Illinois Statutory Short Form Power Of Attorney For Health Care (Page 3 of 7) in pdf

Illinois Statutory Short Form Power Of Attorney For Health Care Page 3

(vi) can be there for you when you need it and is willing to accept this important role.

WHAT IF MY AGENT IS NOT AVAILABLE OR IS UNWILLING TO MAKE DECISIONS

FOR ME?

If the person who is your first choice is unable to carry out this role, then the second agent you

chose will make the decisions; if your second agent is not available, then the third agent you

chose will make the decisions. The second and third agents are called your successor agents and

they function as back-up agents to your first choice agent and may act only one at a time and in

the order you list them.

WHAT WILL HAPPEN IF I DO NOT CHOOSE A HEALTH CARE AGENT?

If you become unable to make your own health care decisions and have not named an agent in

writing, your physician and other health care providers will ask a family member, friend, or

guardian to make decisions for you. In Illinois, a law directs which of these individuals will be

consulted. In that law, each of these individuals is called a “surrogate”.

There are reasons why you may want to name an agent rather than rely on a surrogate:

(i) The person or people listed by this law may not be who you would want to make decisions for

you.

(ii) Some family members or friends might not be able or willing to make decisions as you would

want them to.

(iii) Family members and friends may disagree with one another about the best decisions.

(iv) Under some circumstances, a surrogate may not be able to make the same kinds of decisions

that an agent can make.

WHAT IF THERE IS NO ONE AVAILABLE WHOM I TRUST TO BE MY AGENT?

In this situation, it is especially important to talk to your physician and other health care providers

and create written guidance about what you want or do not want, in case you are ever critically ill

and cannot express your own wishes. You can complete a living will. You can also write your

wishes down and/or discuss them with your physician or other health care provider and ask him

or her to write it down in your chart. You might also want to use written or on-line resources to

guide you through this process.

WHAT DO I DO WITH THIS FORM ONCE I COMPLETE IT?

Follow these instructions after you have completed the form:

(i) Sign the form in front of a witness. See the form for a list of who can and cannot witness it.

(ii) Ask the witness to sign it, too.

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Illinois Statutory Short Form Power Of Attorney For Health Care Page 3