What the rule says
Pennsylvania's Advance Health Care Directive law, codified at 20 Pa.C.S. § 5421 et seq., allows residents to plan for medical decisions during periods of incapacity. The framework permits a single document that combines two functions:
1. Designation of a health care agent — a person to make medical decisions on the principal's behalf when the principal lacks capacity 2. Living will declarations — statements of the principal's preferences for end-of-life care, particularly regarding life-sustaining treatment
The principal can include either or both functions in the same document or execute them as separate documents. Most Pennsylvania advance directives combine both, providing a designated agent along with specific guidance about end-of-life preferences.
What the directive can address
A Pennsylvania advance directive typically addresses:
- Designation of a primary health care agent and alternates. The agent has authority to make health care decisions when the principal lacks capacity. - Specific preferences for end-of-life care. The directive can specify the principal's preferences in cases of terminal condition, end-stage condition, or persistent vegetative state, including preferences about: - Cardiopulmonary resuscitation (CPR) - Mechanical ventilation - Artificial nutrition and hydration - Other life-sustaining treatments - Pain management preferences. Some principals specify preferences about palliative care and pain management. - Religious or philosophical considerations. Specific instructions reflecting the principal's values. - Out-of-hospital DNR considerations. While the formal Out-of-Hospital DNR Order is a separate physician's order, the advance directive can express preferences that inform the physician's decision to issue a DNR.
The directive becomes effective when the principal lacks capacity to make health care decisions for themselves. The treating physician determines incapacity based on the standards in 20 Pa.C.S. § 5454.
Execution requirements
A Pennsylvania advance health care directive must be:
- Signed by the principal (or signed by another person at the principal's direction in the principal's presence, if the principal cannot sign) - Witnessed by two adults who are at least 18 years old
The witnesses cannot be the agent or anyone with a financial interest in the principal's health care. There is no notarization requirement, although notarization is sometimes used for additional reliability.
Pennsylvania does not have a single mandatory statutory form for the advance directive. The statute provides general execution requirements, and various organizations — bar associations, hospitals, religious organizations — provide template forms. Any form that meets the statutory requirements is acceptable.
What happens without an advance directive
If a Pennsylvania resident lacks capacity and has no advance directive, Pennsylvania law applies a surrogate-decision-maker hierarchy under 20 Pa.C.S. § 5461:
1. The patient's spouse (unless an action for divorce is pending), and the patient's adult child or children of more than one marriage 2. An adult child of the patient 3. A parent of the patient 4. An adult sibling of the patient 5. An adult grandchild of the patient 6. A close adult friend of the patient 7. The patient's attending physician (in limited circumstances)
The surrogate hierarchy provides a default but has the same limitations seen in other states: disputes among potential surrogates, ambiguous authority for end-of-life decisions, complications for chosen family or non-traditional family relationships, and time delays during medical crises.
An executed advance directive avoids these problems by giving the agent clear authority and providing the principal's documented preferences.
Coordination with the Health Care Power of Attorney
Pennsylvania law uses the term "health care power of attorney" interchangeably with "healthcare agent designation" within the advance directive framework. The functional document is the same: a written designation of an agent for medical decisions.
The combined advance directive (living will + health care power of attorney) is the most common form in Pennsylvania. Some residents execute the two components as separate documents; others use a single combined form. Either approach is acceptable as long as the statutory requirements are met.
What you can do about it
For Pennsylvania residents:
- Execute an advance health care directive that designates a health care agent and provides specific preferences for end-of-life care. - Designate a primary agent and at least one alternate. A single agent who is unavailable at the moment of need leaves the document without an effective decision-maker. - Address specific treatments. Mention CPR, mechanical ventilation, artificial nutrition and hydration, and other treatments that may be relevant. - Address specific conditions. Mention terminal illness, persistent vegetative state, end-stage conditions, and other situations where the principal has specific preferences. - Discuss preferences with the agent. A written document is more effective when supported by direct conversation about values and wishes. - Provide copies to the agent, primary physician, and key family members. - Consider an Out-of-Hospital DNR for serious illness. A separate physician's order is appropriate for patients with terminal illness who do not want CPR. - Update periodically. Major life events warrant review.
Who this affects most
The advance health care directive is most consequential for:
- Pennsylvania adults who have not executed any directive and rely on default surrogate authority - Patients facing major medical decisions where family members are divided - LGBTQ+ individuals or others whose chosen family may not match the surrogate hierarchy - Anyone with strong preferences about end-of-life care - Those with serious or terminal illness for whom end-of-life decisions are foreseeable
A combined advance directive — designating an agent and stating preferences — is among the most consequential estate planning documents. It directly affects medical decisions during health care crises, often making the difference between care that aligns with the patient's values and care that does not.