Pennsylvania Advance Directives: Living Will, Healthcare POA & DNR

Nobody signs an advance directive for themselves. You sign it for the people who will be standing in a hallway at Hershey Medical Center or Holy Spirit at two in the morning, being asked a question they are not prepared to answer. I have sat with those families. The ones who had documents were sad. The ones who did not were sad, frightened, and arguing.

A Pennsylvania advance health care directive is the umbrella term for the documents authorized under 20 Pa.C.S. Chapter 54 — Act 169 of 2006, which is still the governing law. There are three separate instruments in this space, and they do three different jobs:

• A living will — your written instructions about life-sustaining treatment.
• A healthcare power of attorney — the person you appoint to decide everything else.
• A DNR order or POLST — a physician's medical order that first responders and nurses can act on immediately.

Most Pennsylvania adults need the first two, signed together as one combined directive. The third is a clinical decision you make with your doctor when illness makes it relevant. This guide covers all three, how they interact, how to execute them so a hospital will actually honor them, and what Pennsylvania does to you if you sign nothing.

The Pennsylvania living will: narrow, powerful, often misunderstood

A living will is a written statement of what you want done — and not done — when you cannot speak for yourself. In Pennsylvania it is not a general-purpose medical document. Under 20 Pa.C.S. § 5423 it becomes operative only when both of two things are true:

1. Your attending physician has determined that you are incompetent, and
2. You have an end-stage medical condition or are permanently unconscious.

Both determinations must be documented in your medical record. Until then, you make your own decisions, full stop. A living will does not hand anything over early, and it does not apply during a routine surgery, a recoverable stroke, or a hospitalization with an uncertain prognosis.

Inside those boundaries you can address ventilators and mechanical respiration, cardiopulmonary resuscitation, dialysis, blood products, antibiotics, and — the one that matters most to families — tube feeding and artificial hydration. Pennsylvania's statutory form treats nutrition and hydration as a separate, explicit election, because it is the intervention families disagree about most.

There is one limitation worth knowing. Under 20 Pa.C.S. § 5429, a living will is generally not given effect during pregnancy if life-sustaining treatment would allow the pregnancy to continue to live birth, unless doing so would be physically harmful or cause unmanageable pain. It is a real provision, and women of childbearing age should know it is there and address it deliberately with counsel.

The healthcare power of attorney: the document that does the daily work

If the living will is a narrow instrument, the healthcare power of attorney is the broad one. Under 20 Pa.C.S. § 5454, your health care agent may make any health care decision you could make yourself — choosing physicians and facilities, consenting to or refusing surgery, admitting you to a hospital or nursing facility, hiring and firing providers, and, if you say so, making end-of-life decisions.

It activates on a much lower threshold: whenever your attending physician determines you cannot make or communicate a health care decision. No end-stage diagnosis required. That covers the general anesthesia, the ICU sedation, the mid-course dementia, the head injury with a good prognosis — in other words, nearly every real case.

Three drafting points separate a directive that works from one that does not:

• HIPAA authority. Your agent needs express authorization to receive protected health information. Without it, the records department can lawfully tell them nothing, and an agent who cannot get information cannot make decisions. This is the single most common defect I see in forms downloaded from the internet.
• Successor agents. Name at least one, ideally two. Spouses travel, get sick, and are sometimes the patient in the next bed.
• Guidance, not handcuffs. Say enough about your values that your agent knows what you would want, without writing instructions so rigid that they cannot respond to a situation you never imagined.

One more thing about scope: a healthcare POA covers medicine, not money. Paying the facility, managing the accounts, and dealing with the house all require a financial power of attorney under 20 Pa.C.S. Chapter 56. They are separate chapters of the code for a reason, and they should be separate documents. Our powers of attorney page covers the financial side.

DNR orders and POLST: medical orders, not legal documents

Here is where families are most often surprised. A living will will not stop Pennsylvania paramedics from performing CPR. Emergency medical services follow medical orders, not estate planning documents. If someone calls 911 and there is no valid out-of-hospital DNR in front of the crew, they will resuscitate.

Pennsylvania's Do-Not-Resuscitate Act, 20 Pa.C.S. Chapter 54 Subchapter D, creates the out-of-hospital DNR order — a Department of Health order, bracelet, or necklace, signed by your attending physician, that EMS is authorized to honor. It is available to patients with an end-stage medical condition, and it addresses one thing only: whether CPR is attempted if your heart or breathing stops.

POLST — Pennsylvania Orders for Life-Sustaining Treatment — is the broader version of the same idea. It is a bright pink physician-signed form that travels with the patient and covers resuscitation, level of medical intervention, and artificially administered nutrition. POLST is designed for people who are seriously ill or frail, generally those for whom a clinician would not be surprised if they died within a year. It is not for healthy adults, and it is not a substitute for a directive.

The clean mental model: your advance directive says what you want; the DNR or POLST tells the clinician standing over you what to do right now. Signing one does not replace the other. For the detail on each, see our articles on Pennsylvania DNR orders and POLST in Pennsylvania.

What Pennsylvania does if you sign nothing

You are not left with nothing. You are left with a statutory guess. Under 20 Pa.C.S. § 5461, when there is no health care agent, an attending physician turns to a health care representative in this order of priority:

1. Spouse (unless a divorce action is pending) and adult children who are not the spouse's children
2. Adult children
3. Parents
4. Adult siblings
5. Adult grandchildren
6. A close friend with sufficient knowledge of the person's preferences

Two problems live in that list. First, anyone within a class may act — so three adult children with three opinions have equal standing, and the hospital cannot referee. Second, the list is blind to your actual life: an unmarried partner of twenty years, the daughter-in-law who drives to every appointment, and the estranged son who has not called in a decade are ranked by relationship, not by trust.

A health care representative also cannot direct the withholding of life-sustaining treatment on the same footing as an agent you appointed. When families end up in Orphans' Court over a ventilator, this is usually why. The alternative — a guardianship petition under 20 Pa.C.S. Chapter 55 — routinely runs several thousand dollars and takes weeks. A directive prevents it in an afternoon.

Executing it so it actually holds up

Pennsylvania's requirements are refreshingly simple, which is exactly why people get them wrong by improvising.

• You must be 18 or older (or a high school graduate, married, or emancipated) and of sound mind.
• Sign and date it in front of two adult witnesses, per 20 Pa.C.S. § 5452. If you cannot sign, someone may sign at your direction in your presence.
• Your agent may not be a witness. Neither should the people paid to care for you.
• Notarization is not required by Pennsylvania statute — but get it anyway. Out-of-state hospitals and some national health systems balk at an un-notarized directive, and the notary costs nothing meaningful.

Then do the part almost everyone skips: distribute it. A directive in a safe deposit box is a directive nobody will read. Give copies to your agent and successor agent, your primary care physician's office, and the records department of the hospital system you would realistically be taken to. Keep a copy where a paramedic would look — many families use the refrigerator door. Photograph it and put it in your agent's phone.

When to revisit

Review the directive after any of these:

• A serious diagnosis, or a move into assisted living or skilled nursing
• Divorce — under 20 Pa.C.S. § 5456, a divorce action generally revokes a spouse's appointment as agent, which can leave you with no one named if you never listed a successor
• The death or decline of a named agent
• A move to or from Pennsylvania
• A child turning 18 — at that moment a parent's automatic authority ends, and every college student should sign their own directive with HIPAA language before leaving home

Otherwise, a look every three to five years is enough. Unlike a will, an old directive is not invalid — but an old directive naming an agent who died in 2019 is not much help either.

How this fits the rest of your plan

An advance directive is one of four documents in a complete Pennsylvania plan: a will, a financial power of attorney, a healthcare power of attorney, and a living will. Three of the four are about what happens while you are alive. Families tend to focus on the will, which is the one document that cannot help anyone until after the crisis is over.

If you want to compare the three healthcare instruments side by side, we built a living will vs. healthcare POA vs. DNR comparison. The recurring questions are collected in our Pennsylvania advance directives FAQ. And our healthcare directives service prepares the living will and healthcare power of attorney as a single combined Pennsylvania directive, which is how Chapter 54 intends them to work.

If you take one thing from this page: the document is not the point. The conversation with the person you are naming is the point. Sign the paperwork, then tell them what you actually want — out loud, once, while it is still an abstract conversation.