Durable Power Of Attorney For Healthcare (Page 3 of 8) in pdf

2. Specific Instructions

My patient Advocate is to be guided in making medical and/or mental health decisions for me by what I

have told him/her about my personal preferences regarding life-sustaining treatment.

Choice 1: I do not want my life to be prolonged by providing or continuing life-sustaining treatment if any

of the following medical conditions exist:

• I am in an irreversible coma or persistent vegetative state.

• I am terminally ill and life-sustaining procedures would serve only to artificially delay my death.

• Under any circumstances where my medical condition is such that the burdens of the treatment

outweigh the expected benefits. In weighing the burdens and benefits of treatment, I want my

Patient Advocate to consider the relief of suffering and the quality of my life as well as the

extent of possibly prolonging my life.

I understand that this decision could or would allow me to die.

If this statement reflects your desires, sign here: ___________________________

Choice 2: I want my life to be prolonged by life-sustaining treatment unless I am in a coma or vegetative

state, which my doctor reasonably believes to be irreversible. Once my doctor has reasonably concluded

that I will remain unconscious for the rest of my life, I do not want life sustaining treatment to be provided

or continued. I understand that this decision could or would allow me to die.

If this statement reflects your decisions, sign here: __________________________

Choice 3: I want my life prolonged to the greatest extent possible consistent with sound medical practice

without regard to my condition, the chances I have for recovery, or the cost of my care, and I direct

life-sustaining treatment be provided in order to prolong my life.

If this statement reflects your decisions, sign here: __________________________

Choice 4: My preferences that are not covered in the above choices:

Choice 5:

Specific Instructions Regarding Medical Examinations

My religious beliefs prohibit a medical examination to determine whether I am unable to participate in

making medical treatment decisions, or give informed consent to mental health treatment. I desire this

determination to be made in the following manner:

3. Specific Instructions Regarding Anatomical Gifts (Optional)

My patient Advocate has the authority, upon or immediately before my death, to make an anatomical gift of

all or a part of my body for therapy or transplantation needed by another individual; for medical or dental

education, research or the advancement of medical or dental science; or for any other purpose permitted by

law. This authority granted to my Patient Advocate shall remain exercisable following my death.

If this statement reflects your desires, sign here:

Patient’s Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Durable Power Of Attorney For Healthcare Page 3

Related Articles

Related forms

Related Categories