How to Fill Out and Sign the Nebraska Advance Directive Form

The Nebraska advance directive form is a two-part document: a Power of Attorney for Health Care that names someone to make medical decisions when you cannot, and a Declaration (living will) that states your own wishes about life-sustaining treatment. You can complete one part, the other, or both. No lawyer is required, and the form is free.¹

Where to Get the Form

Nebraska does not require a specific preprinted form. The statutes supply suggested language, and any directive is valid as long as it meets the content, signature, and witness requirements. Using a standard form just reduces the chance of leaving something out.

The Nebraska Department of Health and Human Services hosts a downloadable Power of Attorney for Health Care form,² and Legal Aid of Nebraska offers an automated online tool that walks you through both the Power of Attorney and Declaration sections.¹

Who Can Sign

The age requirement depends on which part you are completing. For the Power of Attorney for Health Care, Nebraska defines “adult” as anyone eighteen or older.³ For the Declaration, the Rights of the Terminally Ill Act sets the floor at nineteen, matching Nebraska’s general age of majority. Both parts require that you be of sound mind when you sign.⁴

Before You Sit Down With the Form

Gather a few things first:

The full legal name, address, and phone number of the person you want as your health care agent, plus a backup in case the first person is unavailable or unwilling.⁵
Your position on specific interventions: CPR, mechanical ventilation, feeding tubes, antibiotics when recovery is not expected.
Any limits you want to place on your agent’s authority, or any treatments you always or never want.
Either two qualified adult witnesses or a notary, lined up so you can sign everything in one sitting.

Part I: Power of Attorney for Health Care

This section names your agent. Print your full name on the line identifying you as the principal, then fill in your agent’s name, address, and phone number. Do the same for your successor agent on the lines below.² Your agent must be a competent adult. They don’t have to live in Nebraska, but choosing someone close enough to respond quickly during a crisis is practical.

The form then provides blank lines for specific instructions or limits on your agent’s authority. This is where you tailor the document. You might prohibit your agent from authorizing a particular procedure, require a second medical opinion before withdrawing treatment, or note religious or personal values you want respected. Leave this section blank and your agent gets broad authority to make any health care decision you could have made yourself.⁶

The Power of Attorney takes effect only when your attending physician determines you can no longer understand health care information or communicate an informed decision. Until that happens, you keep full control over your own care.⁷

Part II: The Declaration

The Declaration covers a narrower situation: it applies only when you have a terminal condition or are in a persistent vegetative state and can no longer make your own treatment decisions. In that scenario, the Declaration speaks directly to your physician about whether to continue or withdraw life-sustaining measures.⁴

The statutory form provides one directive: that life-sustaining treatment not necessary for comfort or pain relief be withheld or withdrawn. If you want more nuance, say for example allowing antibiotics but refusing a ventilator, use the blank lines or an addendum to spell that out. Be specific. “No heroic measures” is too vague for a physician to act on. Name the interventions you want and the ones you do not.

The Pregnancy Boundary

Nebraska law overrides your Declaration if you are pregnant and the fetus is likely to develop to the point of live birth with continued treatment. Your agent under the Power of Attorney is bound by the same restriction.⁷ Writing your preferences into the directive still creates a record for your family and care team, even though the statute limits what physicians can do.

Signing: Witnesses or a Notary

Both parts of the directive must be signed and dated by you, or by someone else at your direction if you are physically unable to sign. You then need either two adult witnesses or a notary public. One or the other is enough; using both is harmless.⁶

Who Cannot Witness the Power of Attorney

Nebraska’s disqualification list for Power of Attorney witnesses is long. None of these people can serve:

Your spouse, parent, child, grandchild, or sibling
Your presumptive heir or a known devisee under your will
Your attending physician or any member of a mental health treatment team
Your romantic or dating partner
The person you are naming as attorney-in-fact
An employee of your life or health insurance provider

No more than one of your two witnesses may be an administrator or employee of a health care provider currently treating you.⁸ In practice, the safest choice is two friends, neighbors, or coworkers with no connection to your medical care, insurance, or estate.

Who Cannot Witness the Declaration

The witness rules for the Declaration are narrower. No witness may be an employee of your life or health insurance provider, and no more than one witness may be an administrator or employee of a health care provider treating you.⁴ The family-member and heir restrictions that apply to the Power of Attorney do not appear in the Declaration statute, but using the same impartial witnesses for both parts keeps things simple.

Using a Notary Instead

If you choose notarization, the notary cannot be the person named as your attorney-in-fact or successor. The witness disqualification rules do not apply to notaries.⁴ Nebraska caps the fee for a notary to take an acknowledgment at $5.00.⁹ Banks and shipping stores commonly provide notary services, and some waive the fee for account holders.

What to Do With the Signed Document

Keep the original somewhere easy to reach, like a home filing cabinet or desk drawer. A safe deposit box is a poor choice because medical emergencies happen outside bank hours.

Make copies and give them to:

Your attorney-in-fact and successor agent
Your primary care physician, who is required to place it in your medical record⁴
Close family members likely to be present during an emergency
Any hospital or specialist you see regularly

Upload a scanned copy to your health system’s patient portal if one is available. Nebraska does not operate a centralized statewide registry for advance directives, so distributing copies yourself is the only way to make sure the document is where it needs to be.⁷

Changing or Canceling It Later

You can revoke your Power of Attorney for Health Care at any time, in any way you can communicate your intent: verbally, in writing, or by any other means. The revocation takes effect once you communicate it to your attending physician, your health care provider, or your attorney-in-fact. Whoever receives the revocation must promptly notify your attending physician, who records it in your medical file.¹⁰

You do not need to destroy the old document to revoke it, though doing so prevents confusion. Signing a new Power of Attorney for Health Care automatically revokes any earlier one, unless the new document says otherwise.¹⁰

One situation catches people off guard. If you divorce or legally separate, your ex-spouse is automatically removed as your attorney-in-fact unless the divorce decree specifically says the appointment survives.¹⁰ If your ex was your only named agent and you have no successor, no one is designated to make health care decisions for you. Updating your directive after a divorce is one of the most commonly skipped steps.

1
Nebraska Department of Health and Human Services. Advance Directives
2
Nebraska Department of Health and Human Services. Nebraska Power of Attorney for Health Care
3
Nebraska Legislature. Nebraska Code 30-3402 – Definitions
4
Nebraska Legislature. Nebraska Code 20-404 – Declaration Relating to Use of Life-Sustaining Treatment
5
Nebraska Legislature. Nebraska Code 30-3408 – Power of Attorney Form and Validity
6
Nebraska Legislature. Nebraska Code 30-3404 – Power of Attorney Contents
7
CaringInfo. Nebraska Advance Directive
8
Nebraska Legislature. Nebraska Code 30-3405 – Witness Disqualifications
9
Nebraska Legislature. Nebraska Code 33-133 – Notaries Public Fees
10
Nebraska Legislature. Nebraska Code 30-3420 – Power of Attorney Revocation, Limitations, and Effect