Power Of Attorney For Health Care - Sage Medical Group (Page 2 of 3) in pdf

Illinois Statutory Short Form Power of Attorney for Health Care

Page 2

(The subject of life-sustaining treatment is of particular importance. For your convenience in dealing with that

subject, some general statements concerning the withholding or removal of life-sustaining treatment are set forth

below. If you agree with one of these statements, you may initial that statement; but do not initial more than one):

I do not want my life to be prolonged nor do I want life-sustaining treatment to be provided or continued if my

Initialed

agent believes the burdens of the treatment outweigh the expected benefits. I want my agent to consider the

relief of suffering, the expense involved and the quality as well as the possible extension of my life in making

decisions concerning life-sustaining treatment.

I want my life to be prolonged and I want life-sustaining treatment to be provided or continued unless I am in a

Initialed

coma which my attending physician believes to be irreversible, in accordance with reasonable medical standards

at the time of reference. If and when I have suffered irreversible coma, I want life-sustaining treatment to be

withheld or discontinued.

I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have

Initialed

for recovery or the cost of the procedures.

(This power of attorney may be amended or revoked by you in the manner provided in section 4-6 of the Illinois

“powers of attorney for health care law” (see the back of this form). Absent amendment or revocation, the author-

ity granted in this power of attorney will become effective at the time this power is signed and will continue until

your death, and beyond if anatomical gift, autopsy or disposition of remains is authorized, unless a limitation on

the beginning date or duration is made by initialing and completing either or both of the following:)

3.( ) This power of attorney shall become effective on ______________________________________________________

_________________________________________________________________________________________________

(insert a future date or event during your lifetime, such as court determination of your disability, when you want this power to first take effect)

4.( ) This power of attorney shall terminate on ____________________________________________________________

_________________________________________________________________________________________________

(insert a future date or event, such as court determination of your disability, when you want this power to terminate prior to your death)

(If you wish to name successor agents, insert the names and addresses of such successors in the following paragraph.)

5. If any agent named by me shall die, become incompetent, resign, refuse to accept the office of agent or be unavailable,

I name the following (each to act alone and successively, in the order named) as successors to such agent:

_________________________________________________________________________________________________

For purposes of this paragraph 5, a person shall be considered to be incompetent if and while the person is a minor or an

adjudicated incompetent or disabled person or the person is unable to give prompt and intelligent consideration to health

care matters, as certified by a licensed physician.

(continued)

Power Of Attorney For Health Care - Sage Medical Group Page 2