. 592; 1991, c. 583;\n1992, cc. 748, 772; 1997, c. 609; 1999, c. 814; 2000, c. 810; 2005, c. 186;\n2007, cc. 92, 907; 2009, cc. 211, 268; 2010, c. 792; 2015, c. 109.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}