Free Mississippi Living Will Form

The Mississippi living will clearly outlines the types of medical treatments and life-sustaining measures the person consents to or refuses. This includes decisions about resuscitation, mechanical ventilation, artificial nutrition and hydration, and other treatments. The living will also establishes a medical power of attorney (a separate but related document), allowing a designated person to make healthcare decisions on the individual’s behalf.

How to Do a Mississippi Living Will

A Mississippi living will is completed by writing out your health care wishes and naming a health care agent. You then sign the document in front of two qualified witnesses, or have it acknowledged before a notary public. At least one witness must not be related to you by blood, marriage, or adoption, and must not be entitled to any part of your estate.^[1.1] Once signed, the directive lets your agent and health care providers follow the choices you wrote down.

A living will is different from a last will and testament:

• Living will: states your medical treatment preferences and names a health care agent, effective while you are alive but unable to communicate.
• Last will and testament: addresses your property and belongings after you die.

Adults of any age can benefit from having one on file, especially before a major surgery or if you live with a chronic condition. Without a living will, your family and physician are left guessing at your wishes during a medical crisis, which adds stress at an already difficult time.

Signing Requirements and Laws

Mississippi’s living will law, found in Miss. Code Ann. 41-41-205, sets out how the document, called an advance health care directive, must be signed to be valid. The person making the directive, called the declarant or principal, puts it in writing and signs it, then has it witnessed or notarized.^[1.1] The rest of this section explains who can witness the document and what limits apply to your agent.

Your agent can act either when a physician decides you can no longer make health care decisions, or immediately if you prefer. The statutory form lets an agent act for you even while you are still capable of deciding for yourself.^[1.3] Choose someone who understands your wishes and is willing to carry them out, such as a spouse, adult child, or close friend.

If you name a health care agent, one limit applies. Unless the agent is related to you by blood, marriage, or adoption, the agent cannot be an owner, operator, or employee of a residential long-term care facility where you live.^[1.1]

State law offers two ways to complete the signing: two witnesses, or acknowledgment before a notary public. A directive that is witnessed, rather than notarized, needs at least two witnesses who watched you sign it or heard you acknowledge your signature.^[1.1] Each witness must be an adult.^[1.2]

Every witness must also sign a declaration required by the statute:

• Personally knows you and watched you sign or acknowledge the directive.^[1.1]
• Believes you are of sound mind and acting free from duress, fraud, or undue influence.^[1.1]
• Is not the agent named in the document.^[1.1]
• Is not a health care provider, or an employee of a health care provider or facility.^[1.1]

Mississippi law sets out the exact words each witness declaration must include, in substance:^[1.1]

I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code of 1972, that the principal is personally known to me, that the principal signed or acknowledged this power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as agent by this document, and that I am not a health-care provider, nor an employee of a health-care provider or facility.

At least one of the two witnesses must also be independent. This means the witness is not related to you by blood, marriage, or adoption. The same witness also cannot be entitled to any part of your estate, whether under an existing will or by operation of law.^[1.1]

Mississippi Living Will Form Details

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Steps to Fill Out the Form

The Mississippi living will form has nine fillable pages, covering your health care agent, your treatment wishes, and your signature. Filling it out takes about 15 to 20 minutes once you have your agent’s contact information ready, and the steps below follow the form’s own page order.

1. Complete the Declaration. On page 2, fill in today’s date, your full name, and your residing address at the top of the form.
2. Initial the Treatments to Refuse. In the Health Care section on page 2, initial each listed treatment you want withheld, such as CPR, artificial nutrition and hydration, or mechanical ventilation, dialysis, blood transfusions, and organ transplants.
3. Initial the End-of-Life Conditions. In the End-of-Life Care section, initial the conditions under which you want treatment withheld. Options include an inability to communicate, a severely deteriorated mental condition, a terminal condition, or no reasonable chance of recovery as confirmed by your physician.
4. Add Additional Instructions. Page 3 has blank lines for any further health care wishes. Leave them blank if you have none.
5. Name Your Health Care Agent. Still on page 3, enter your agent’s name, address, and phone number.
6. Name a Substitute Agent. On page 4, enter the name, address, and phone number of the person who steps in if your first agent cannot serve.
7. Review the Powers Granted to Your Agent. Pages 4 through 6 list your agent’s powers, including medical decisions, access to records, and life-prolonging procedures, unless you limited them in your instructions on page 3.
8. Review the Additional Provisions. Pages 6 through 8 set out standard terms: when the agent’s authority begins, HIPAA access, revocation of prior directives, and governing law. No entries are needed here. These terms are legally binding, so our chat with PDF tool can help you work through them before you sign.
9. Sign and Date the Declaration. On page 8, sign, print your name, and date the document in front of your two witnesses.
10. Have Your Witnesses Sign. Each witness reads the Witness Acknowledgment on page 8 and fills in their printed name, address, signature, and date.
11. Complete the Independent Witness Declaration. On page 9, the witness who is not related to you and not entitled to your estate signs, prints their name, and dates this additional declaration.

Once every section is complete, you can fill in and sign the PDF directly using our online PDF editor. Then print or save a copy for your agent, your physician, and any health care facility where you receive care.

Other Mississippi Forms
Below are various other Mississippi templates completed by our users. Try our simple builder to customize these forms to your preferences.

Mississippi Last Will Mississippi Small Estate Affidavit Mississippi Bill of Sale Mississippi Power of Attorney Mississippi Non-compete Agreement Mississippi Prenuptial Agreement Mississippi LLC Operating Agreement

General information, not legal or tax advice.

Sources

1. Miss. Code Ann. 41-41-205 §§ Miss. Code Ann. 41-41-205, Miss. Code Ann. 41-41-209, 41-41-209.
   • 1.1 Miss. Code Ann. 41-41-205
   • 1.2 Miss. Code Ann. 41-41-209
   • 1.3 § 41-41-209