Mississippi Advance Health-Care Directive
You have the right to give instructions about your own health care. You also have the
right to name someone else to make health-care decisions for you. This form lets you do
either or both of these things. It also lets you express your wishes regarding the
designation of your primary physician. If you use this form, you may complete or modify
all or any part of it. You are free to use a different form.
Part 1 of this form is a power of attorney for health care. Part 1 lets you name another
individual as agent to make health-care decisions for you if you become incapable of
making your own decisions or if you want someone else to make those decisions for you
now even though you are still capable. You may name an alternate agent to act for you if
your first choice is not willing, able or reasonably available to make decisions for you.
Unless related to you, your agent may not be an owner, operator, or employee of a
residential long-term health-care institution at which you are receiving care.
Unless the form you sign limits the authority of your agent, your agent may make all
health-care decisions for you. This form has a place for you to limit the authority of your
agent. You need not limit the authority of your agent if you wish to rely on your agent for
all health-care decisions that may have to be made. If you choose not to limit the
authority of your agent, your agent will have the right to:
(a) Consent or refuse consent to any care, treatment, service, or procedure to
maintain, diagnose, or otherwise affect a physical or mental condition;
(b) Select or discharge health-care providers and institutions;
(c) Approve or disapprove diagnostic tests, surgical procedures, programs of
medication, and orders not to resuscitate; and
(d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration
and all other forms of health care.
Part 2 of this form lets you give specific instructions about any aspect of your health
care. Choices are provided for you to express your wishes regarding the provision,
withholding, or withdrawal of treatment to keep you alive, including the provision of
artificial nutrition and hydration, as well as the provision of pain relief. Space is provided
for you to add to the choices you have made or for you to write out any additional
Part 3 of this form lets you designate a physician to have primary responsibility for
your health care.
After completing this form, sign and date the form at the end and have the form
witnessed by one of the two alternative methods listed below. Give a copy of the signed
and completed form to your physician, to any other health-care providers you may have,
to any health-care institution at which you are receiving care, and to any health-care
agents you have named. You should talk to the person you have named as agent to
make sure that he or she understands your wishes and is willing to take the
You have the right to revoke this advance health-care directive or replace this form at