v13 · IMPACT Grant Project 2025
Filling out on behalf of someone else
Your ACP planning assistant
Take control of your healthcare wishes — at your own pace, on your terms.
This guide helps you think through important healthcare decisions and make sure your wishes are known.
Help us understand your current health picture
Can you make your own health decisions?
If you need someone to decide for you
Choose someone to speak for you
Document your treatment preferences
Share your wishes about donation
Plan for after-death wishes
Define what matters most to you
Details based on your goals choice
Turn your wishes into medical orders
Review everything in one place
1. A health condition that carries a high risk of mortality AND either negatively impacts your daily function or quality of life, OR excessively strains your caregivers.
2. Any condition that could severely affect your life expectancy, quality of life, or limit your activities of daily living.
3. A progressive condition that may get worse over time. For example: cancer, heart disease, COPD, chronic kidney disease, or progressive neurologic illness (Parkinson's, stroke, Alzheimer's disease).
4. Whether or not you have a serious illness, advance care planning is valuable for everyone.
5. Your path through this guide may differ based on your health situation, but every step is important.
Whether or not you have a serious illness, advance care planning is valuable for everyone. Your path through this guide may differ, but every step is important.
Your physician (MD or DO), physician associate (PA), or nurse practitioner (NP) can help clarify your health situation.
1. It means you can understand your medical situation and treatment options, and can repeat your understanding of them if necessary.
2. You can appreciate how those options affect you personally.
3. You can reason through and weigh the risks and benefits of a medical decision.
4. You can clearly express your choice related to treatment.
5. Your provider makes this determination — it's not the same as a legal competency ruling.
6. Capacity can change over time — it may be reassessed if your condition changes.
If you're unable to make decisions and don't have a Health Care Proxy, New York State law provides a process to identify a legal surrogate (the FHCDA). The next step covers this.
Your physician (MD or DO), physician associate (PA), or nurse practitioner (NP) evaluates capacity.
Nurse or social worker can support you.
If you're unable to make your own decisions and don't have a Health Care Proxy, New York law (FHCDA) provides a way to identify a legal surrogate — someone who can speak for you.
Under New York's FHCDA law, your surrogate is identified in this specific order:
1. Your spouse or domestic partner
2. Your adult child (18 years or older)
3. Your parent
4. Your sibling (18 years or older)
5. A close friend (with documentation of the relationship)
6. If no surrogate is available — your doctor, with another doctor's agreement, may make decisions.
7. Surrogates may only make decisions based on your religious or moral beliefs, or in the absence of those, your best interests.
Your doctor and social worker guide this process.
Hospital ethics committee if there are disagreements.
NYS Advance Directives: ag.ny.gov — Advance Directives
1. Must be at least 18 years old.
2. Cannot be your attending doctor or provider.
3. A former spouse cannot serve unless you specifically choose them.
4. Must be willing to speak for you in an emergency.
5. Must be available — physically or virtually — when needed.
6. Must have a current copy of your HCP form.
7. Your proxy or their alternate cannot also sign as a witness.
Your doctor, physician associate, nurse, or social worker can walk you through this process.
NYS HCP Form: health.ny.gov/publications/1430.pdf
A Living Will is a written document that states your wishes about medical treatments you do or do not want if you become seriously ill and cannot communicate.
1. CPR: Chest compressions and rescue breaths to restart your heart. May include electric shocks and medications.
2. Mechanical ventilation: A breathing machine pushes air into your lungs through a tube. Can be short-term or long-term.
3. Artificial nutrition: Food and fluids delivered through a tube or IV when you cannot eat or drink on your own.
4. Dialysis: Filters your blood when your kidneys can't. Usually requires treatment several times a week.
5. Noninvasive respiratory support: Breathing help through a mask (not a tube in your throat).
6. You can say YES or NO to any of these — there are no right or wrong answers.
Your doctor, physician associate, or nurse practitioner explains treatment options.
Nurse or social worker helps with the form.
NYS Living Will Template: ag.ny.gov — Living Will
Also consider: Five Wishes advance directive
1. This is entirely your decision — you can change your mind anytime.
2. Medical suitability is determined later, not during planning.
3. Your family will be informed of your wishes.
4. Religious and cultural preferences are respected and documented.
5. You can choose to donate some things and not others.
6. You can add any notes or specific concerns about your wishes.
Your doctor, nurse, physician associate, chaplain, or social worker can discuss this with you.
NY Donate Life Registry
Organ Procurement Organization (OPO)
1. Burial vs. cremation — what's your preference?
2. Have you selected a funeral home or memorial service?
3. Are there financial arrangements for services?
4. Do your family and loved ones know your wishes?
5. Are there specific religious or cultural ceremonies you want?
6. Would you like to leave letters, video messages, or an ethical will? Sometimes this is called a Legacy.
7. It's okay if you haven't decided everything yet — this is a starting point to encourage discussion with your loved ones and spiritual counselors (chaplains, clergy, psychologists).
Social worker can help with arrangements.
Chaplain/Minister/Pastor/Reverend for cultural and religious needs.
A Consumer's Guide to Arranging a Funeral: health.ny.gov/publications/0704
This is the most important conversation in your care plan. You'll talk with your care team — including your family and care partners — about what matters most to you.
It's completely normal for your care goals to shift over time as your health changes. This is a shared decision between you, your family, and your care team. You can update anytime.
That's okay. You can come back to this step anytime. There's no rush — what matters is that you're thinking about it.
1. There are no wrong answers — only what matters most to YOU.
2. Your choice determines which care pathway you follow next.
3. Longevity Focus → life-extending treatments, Health Care Proxy, Living Will, EOL Arrangements.
4. Functional Focus → treatments to maintain independence, MOLST/POLST.
5. Comfort Focus → symptom management, Terminal Care, Organ Donation, MOLST/POLST.
6. End of Life → hospice-level care, Terminal Care.
7. Your goals can and will change over time — you can update them anytime.
8. This is a shared decision between you, your family, and your care team.
Your physician (MD/DO), physician associate (PA), or nurse practitioner (NP) leads this conversation.
Your nurse, social worker, or chaplain can support you.
Deciding About Health Care — A Guide for Patients and Families: health.ny.gov/publications/1503.pdf
Based on what you selected in Goals of Care, your care team will tailor your plan. Review the details below for your chosen path.
That's okay — review the one that matches your Goals of Care choice from the previous step. You can always come back and update.
1. Aggressive medical management and possible surgical intervention.
2. Full resuscitation: CPR, intubation, vasopressors if needed.
3. Artificial nutrition and hydration if you can't eat or drink.
4. Hemodialysis, blood product transfusions, and other interventions as needed.
5. Your care team will regularly check if the treatment burden is worth the benefit.
6. If your goals change, you can switch to Function, Comfort, or End of Life focus anytime.
1. Functional focus means quality of function matters more than maximum survival.
2. You define what "functional" means to you — there's no standard definition.
3. You may try treatments on a trial basis to see if they help.
4. Nutritional support will match your functional goals.
5. Therapy services help you maintain or regain abilities.
6. If your situation changes, you can switch to Longevity, Comfort, or End of Life anytime.
1. Comfort focus means prioritizing how you feel about extending your life — including where you want to be (home, inpatient hospice, hospital, skilled nursing facility).
2. This typically includes DNR/DNI orders (no resuscitation, no intubation).
3. You may choose to decline artificial nutrition or hydration.
4. Your spiritual, emotional, and cultural needs are central to your care.
5. Your family will be supported throughout this process.
6. You can change your mind and switch focus areas anytime.
End of Life (#8):
1. This pathway focuses on hospice-level care — comfort and peace.
2. No life-prolonging treatments will be given unless you change your mind.
3. Support for your family (care partner/caregiver support) begins now, not just at the end.
4. Legacy planning is available — letters, recordings, ethical will.
5. Cultural and religious practices will be honored per your wishes.
6. Your care team is here for you and your family and loved ones every step of the way.
Terminal Care (#8A):
1. Terminal care is the final phase of the care journey.
2. The focus is entirely on comfort — not extending life.
3. Medications for comfort (pain relief, anxiety relief) are adjusted as needed.
4. Communication with your family is continuous and transparent.
5. Your hospice team coordinates all aspects of care.
6. Bereavement support for your family continues after your passing.
Longevity: Your full care team — physician, PA, NP, nurses, therapists, nutritionist, social worker.
Functional: Your full care team — physician, PA, NP, nurses, therapists, nutritionist, social worker.
Comfort: Physician, PA, NP, nurses, social worker, plus palliative care team, chaplain, family caregivers.
End of Life: Physician, PA, NP, nurses, social worker, plus hospice team, chaplain, family caregivers.
Advance Care Planning: health.ny.gov/publications/1503
Hospice Consumer Guide: health.ny.gov/facilities/hospice
Medicare grief/bereavement support (for Terminal Care)
A MOLST/POLST form turns your care goals into official medical orders that follow you everywhere — hospital, home, nursing facility, and with EMS.
When the patient has no pulse and/or is not breathing. Choose: Resuscitate (CPR) or Do Not Resuscitate (DNR).
Life-sustaining treatment when the patient has a pulse and is breathing. Choose: Intubate or Do Not Intubate (DNI).
What level of treatment do you want? Choose: Full Treatment, Limited Treatment, or Comfort Only.
Specific treatments to be provided or avoided based on your goals and condition.
Transfer preferences: Yes, Limited (comfort only), or No (remain in current setting).
Feeding tube or IV fluids: Yes, Trial Period, or No.
Antibiotic use: Full, Limited (comfort only), or None.
Dialysis if kidneys fail: Yes, Trial Period, or No.
Additional orders or specific instructions from you and your provider.
1. Your provider will review your Goals of Care decision with you.
2. Together, you'll complete a MOLST/POLST form — this turns your wishes into medical orders.
3. The form covers: resuscitation (CPR), medical interventions, antibiotics, and artificial nutrition.
4. Your provider makes sure these orders match your Living Will, HCP, and Goals of Care.
5. Both you (or your surrogate) and your provider sign the form.
6. Copies go to: your medical chart, you and your family, and EMS if needed.
7. This form is reviewed and updated whenever your health changes or you move to a new care setting.
The MOLST/POLST must be signed by both you (or your surrogate) and your provider. It's a portable document — make sure copies go to your chart, your family, and EMS if applicable.
Your doctor, physician associate, or nurse practitioner completes the form with you.
Nurse and social worker help coordinate and distribute copies.
NYS MOLST form and guidelines
eMOLST electronic registry
Share this summary with your healthcare provider at your next visit. They can help you complete or update any documents based on your preferences.