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Making Health Care Decisions in North Dakota

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STATUTORY FORM
HEALTH CARE DIRECTIVE

(North Dakota Century Code 23-06.5.17)

I , understand this document allows me to do ONE OR ALL of the following:

PART I: Name another person (called the health care agent) to make health care decisions for me if I am unable to make and communicate health care decisions for myself. My health care document (Part II), if any, the wishes I have made known to him or her, or my agent must act in my best interest if I have not made my health care wishes known.

AND/OR

PART II: Give health care instructions to guide others making health care decisions for me. If I have named a health care agent, these instructions are to be used by the agent. These instructions may also be used by my health care providers, others assisting with my health care and my family, in the event I cannot make and communicate decisions for myself.

AND/OR

PART III: Allows me to make an organ and tissue donation upon my death by signing a document of anatomical gift.

PART I: APPOINTMENT OF HEALTH CARE AGENT THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS FOR ME IF I AM UNABLE TO MAKE AND COMMUNICATE HEALTH CARE DECISIONS FOR MYSELF

(I know I can change my agent or alternate agent at any time and I know I do not have to appoint an agent or an alternate agent)

NOTE: If you appoint an agent, you should discuss this health care directive with your agent and give your agent a copy. If you do not wish to appoint an agent, you may leave Part I blank and go to Part II and/or Part III. None of the following may be designated as your agent: your treating health care provider, a nonrelative employee of your treating health care provider, an operator of a long-term care facility, or a nonrelative employee of a long-term care facility.

When I am unable to make and communicate health care decisions for myself, I trust and appoint to make health care decisions for me. This person is called my health care agent.

Relationship of my health care agent to me:

Telephone number of my health care agent:

Address of my health care agent:

(OPTIONAL) APPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If my health care agent is not reasonably available, I trust and appoint to be my health care agent instead.

Relationship of my alternate health care agent to me:

Telephone number of my alternate health care agent:

Address of my alternate health care agent:

THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO DO IF I AM UNABLE TO MAKE AND COMMUNICATE HEALTH CARE DECISIONS FOR MYSELF (I know I can change these choices)

My health care agent is automatically given the powers listed below in (A) through (D). My health care agent must follow my health care instructions in this document or any other instructions I have given to my agent. If I have not given health care instructions, then my agent must act in my best interest.

Whenever I am unable to make and communicate health care decisions for myself, my health care agent has the power to:

(A) Make any health care decision for me. This includes the power to give, refuse, or withdraw consent to any care, treatment, service, or procedures. This includes deciding whether to stop or not start health care that is keeping me or might keep me alive and deciding about mental health treatment.

(B) Choose my health care providers.

(C) Choose where I live and receive care and support when those choices relate to my health care needs.

(D) Review my medical records and have the same rights that I would have to give my medical records to other people.

If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR if I want to LIMIT any power in (A) through (D), I MUST say that here:

My health care agent is NOT automatically given the powers listed below in (1) and (2). If I WANT my agent to have any of the powers in (1) and (2), I must INITIAL the line in front of the power; then my agent WILL HAVE that power.

(1) To decide whether to donate any parts of my body, including organs, tissues, and eyes, when I die.

(2) To decide what will happen with my body when I die (burial, cremation).

If I want to say anything more about my health care agent's powers or limits on the powers, I can say it here:

PART II: HEALTH CARE INSTRUCTIONS

NOTE: Complete this Part II if you wish to give health care instructions. If you appointed an agent in Part I, completing this Part II is optional but would be very helpful to your agent. However, if you chose not to appoint an agent in Part I, you MUST complete, at a minimum, Part II (B) if you wish to make a valid health care directive.

These are instructions for my health care when I am unable to make and communicate health care decisions for myself. These instructions must be followed (so long as they address my needs).

(A) THESE ARE MY BELIEFS AND VALUES ABOUT MY HEALTH CARE (I know I can change these choices or leave any of them blank).

I want you to know these things about me to help you make decisions about my health care:

My goals for my health care:

My fears about my health care:

My spiritual or religious beliefs and traditions:

My beliefs about when life would be no longer worth living:

My thoughts about how my medical condition might affect my family:

(B) THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE (I know I can change these choices or leave any of them blank)

Many medical treatments may be used to try to improve my medical condition or to prolong my life. Examples include artificial breathing by a machine connected to a tube in the lungs, artificial feeding or fluids through tubes, attempts to start a stopped heart, surgeries, dialysis, antibiotics, and blood transfusions. Most medical treatments can be tried for a while and then stopped if they do not help.

I have these views about my health care in these situations:

(Note: You can discuss general feelings, specific treatments, or leave any of them blank).

If I had a reasonable chance of recovery and were temporarily unable to make and communicate health care decisions for myself, I would want:

If I were dying and unable to make and communicate health care decisions for myself, I would want:

If I were permanently unconscious and unable to make and communicate health care decisions for myself, I would want:

If I were completely dependent on others for my care and unable to make and communicate health care decisions for myself, I would want:

In all circumstances, my doctors will try to keep me comfortable and reduce my pain. This is how I feel about pain relief if it would affect my alertness or if it could shorten my life:

There are other things that I want or do not want for my health care, if possible:

Who I would like to be my doctor:

Where I would like to live to receive health care:

Where I would like to die and other wishes I have about dying:

My wishes about what happens to my body when I die (cremation, burial):

Any other things:

PART III: MAKING AN ANATOMICAL GIFT

I would like to be an organ donor at the time of my death. I have told my family my decision and ask my family to honor my wishes. I wish to donate the following (initial one statement):

Any needed organs and tissue.

Only the following organs and tissue:

PART IV: MAKING THE DOCUMENT LEGAL

PRIOR DESIGNATIONS REVOKED. I revoke any prior health care directive.

DATE AND SIGNATURE OF PRINCIPAL (YOU MUST DATE AND SIGN THIS HEALTH CARE DIRECTIVE)

I sign my name to this Health Care Directive Form on at

___________________________________________________

(you sign here)

(THIS HEALTH CARE DIRECTIVE WILL NOT BE VALID UNLESS IT IS NOTARIZED OR SIGNED BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS HEALTH CARE DIRECTIVE.)

NOTARY PUBLIC OR STATEMENT OF WITNESSES

This document must be (1) notarized or (2) witnessed by two qualified adult witnesses. The person notarizing this document may be an employee of a health care or long-term care provider providing your care. At least one witness to the execution of the document must not be a health care or long-term care provider providing you with direct care or an employee of the health care or long-term care provider providing you with direct care. None of the following may be used as a notary or witness:

1. A person you designate as your agent or alternate agent;

2. Your spouse;

3. A person related to you by blood, marriage, or adoption;

4. A person entitled to inherit any part of your estate upon your death;

or

5. A person who has, at the time of executing this document, any claim against your estate.

Option 1: Notary Public

In my presence on , acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person signing this document to sign on the declarant's behalf.

____________________________

(Signature of Notary Public)

My commission expires , 20.

Option 2: Two Witnesses

Witness One:

(1) In my presence on , acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person signing this document to sign on the declarant's behalf.

(2) I am at least eighteen years of age.

(3) If I am a health care provider or an employee of a health care provider giving direct care to the declarant, I must initial this box:

I certify that the information in (1) through (3) is true and correct.

____________________________

(Signature of Witness One)

____________________________

(Address)

Witness Two:

(1) In my presence on , acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person signing this document to sign on the declarant's behalf.

(2) I am at least eighteen years of age.

(3) If I am a health care provider or an employee of a health care provider giving direct care to the declarant, I must initial this box:

I certify that the information in (1) through (3) is true and correct.

____________________________

(Signature of Witness Two)

____________________________

(Address)

ACCEPTANCE OF APPOINTMENT OF POWER OF ATTORNEY. I accept this appointment and agree to serve as agent for health care decisions. I understand I have a duty to act consistently with the desires of the principal as expressed in this appointment. I understand that this document gives me authority over health care decisions for the principal only if the principal becomes incapacitated. I understand that I must act in good faith in exercising my authority under this power of attorney. I understand that the principal may revoke this power of attorney at any time in any manner.

If I choose to withdraw during the time the principal is competent, I must notify the principal of my decision. If I choose to withdraw when the principal is not able to make health care decisions, I must notify the principal's physician.

______________________________________

(Signature of agent/date)

______________________________________

(Signature of alternate agent/date)

PRINCIPAL'S STATEMENT

I have read a written explanation of the nature and effect of an appointment of a health care agent that is attached to my health care directive.

Dated this day of , 20.

_____________________________________

(Signature of Principal)

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What Making Health Care Decisions in North Dakota Covers

Making Health Care Decisions in North Dakota describes the primary advance directive options available under state law, including durable power of attorney for health care, living will statements, and instructions such as do-not-resuscitate (DNR) orders. The document enables you to appoint an agent to make medical decisions if you lack capacity, state preferences for life-sustaining treatment, and authorize PHI release consistent with HIPAA. The overview explains signature, witness, and notarization mechanics and how electronic signatures and remote notarization may affect validity.

Why Preparing These Directives Matters

Use a correctly executed advance directive to name a decision-maker, record specific treatment preferences, and reduce uncertainty during serious illness. Clear directives streamline clinical decisions, help providers follow your wishes, and limit family disputes while preserving legal authority over health care choices.

Why Preparing These Directives Matters

Who Relies on Making Health Care Decisions in North Dakota

Individuals, appointed agents, and healthcare professionals use this guidance to prepare, accept, or implement health care directives under North Dakota practice and law.

  • Adults planning for incapacity who want to name a health care agent and outline treatment wishes.
  • Family members and substitute decision-makers seeking clarity on legal authority and care preferences in emergencies.
  • Healthcare providers needing documented consent, agent contact information, and treatment limitations for clinical decision-making.

Identifying the right participants helps ensure valid execution, timely activation of authority, and smooth communication among family members and clinical teams.

Who May Sign and Who Acts on the Directive

Declarant — Individual

The declarant is the adult who creates the directive. They must have the capacity to understand and sign; the signature expresses intent and appoints any agent. If capacity is later lost, the directive guides providers and appointed agents.

Agent — Health Care Agent

A named agent steps in when the declarant lacks decision-making capacity. The agent must act in accordance with stated preferences and applicable law; some forms request the agent’s written acceptance to confirm willingness to serve.

Key Parts of a North Dakota Advance Directive

A complete directive typically contains an agent designation, specific treatment preferences, HIPAA release, witness/notary area, organ donation option, and revocation instructions.

Agent Designation

Name a primary agent and at least one alternate, include contact details, and state the scope of authority to make health care decisions when you lack capacity.

Treatment Preferences

Specify instructions about life-sustaining treatment, artificial nutrition and hydration, pain management, and any conditions under which treatments should be withheld or withdrawn.

HIPAA Release

Include authorization language to permit providers to share protected health information with your agent; this avoids delays caused by privacy restrictions.

Witness & Notary

Provide signature lines for the declarant, witnesses, and a notary acknowledgment if required or chosen; some states accept witness-only execution for validity.

Organ Donation

Declare anatomical gift preferences and whether donation is conditional; align organ donation choices with driver’s license or state donor registry entries.

Revocation Clause

Describe how to revoke or amend the directive, including whether later signed documents, recorded revocations, or physical destruction constitute revocation.

Required Information and Fields

Declarant Name: Full legal name
Agent Name: Full legal name
Alternate Agent: Contact and relationship
Effective Date: MM/DD/YYYY format
Signature Block: Declarant signature and date
Witness/Notary: Witness signatures or notary block

Step-by-Step: Completing the Directive

Follow these sequential steps to prepare, sign, and distribute a valid advance directive in North Dakota.

  • 01
    Prepare the Form: Select the state-compliant template and read instructions fully.
  • 02
    Name an Agent: Enter primary and alternate agent details and contact information.
  • 03
    Record Preferences: Specify life-sustaining treatment choices and any limits.
  • 04
    Sign with Witnesses: Sign, obtain required witness or notary acknowledgment, and date the document.

Customizing an Online Execution Workflow

Configure eSignature and authentication settings to match legal and clinical needs when completing directives electronically.

Field Configuration
Authentication Method Email link | SMS code or KBA for added identity assurance
Signature Type ESIGN-compliant electronic signature allowed
Document Retention Secure cloud storage, tamper-evident PDF
Audit Trail Capture IP, timestamp, and action log required

Where to Send Signed Copies

Distribute executed directives to the right parties so they are available when needed for care decisions.

  • Primary Care Provider: Add a copy to the declarant’s medical record at the clinic or hospital.
  • Named Agent: Provide agent with an original or certified copy for immediate access.
  • Family/Support: Share copies with trusted family members so they understand your wishes.
  • Personal Records: Keep a signed original or provable electronic copy accessible at home.

Digital Signing, Formats, and Integrations

Use eSignature platforms that produce tamper-evident PDFs and capture an auditable signing history for legal compliance.

  • File Formats: PDF, DOCX supported
  • Integrations: EHR and cloud storage integrations
  • Authentication: Email, SMS, or advanced KBA

Timing, Activation, and Record Expectations

Key timing rules determine when the directive takes effect, how revocations operate, and how long records should be accessible.

Effective Date:

Be explicit; effective date controls when agent authority begins.

Agent Activation:

Agent authority typically activates upon clinician determination of incapacity.

Revocation Process:

You may revoke in writing, by oral statement to the treating clinician, or by executing a later directive.

Updating Recommendations:

Review after major health events or every few years to keep preferences current.

Record Availability:

Ensure signed copies are accessible in the medical record and with the agent.

Frequent Errors to Avoid

  • Failing to name an alternate agent leaves decisions unresolved if the primary agent is unavailable or incapacitated.
  • Using vague language about treatment choices can cause clinicians and agents to disagree on appropriate care actions.
  • Missing or incomplete witness and notary sections can render an advance directive invalid or subject to challenge.
  • Not distributing signed copies to clinicians and the named agent often results in delays or inability to enforce preferences.

Consequences of Incorrect or Missing Documents

Invalid Execution: Directive may be unenforceable
Delayed Care: Treatment may pause pending legal clarification
Family Disputes: Conflicting claims can lead to disputes
Privacy Risk: Absent HIPAA release, PHI sharing may be restricted
Provider Liability: Clinicians may face uncertainty following unclear instructions
Benefit Complications: Errors can affect long-term care or Medicaid planning

Notarization and Witness Steps for Valid Execution

Follow this sequence when completing witness or notary formalities to help ensure a directive is accepted by providers and courts.

01

Signing by Declarant

Declarant signs in presence of required witnesses or notary as specified by state law.

02

Witness Attestation

Witnesses confirm the declarant’s capacity and sign their attestation lines as required.

03

Notary Acknowledgement

If chosen or required, a notary acknowledges the declarant’s signature and completes a certificate.

04

Remote Notary Session

When RON is used, record identity proofing and retain the audio-video session per state rules.

05

Agent Acceptance

Some forms include an agent acceptance line to confirm the agent’s willingness to serve.

06

Copy Distribution

Provide signed copies to agent, primary clinician, and family members as applicable.

07

File in Medical Record

Ask providers to add the directive to the medical chart and to note agent contact details.

08

Update Documentation

Record any subsequent revocations or amendments, and distribute updated copies promptly.

eSignature Pricing Comparison for Executing Advance Directives

Compare representative starting prices and core features across common eSignature providers; signNow is shown first per platform data.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently Asked Questions About Making Health Care Decisions in North Dakota

Answers to common execution, validity, and distribution questions for North Dakota advance directives and the use of electronic signatures.


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