Durable Power Of Attorney For Health Care Page 3
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42. If I am persistently unconscious or there is no reasonable expectation of my recovery from a seriously incapacitating
or terminal illness or condition, I direct that all of the life-prolonging procedures that I have initialed below be withheld or
withdrawn.
artificially supplied nutrition and hydration (including tube feeding of food and water)
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surgery or other invasive procedures
heart-lung resuscitation (CPR)
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antibiotics
dialysis
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mechanical ventilator (respirator)
chemotherapy
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radiation therapy
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other procedures specified by me (insert) ______________________________________________
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all other “life-prolonging” medical or surgical procedures that are merely intended to keep me alive
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without reasonable hope of improving my condition or curing my illness or injury
3. However, if my physician believes that any life-prolonging procedure may lead to a recovery significant to me as
communicated by me or my Agent to my physician, then I direct my physician to try the treatment for a reasonable period
of time. If it does not cause my condition to improve, I direct the treatment to be withdrawn even if it shortens my life. I
also direct that I be given medical treatment to relieve pain or to provide comfort, even if such treatment might shorten my
life, suppress my appetite or my breathing, or be habit-forming.
4. If I have already consented to be on the Missouri organ and tissue donor registry or my Agent has authorized the
donation of my organs or tissues, I realize it may be necessary to maintain my body artificially after my death until my
organs or tissues can be removed.
IF I HAVE NOT DESIGNATED AN AGENT IN THE DURABLE POWER OF ATTORNEY, PART II OF THIS
DOCUMENT IS MEANT TO BE IN FULL FORCE AND EFFECT AS MY HEALTH CARE DIRECTIVE.
PART III. GENERAL PROVISIONS INCLUDED IN THE DURABLE POWER OF
ATTORNEY FOR HEALTH CARE AND HEALTH CARE DIRECTIVE
1. Relationship Between Durable Power of Attorney for Health Care and Health Care Directive . If I have executed
both the Durable Power of Attorney for Health Care and Health Care Directive, I encourage my Agent to:
A.
First, follow my choices as expressed in the above Directive or otherwise from knowing me or having had
various discussions with me about making decisions regarding life-prolonging procedures.
B.
Second, if my Agent does not know my choices for the specific decision at hand, but my Agent has evidence of
my preferences, my Agent can determine how I would decide. My Agent should consider my values, religious
beliefs, past decisions, and past statements. The aim is to choose as I would choose, even if it is not what my
Agent would choose for himself or herself.
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Parts II & III - The Missouri Bar Form Detachable Insert
Page 3 of 4
Durable Power of Attorney for Health Care and/or Health Care Directive
Revised 9/11
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