Durable Power Of Attorney For Healthcare Decisions (Page 4 of 8) in pdf

Durable Power Of Attorney For Healthcare Decisions Page 4

5. I do not desire treatment to be provided and/or continue if the burdens of the

treatment outweigh the expected benefits. My attorney-in-fact is to consider

relief of suffering, the preservation or restoration of functioning, and the

quality as well as the extent of the possible extension of my life.

___________

(If you wish to change your answer, you may do so by drawing an “X”

through the answer you do not want, and circling the answer you prefer.)

Other or Additional Statements of Desires: _________________________________

_________________________________________________________________

7. DESIGNATION OF ALTERNATE ATTORNEY-IN-FACT

(You are not required to designate any alternative attorney-in-fact but you may do so. Any

alternative attorney-in-fact you designate will be able to make the same health care decisions

as your attorney-in-fact. Also, if the attorney-in-fact designated in paragraph 1 is revoked by

law if your marriage is dissolved.)

If the person designated in paragraph 1 as my attorney-in-fact is unable to make health care

decision for me, then I designate the following persons to serve as my attorney-in-fact to

make heath care decisions for me as authorized in this document, such person to serve in the

order listed below:

A. First Alternative Attorney-in-Fact

Name: __________________________________________________________________

Address: ________________________________________________________________

________________________________________________________________

Telephone Number: _______________________________________________________

B. Second Alternative Attorney-in-Fact

Name: __________________________________________________________________

Address: ________________________________________________________________

_________________________________________________________________

Telephone Number: _______________________________________________________

Durable Power Of Attorney For Healthcare Decisions Page 4