Health Care Power Of Attorney Questionnaire Template (Page 3 of 4) in pdf

6. EFFECT ON DECLARATION OF A DESIRE FOR A NATURAL DEATH (LIVING WILL)

I understand that if I have a valid Declaration of a Desire for a Natural Death, the

instructions contained in the Declaration will be given effect in any situation to which they

are applicable. My agent will have authority to make decisions concerning my health care

only in situations to which the Declaration does not apply.

7. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING TREATMENT

With respect to any Life-Sustaining Treatment, I direct the following:

(INITIAL ONLY ONE OF THE FOLLOWING 3 PARAGRAPHS)

(1) ___ GRANT OF DISCRETION TO AGENT. 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, my personal beliefs, the expense involved and the quality as well

as the possible extension of my life in making decisions concerning life-sustaining

treatment.

(2) ___ DIRECTIVE TO WITHHOLD OR WITHDRAW TREATMENT. I do not want my life to

be prolonged and I do not want life-sustaining treatment:

a. if I have a condition that is incurable or irreversible and, without the administration of

life-sustaining procedures, expected to result in death within a relatively short period of

time; or

b. if I am in a state of permanent unconsciousness.

(3) ___ DIRECTIVE FOR MAXIMUM TREATMENT. I want my life to be prolonged to the

greatest extent possible, within the standards of accepted medical practice, without

regard to my condition, the chances I have for recovery, or the cost of the procedures.

8. STATEMENT OF DESIRES REGARDING TUBE FEEDING

With respect to Nutrition and Hydration provided by means of a nasogastric tube or tube

into the stomach, intestines, or veins, I wish to make clear that in situations where life-

sustaining treatment is being withheld or withdrawn pursuant to Item 7,

(INITIAL ONLY ONE OF THE FOLLOWING THREE PARAGRAPHS):

(a) ___ GRANT OF DISCRETION TO AGENT. I do not want my life to be prolonged by tube

feeding if my agent believes the burdens of tube feeding outweigh the expected benefits.

I want my agent to consider the relief of suffering, my personal beliefs, the expense

involved, and the quality as well as the possible extension of my life in making this

decision.

(b) ___ DIRECTIVE TO WITHHOLD OR WITHDRAW TUBE FEEDING. I do not want my life

prolonged by tube feeding.

Health Care Power Of Attorney Questionnaire Template Page 3