Health Care Power Of Attorney Questionnaire Template (Page 2 of 4) in pdf

THE FOLLOWING IS AN EXCERPT FROM THE HEALTH CARE POWER OF

ATTORNEY AND YOU WILL HAVE TO CHOOSE AT SIGNING ONE OF THE

VARIOUS CHOICES.

THIS IS PROVIDED SO THAT YOU WILL BE

BETTER PREPARED TO MAKE THOSE CHOICES AT SIGNING.

4. AGENT'S POWERS

I grant to my agent full authority to make decisions for me regarding my health care. In

exercising this authority, my agent shall follow my desires as stated in this document or

otherwise expressed by me or known to my agent. In making any decision, my agent

shall attempt to discuss the proposed decision with me to determine my desires if I am

able to communicate in any way. If my agent cannot determine the choice I would want

made, then my agent shall make a choice for me based upon what my agent believes to

be in my best interests. My agent's authority to interpret my desires is intended to be as

broad as possible, except for any limitations I may state below.

Accordingly, unless specifically limited by the provisions specified below, my agent is

authorized as follows:

A. To consent, refuse, or withdraw consent to any and all types of medical care,

treatment, surgical procedures, diagnostic procedures, medication, and the use of

mechanical or other procedures that affect any bodily function, including, but not limited

to, artificial respiration, nutritional support and hydration, and cardiopulmonary

resuscitation.

B. To authorize, or refuse to authorize, any medication or procedure intended to relieve

pain, even though such use may lead to physical damage, addiction, or hasten the

moment of, but not intentionally cause, my death.

C. To authorize my admission to or discharge, even against medical advice, from any

hospital, nursing care facility, or similar facility or service.

D. To take any other action necessary to making, documenting, and assuring

implementation of decisions concerning my health care, including, but not limited to,

granting any waiver or release from liability required by any hospital, physician, nursing

care provider, or other health care provider; signing any documents relating to refusals of

treatment or the leaving of a facility against medical advice, and pursuing any legal

action in my name, and at the expense of my estate to force compliance with my wishes

as determined by my agent, or to seek actual or punitive damages for the failure to

comply.

E. The powers granted above do not include the following powers or are subject to the

following rules or limitations:

_______________________________________________________________________

5. ORGAN DONATION (INITIAL ONLY ONE)

My agent may ___; may not ___ consent to the donation of all or any of my tissue or

organs for purposes of transplantation.

Health Care Power Of Attorney Questionnaire Template Page 2