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Virginia Advance Medical Directive | POA & Living Will

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The Virginia advance medical directive, also known as a ‘medical power of attorney’ and ‘living will’ packet, is a group of legal documents that will provide a Declarant/Principal a legal avenue to select their own options with regard to what provisions they would like to have available to them at the end of their life when they are no longer able to speak for themselves in a critical medical situation. This document may be revoked at any time. If at any point the Declarant is unclear with regard to how the document works or knows they will require assistance, they should consider consultation with a qualified attorney.

Definition – § 54.1-2982

Laws – § 54.1-2981 – § 54.1-2993 (Virginia Health Care Decisions Act)

How to Write

Step 1 Establishment of Declarant/Principal – Download the document and begin by entering the full legal name of the Declarant/Principal into the first line of the document.

Step 2 – Appointment and Powers of Appointed Agent –

  • Enter the name of the primary chosen agent
  • Email address
  • Enter the physical home address information of the agent
  • Provide the agent’s telephone number

Successor Agent – The successor agent would take the place of the primary agent in the event that the primary agent is no longer able or willing to serve:

  • Enter the name of the successor agent agent
  • Email address
  • Enter the physical home address information of the successor agent
  • Provide the successor agent’s telephone number

Second Successor Agent – The second successor agent would take the place of the primary and secondary agent in the event that the primary and secondary agent woukd no longer able or willing to serve:

  • Enter the name of the 2nd successor agent agent
  • Email address
  • Enter the physical home address information of the 2nd successor agent
  • Provide the 2nd successor agent’s telephone number

Step 3 – This document now declares that the Declarant is granting powers to the named agent’s. The Declarant and agent’s should carefully read the information following appointment. If the Declarant wishes to exclude any of the powers they my strike through them individually. If the Declarant would like to provide additional powers they may do so in the lines provided under item 10

Step 4 – Declarant’s Health Care Instructions – These will be instructions provided by the Declarant, in the event their physician determines that death is undoubtedly imminent.

  • Declarant must make only one selection in this section by initialing the preferred box
  • If the Declarant would like to their own instructions, they may do so in the lines provided at the end of the section, on the lines provided
  • If the Declarant has “Other Instructions” they may write or type these also into the lines provided in the lines provided

Step 5 – Anatomical Gifts – If the Declarant would like to provide anatomical gifts, they may record this fact within this area of this document, The Declarant may access the donor registry to amend or revoke their decision.

  • If the donor would like to specify how the anatomical gifts would be use, write or type this information into the lines provided

Step 6 – Affirmation and Right ti Revoke – This section states clearly that the Declarant has not only made the decision to create the document, but also reserves the right to revoke the document at their choosing as stated by law. Enter the following information:

  • Date the Declarant’s Signature in mm/dd/yyyy format
  • Enter the full legal name of the Declarant/Principal

Step 7 – Witness Signature (both must be over the age of 18 years) Both must read the statement just above the witness signature areas. If in agreement, provide the following:

Witness 1 – 

  • Signature of Witness
  • Print or type name of witness

Witness 2 – 

  • Signature of Witness
  • Print or type name of witness


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