Illinois Statutory Short Form Power Of Attorney For Health Care (Page 2 of 6) in pdf

RULES OR LIMIT THE POWER TO MAKE AN ANATOMICAL GIFT, AUTHORIZE AUTOPSY

OR DISPOSE OF REMAINS, YOU MAY DO SO IN THE FOLLOWING PARAGRAPHS.)

2. The powers granted above shall not include the following powers or shall be subject to the

following rules or limitations (here you may include any specific limitations you deem appropriate,

such as: your own definition of when life-sustaining measures should be withheld; a direction to

continue food and fluids or life-sustaining treatment in all events; or instructions to refuse any

specific types of treatment that are inconsistent with your religious beliefs or unacceptable to you

for any other reason, such as blood transfusion, electro-convulsive therapy, amputation,

psychosurgery, voluntary admission to a mental institution, etc.):

________________________________________________________________________

(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. IFYOU 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 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.

Initialed ________

I want my life to be prolonged and I want life-sustaining treatment to be provided or continued

unless I am in a 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.

Initialed ________

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

chances have for recovery or the cost of the procedures.

Initialed ________

(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 END OF THIS FORM). ABSENT AMENDMENT OR REVOCATION, THE

AUTHORITY 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:)

Illinois Statutory Short Form Power Of Attorney For Health Care Page 2