Advance Directives: A Nursing Student Guide to Living Wills, POLST, and the PSDA

Advance directives are legal documents that record a competent adult's healthcare wishes for use if that adult later loses the capacity to make medical decisions. In United States practice they generally take one of two foundational forms: a living will, which lists which life-sustaining treatments the person would or would not accept, and a durable power of attorney for healthcare, which names a surrogate decision-maker who can speak for the patient when the patient cannot speak for themselves. Advance directives only activate after a clinician confirms the patient lacks decisional capacity, and they remain revocable at any time the patient regains capacity. For nursing students, mastering advance directives means understanding the federal Patient Self-Determination Act of 1990, the Cruzan ruling that prompted it, state-by-state variation, the rise of POLST orders, and the bedside conversations that turn paperwork into ethical care.

The Cruzan case and how the Patient Self-Determination Act passed in 1990

The modern doctrine behind advance directives grew out of two sentinel cases. The first was Karen Quinlan in 1976, in which the New Jersey Supreme Court ruled that a surrogate could request withdrawal of mechanical ventilation from a young woman in a persistent vegetative state. Quinlan opened the door to surrogate refusal of life-sustaining treatment but did not produce uniform federal policy. The second and more decisive case was Cruzan v. Director, Missouri Department of Health, decided by the United States Supreme Court in June 1990. Nancy Cruzan was a 25-year-old left in a persistent vegetative state after a 1983 car accident; her parents asked that artificial nutrition and hydration be withdrawn. The Court held that competent adults have a constitutional liberty interest in refusing unwanted medical treatment, but that states may require clear and convincing evidence of an incapacitated patient's prior wishes.

The Cruzan ruling exposed a national problem: very few patients had documented their wishes in writing, and surrogates were often left guessing. Senators John Danforth and Daniel Patrick Moynihan responded by drafting the Patient Self-Determination Act, passed as part of the Omnibus Budget Reconciliation Act of 1990 and effective December 1, 1991. The PSDA applied to all hospitals, skilled nursing facilities, hospices, and home health agencies receiving Medicare or Medicaid reimbursement. It required these institutions to ask each adult patient at admission whether they had an advance directive, document the answer, provide written information about state law and institutional policy, never discriminate in care based on whether a directive existed, and educate staff and the community.

For nurses this changed admission workflow permanently. The intake nurse, not just the social worker or physician, became responsible for surfacing the question. The chart now contains a template field asking whether the patient has advance directives, whether copies are on file, and who the named agent is. Cruzan and the PSDA together moved the United States from a regime where end-of-life decisions were improvised at the bedside to one where every Medicare-funded facility must at minimum ask the question. Nursing students writing on this history should summarize Quinlan, Cruzan, and the PSDA in their own words and explain why a 1990 federal statute remains the operating frame for documentation today.

The two foundational document types: living will and durable power of attorney for healthcare

Advance directives in United States law fall into two foundational categories that work best together rather than alone. The first is the living will, sometimes called a directive to physicians or a healthcare declaration. A living will is a written statement, signed by a competent adult and usually witnessed or notarized according to state requirements, that lists in advance which medical treatments the patient would accept or refuse if they were terminally ill, permanently unconscious, or otherwise unable to communicate. It is essentially a treatment menu prepared in advance for a future self who cannot order from it.

The second category is the durable power of attorney for healthcare, also called a healthcare proxy, healthcare power of attorney, or appointment of a healthcare agent. This document does not list treatments; it names a person. The named agent steps into the patient's shoes once a clinician confirms incapacity and makes decisions the patient would have made. The word durable distinguishes this instrument from an ordinary financial power of attorney; durable means the authority survives the principal's incapacity, which is exactly when it is needed. Most jurisdictions require the agent to be an adult, usually exclude the patient's attending physician or facility staff from serving, and allow naming a primary plus one or two alternates.

Used together, these two documents complement one another. The living will speaks to recognizable scenarios the patient anticipated; the durable power of attorney speaks to everything else. Modern combined forms, including the federal Veterans Affairs advance directive and many state-issued forms, place both functions on a single signed document. Nursing students should be careful never to refer to these instruments by informal labels alone, since in chart documentation precision protects the patient. A nurse rooted in the standards described in our overview of the nursing code of ethics treats the directive as a living expression of patient autonomy, not a clerical box to tick. Good documentation in the SOAP note structure reflects this distinction by noting both the existence of a written directive and the named agent's contact information.

How a living will captures treatment preferences

A living will translates abstract values into concrete clinical instructions. Most state-issued forms used to record advance directives ask the signer to indicate preferences across a recognizable cluster of life-sustaining interventions. Cardiopulmonary resuscitation, or CPR, is usually listed first; the patient may accept or refuse chest compressions, defibrillation, and emergency drug administration in cardiac arrest. Mechanical ventilation is the next major category, including endotracheal intubation, non-invasive positive-pressure ventilation such as BiPAP, and tracheostomy. Artificial nutrition and hydration cover nasogastric tubes, percutaneous endoscopic gastrostomy or PEG tubes, total parenteral nutrition, and intravenous fluid given solely to sustain life. Dialysis appears on most forms. Antibiotics for opportunistic infection in a patient with a terminal underlying disease often have their own checkbox. Blood products and non-curative surgical interventions round out the list.

Living wills typically include a comfort-care default. Even when life-sustaining treatments are refused, the patient retains an explicit right to pain management, oral hygiene, repositioning, wound care, and emotional support. This matters at the bedside because the nurse is rarely the person who withholds the ventilator; the nurse is the person who ensures comfort care continues as written. Many forms include narrative space where the patient describes their values, for example valuing quality of life over quantity, wishing to die at home, or considering a dependent existence inconsistent with their identity.

A common student misunderstanding is that a living will only applies in terminal illness. In most states it also activates in permanent unconsciousness, end-stage chronic disease, or any condition meeting the form's defined trigger. This is why nurses should read the directive itself, not merely note that one exists. Advance directives are only as useful as the staff who actually read them; the most consequential bedside skill is pulling the document, reading it line by line, and translating it into active orders. The communication skills covered in our guide to therapeutic communication apply when the nurse must explain to a family member what the document says and what it does not.

How a durable power of attorney for healthcare designates a surrogate

A durable power of attorney for healthcare names a person rather than a treatment. This person is referred to in different jurisdictions as a healthcare agent, healthcare proxy, surrogate decision-maker, or attorney-in-fact. The instrument is durable because the agent's authority specifically begins or remains in force after the principal loses capacity, the moment when an ordinary power of attorney would terminate.

The agent's job is to make the decision the patient would have made, a standard called substituted judgment. Where the agent has no idea what the patient would have chosen, decision-making falls back to the best-interest standard, asking what a reasonable person would choose. The agent is not a free-form decision-maker; the agent must follow the principal's known wishes, including any written limitations. Most state statutes empower the agent to consent to or refuse any treatment the patient could have refused, request transfer to another facility, access medical records, hire and fire clinicians, and authorize organ donation if the patient permitted it.

Limitations are common and often misunderstood. Most jurisdictions require the principal's express written authorization before an agent can withhold artificial nutrition and hydration, withdraw mental health treatment, consent to research participation, or order an autopsy. Some states limit the agent's authority over pregnancy-related care. Most states bar attending physicians, facility staff, and the agent's own paid caregivers from serving as agent unless they are relatives. Successor agents are the safety net when the primary agent is unavailable or declines to serve.

The principle of strong patient advocacy matters most when the named agent is absent and a non-designated family member is at the bedside demanding decisions. Nurses must know that a living will controls the question if the agent is unreachable, that state-law hierarchies of family decision-makers govern absent a document, and that the agent's authority over advance directives never overrides the patient's clearly expressed prior wishes.

State variation: why advance directive forms differ from state to state

The PSDA is a federal statute, but the actual forms used to record advance directives are governed by state law. This creates real variation in witnessing requirements, reciprocity rules, default terminology, and content. New York and Massachusetts use a healthcare proxy as the dominant instrument and treat living-will narrative content as supporting evidence rather than a controlling document. California uses an Advance Health Care Directive that combines living will and durable power of attorney into one form. Texas separates a Directive to Physicians and Family or Surrogates from a Medical Power of Attorney. Florida law governs both a Living Will and a Designation of Health Care Surrogate.

Witnessing rules vary almost as much as the forms. Some states require two adult witnesses, neither of whom may be a relative, beneficiary, attending clinician, or facility employee. Others require notarization. A few accept either. Reciprocity also varies; most states honor a directive validly executed elsewhere, but a few apply their own substantive rules, which can matter when a snowbird patient is admitted out of state.

For nursing students, the practical takeaway is to never assume the form is uniform. Always confirm which state's law governs, scan the document for witnessing or notary marks before relying on it, and verify the named agent has not predeceased. Hospital policy normally requires escalation to risk management or social work when the document looks ambiguous, when out-of-state forms are presented, or when a digital copy needs to be authenticated. Documenting these checks in the chart, in line with the structured nursing process workflow, prevents downstream confusion if the patient deteriorates overnight.

POLST and MOLST: the medical-orders-for-life-sustaining-treatment movement

POLST stands for Physician Orders for Life-Sustaining Treatment, and MOLST stands for Medical Orders for Life-Sustaining Treatment; the labels vary by state but the instrument is the same. POLST originated in Oregon in 1991 to solve a problem advance directives alone could not. A patient with terminal illness might have a beautifully drafted living will, but if they went into cardiac arrest at home and EMS arrived, EMTs were trained to start CPR unless they saw an active medical order. A directive is a patient document, not an order, and EMTs follow orders.

POLST converts patient wishes into actionable medical orders signed by a physician, advanced practice registered nurse, or physician assistant, depending on state scope-of-practice rules. The form is typically printed on bright pink card stock so that responders can find it quickly on a refrigerator or in a chart. It addresses a small, targeted set of decisions: whether to attempt CPR in a pulseless apneic patient; the level of medical interventions desired short of arrest, such as full treatment, selective treatment, or comfort-focused care; whether to use artificial nutrition; and any additional orders the clinician documents. POLST is valid across care settings and travels with the patient between home, hospital, nursing facility, and hospice.

POLST is not a substitute for an advance directive; the two are complementary. Advance directives are written by competent adults at any stage of life. POLST is appropriate for patients who are seriously ill or frail and whose clinician would not be surprised if they died within the next year, the so-called surprise question. A young healthy adult should have an advance directive but should not have a POLST. A frail nursing-home resident with end-stage heart failure should have both: the directive expressing background values and the POLST converting current wishes into immediate orders.

The table below summarizes how the three main instruments differ in scope, who signs, where they apply, and when they take effect.

The Five Wishes document and other commonly used templates

The Five Wishes document, published by Aging with Dignity, is among the most widely used advance directive templates in the United States. It is recognized as a legally valid form in most states, either on its own or in combination with state-specific witnessing language. Five Wishes deliberately covers more than the medical decisions that anchor most state-issued forms. The five sections ask the signer to record who they want to make decisions for them when they cannot, the kind of medical treatment they want or do not want, how comfortable they want to be, how they want people to treat them, and what they want their loved ones to know.

The third, fourth, and fifth wishes go beyond standard living-will territory and into psychological, spiritual, and relational care. The patient can record preferences about pain management, spiritual support, music, photographs at the bedside, who should be present, what should be read aloud, what the patient wants said at the funeral, and what messages the patient wants to leave for family members. For nurses providing whole-person holistic nursing care, Five Wishes is an unusually rich document because it tells the staff how the patient wants to be cared for, not only what should be withheld.

Other widely circulated templates include Caring Conversations from the Center for Practical Bioethics, Go Wish cards used to elicit values in family conversations, the Stanford Letter Project, and state-specific forms drafted by bar associations. Faith-based versions exist too, including Catholic, Jewish, Buddhist, and Islamic templates that align treatment refusals with the signer's tradition. Veterans Affairs publishes its own VA Advance Directive used inside the VA system. Choosing among these templates is partly clinical, partly cultural, and partly legal; nurses should know that any template signed under the witnessing rules of the patient's state is generally valid, that advance directives are revocable at any time, and that providing patients with templates as part of structured patient education meets one prong of the PSDA institutional obligation.

Capacity assessment: what nurses need to confirm before a directive is valid

An advance directive is only signed validly when the principal had capacity at signing, and only activates when the patient currently lacks capacity. Nurses are central to both ends of this assessment, even when the formal determination is documented by a physician or advanced practice provider.

Decisional capacity is a clinical judgment with four elements from the Appelbaum and Grisso framework. The patient must communicate a choice, understand the relevant information, appreciate how it applies to their situation, and reason through the consequences of accepting or refusing treatment. Capacity is decision-specific and time-specific. A patient may lack capacity to consent to multi-organ surgery while retaining capacity to refuse a blood draw. A delirious patient at 0300 may regain capacity by 0900. The nurse's serial assessments across a shift are often the most reliable signal of fluctuating capacity.

Capacity must be distinguished from competence, a legal term referring to a court determination. A patient is presumed competent unless a court rules otherwise; capacity is what clinicians evaluate at the bedside. Conflating these is a common student error, and nurses who muddle them in chart notes create medico-legal risk.

Once incapacity is established, advance directives activate; if capacity returns, the patient resumes direct decision-making and the directive recedes. Documentation should record what was assessed, what tools were used, and which clinician confirmed the determination, integrated with the broader workflow in our nursing process guide.

The nurse's role under ANA Code Provision 1 in advance care planning

The American Nurses Association Code of Ethics for Nurses with Interpretive Statements, revised in 2015, opens with Provision 1: the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. Interpretive Statement 1.4 obligates nurses to support self-determination, provide information needed for informed decisions, and respect advance directives as expressions of that self-determination.

This provision shapes daily practice. The nurse asks every adult inpatient at admission whether they have an advance directive, documents the answer, requests copies for the chart, and offers educational materials when none exists. The nurse identifies the named agent in the chart and verifies contact information. When the patient deteriorates, the nurse retrieves the document, reads it line by line, and ensures the active treatment plan reflects what the patient wrote. The nurse advocates for the patient's wishes against pressure from family, clinicians, or institutional cultures that default to maximum intervention.

Provision 2 reinforces that the nurse's primary commitment is to the patient, even when that loyalty conflicts with family preferences or physician habit. Provision 4 makes the nurse responsible and accountable for individual nursing practice and decisions. Provision 5 obligates the nurse to preserve their own integrity, which supports the right of conscientious objection in narrow circumstances. Provision 6 obligates the nurse to shape an ethical environment of care. Together these provisions move advance directives from a clerical task to a core ethical obligation, anchored in the standards explored in our broader nursing leadership and ethics resources.

Conversations with patients and families: SPIKES, NURSE, and Ariadne Labs serious-illness conversation guide

Documents do not write themselves. Advance directives originate in conversations, and structured communication frameworks help nurses guide those conversations with skill rather than improvisation. Three frameworks dominate United States practice.

SPIKES, developed by Walter Baile, Robert Buckman, and colleagues and published in The Oncologist in 2000, is a six-step protocol for delivering serious news. Setting establishes a private, uninterrupted environment. Perception asks what the patient already understands. Invitation asks how much the patient wants to know. Knowledge delivers the information in calibrated language. Emotion responds to feelings before facts. Strategy and Summary close with a clear plan. SPIKES anchors most United States curricula on breaking bad news and pairs naturally with directive conversations.

NURSE, taught by VitalTalk, is a tighter framework for responding to emotion in the moment: Naming the emotion, Understanding by reflecting back, Respecting by acknowledging strength or values, Supporting by signaling presence, and Exploring by asking gentle open questions. NURSE is what a nurse uses inside a SPIKES conversation when the patient cries, falls silent, or becomes angry.

The Ariadne Labs Serious Illness Conversation Guide, developed by Atul Gawande and colleagues, uses a single-page script that asks permission, explores understanding of illness, asks how much information the patient wants, explores fears, asks what abilities matter most, asks what trade-offs the patient will accept, and closes by reflecting what was heard. The guide is grounded in evidence that structured serious-illness conversations earlier in the disease course are associated with lower anxiety, lower depression, and care more aligned with patient goals. Frameworks like these, paired with the bedside skills covered in our therapeutic communication overview, turn directive paperwork into ethically responsive care.

Common ethical conflicts: family override, surrogate disagreement, conscientious objection

Even with well-drafted advance directives, conflict arises. Three conflict patterns recur in United States nursing practice and routinely appear in student case studies.

The first is family override. A patient signed a directive refusing CPR; the patient is now obtunded; an adult child arrives, demands everything be done, and threatens litigation. The directive controls. The named agent, not a non-designated relative, has surrogate authority, and even the agent must follow the patient's known wishes. Nurses must escalate to the attending, ethics consult, or risk management when family pressure threatens to override a valid directive, while continuing to support the family's grief.

The second is surrogate disagreement. Two siblings are co-agents, or the agent disagrees with the patient's non-agent spouse. Most state statutes resolve disputes among co-agents through majority rule or grant the primary agent final authority; disputes between the agent and other relatives are resolved in favor of the agent. Bedside nurses are not adjudicators; they document the directive and the agent's decision, then escalate.

The third is conscientious objection. Provision 5 of the ANA Code recognizes that a nurse may decline to participate in a treatment that violates the nurse's deeply held moral or religious beliefs, provided the nurse arranges safe transfer of care so the patient is not abandoned. This is narrow. A nurse may not refuse to honor a patient's directive merely because the nurse disagrees, and conscientious objection does not extend to refusing pain management, hydration of the conscious patient, or other comfort measures.

Each of these conflict patterns is a candidate ethics-paper case study and pairs naturally with the safeguards described in our evidence-based practice resource when students argue from data rather than emotion.

Cultural and religious variation in advance care planning

Advance care planning in the United States rests on a doctrine of individual autonomy. That doctrine is not universally shared, and culturally responsive nursing requires acknowledging variation.

Many East Asian cultural traditions, including Chinese, Korean, and Vietnamese family patterns, treat serious-illness disclosure as a family event rather than an individual one. Adult children may ask the team not to disclose a terminal diagnosis to the elderly parent, believing disclosure causes despair. Nursing students should recognize that the patient retains the right to receive or decline information, and the negotiation is about how much the patient wants to know, not whether the family can silence the team.

Latino and Hispanic families often emphasize collective decision-making centered on the eldest son or designated relative, sometimes called familismo. African American patients, against a backdrop of historical mistreatment in healthcare, are statistically less likely to complete advance directives and more likely to request continued life-sustaining treatment, a pattern documented by the Institute of Medicine in Dying in America (2014). Trust-building, not paperwork pressure, is the appropriate nursing response.

Religious traditions add another layer. Orthodox Jewish bioethics distinguishes between actively shortening life, generally prohibited, and removing impediments to natural death, generally permitted, shaping preferences around ventilation and artificial nutrition. Catholic teaching, articulated in the United States Conference of Catholic Bishops Ethical and Religious Directives, accepts refusal of disproportionate or burdensome treatment but treats nutrition and hydration as ordinarily obligatory. Islamic bioethics opposes hastening death but permits forgoing futile treatment. Buddhist traditions emphasize lucidity at the moment of death. Culturally competent care does not impose the standard Five Wishes script on every patient; it asks first.

How nursing students should structure papers on advance directives

Three formats dominate nursing-school assignments on this topic. The first is a concept analysis using the Walker and Avant method. The student selects advance directives as the concept of interest, defines uses, identifies defining attributes such as voluntariness and capacity, builds a model, contrasting, and borderline case, lists antecedents and consequences, and identifies empirical referents such as documentation rates. Concept-analysis papers reward precision; treat the eight Walker and Avant steps as a checklist.

The second is the ethics case study. The student presents a patient scenario, identifies the ethical issue, applies a framework such as the four principles from Beauchamp and Childress, applies relevant ANA Code provisions, evaluates options, recommends an action, and discusses limitations. Strong case studies cite Cruzan, the PSDA, and assigned-facility policy, and integrate SPIKES or Ariadne Labs when communication is at issue.

The third is the capstone or evidence synthesis paper, often built on the Iowa or Johns Hopkins Evidence-Based Practice models. The student frames a PICOT question, runs a literature search, appraises evidence using GRADE or Joanna Briggs hierarchies, synthesizes findings, and proposes a practice change such as a new admission script for surfacing advance directives. The structured workflow in our evidence-based practice in nursing guide applies directly. Whichever format is assigned, citations should follow APA 7, headings should reflect the rubric exactly, and clinical scenarios should be drawn from real practice rather than invented.

Common student misunderstandings about advance directives

Five misunderstandings show up repeatedly in student papers and bedside handoffs and deserve direct correction.

First, students often treat POLST as a type of advance directive. It is not. An advance directive is a patient document; a POLST is a medical order signed by a clinician. Both can coexist; they are not interchangeable, and EMTs follow POLST while disregarding directives that lack clinician signature.

Second, students conflate capacity with competence. Capacity is a clinical, decision-specific, time-specific judgment made at the bedside. Competence is a court determination of legal status. Documenting that a patient is incompetent when the team only assessed capacity is medico-legally incorrect.

Third, students forget revocation rights. Advance directives are revocable at any time the patient has capacity, by any clear method including a verbal statement to the treating clinician, destruction of the original, or execution of a new directive. A revoked directive must be physically removed from the chart and the agent notified.

Fourth, students confuse a do-not-resuscitate order with an advance directive. A DNR is a clinician-signed order limited to CPR; an advance directive is a broader patient document. Many patients have one without the other.

Fifth, students assume advance directives activate immediately on admission. They do not. They activate only after a clinician confirms the patient lacks decisional capacity in the form's defined trigger. Until then the patient speaks for themselves, regardless of how detailed the directive is. Working through these misconceptions in early coursework, supported by the structured formats in our SOAP note guide, prevents documentation errors that follow students into practice.

How EssayFount writing experts support ethics case studies and end-of-life nursing papers

EssayFount's writing experts help nursing students translate the legal, ethical, and clinical material in this guide into rubric-aligned written work. Our health-sciences team coaches across the formats most often assigned: concept analysis using the Walker and Avant method, four-principles ethics analysis using Beauchamp and Childress, evidence synthesis under Iowa or Johns Hopkins models, capstone change-project papers, reflective journaling using Gibbs or Driscoll, and DNP capstones on advance care planning quality improvement. We coach Cruzan and PSDA history, Quinlan precedent, the rise of POLST, the Ariadne Labs Serious Illness Conversation Guide, the SPIKES and NURSE protocols, and the ANA Code provisions students are expected to cite.

The team also supports the documentation-side artifacts students bring back from clinicals: SOAP notes about advance care planning conversations, ISBAR handoffs that flag the existence and content of advance directives, care-plan entries linking patient autonomy to NANDA diagnoses such as Decisional Conflict, and policy briefs proposing improvements to admission directive screening. Every engagement is led by named writing experts, never anonymous freelancers. Students remain the authors; we coach. The aim is professional academic writing that survives Turnitin, AI-content detectors, faculty rubrics, and clinical preceptors. Our resources on the nursing process and on patient education coursework support pair well with this pillar.

Reader questions about advance directives

What are the three types of advance directives?

The three types are the living will, the durable power of attorney for healthcare (also called a healthcare proxy), and the Physician Orders for Life-Sustaining Treatment (POLST). A living will documents the patient's preferences about specific interventions such as mechanical ventilation, artificial nutrition, and resuscitation. The healthcare proxy names a surrogate who can speak for the patient when capacity is lost. POLST is a portable medical order signed by a clinician that travels with the patient between settings and is followed by emergency responders without further authorisation.

What is the meaning of an advance directive?

An advance directive is a written legal document that states a person's preferences for medical care if they lose the capacity to make or communicate those decisions themselves. The Patient Self-Determination Act of 1990 requires every Medicare-funded United States hospital, nursing home, hospice, and home-health agency to ask patients on admission whether they have an advance directive and to record the answer. The directive becomes operative only when capacity is lost; while the patient retains capacity, they make their own decisions and the document sits unused in the chart.

What are examples of advance directives?

Common examples include a living will documenting refusal of mechanical ventilation, a durable power of attorney for healthcare naming a spouse as surrogate, a do-not-resuscitate order written into the chart, a POLST form signed by a primary-care clinician for a patient with advanced disease, and an advance directive specifying organ-donation preferences. Each is documented in the medical record and reviewed at every transition of care. State-specific forms add variations such as Five Wishes, the most widely used non-statutory directive in the United States.

Can I download an advance directive form?

Yes. Every state in the United States publishes its statutory advance directive form, available through the state attorney general's office or the state department of health. The American Bar Association maintains a state-by-state directory linking to current forms. Five Wishes, a non-statutory directive recognised in 46 states, is available through Aging with Dignity. Patients should use a form that meets the witnessing or notarisation requirements of the state where care will be received, since the requirements vary by jurisdiction.

Under what conditions are advance directives no longer valid?

A directive becomes invalid when the patient revokes it (orally or in writing while still possessing capacity), when a more recent directive supersedes it, or when a court overturns it. State law may also invalidate a directive if the named surrogate is divorced from the patient, if the directive contradicts state public policy, or if the patient was incompetent at the time of signing. Pregnancy clauses in some states limit how the directive applies to a pregnant patient, and the directive only operates while the patient lacks decision-making capacity.