Protective Durable Power Of Attorney For Health Care Page 5
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8DESIGNATION OF HEALTH CARE AGENT(S)
(Print the information in this section.)
I,
Name: __________________________________________________________________
Address: ________________________________________________________________
Date of birth: ____________________________________________________________
do hereby designate
Name: __________________________________________________________________
Address: ________________________________________________________________
Telephone: ______________________________________________________________
to be my health care agent (attorney-in-fact).
If he/she is ever unable or unwilling to be my health care agent, I hereby designate
Name: __________________________________________________________________
Address: ________________________________________________________________
Telephone: ______________________________________________________________
to be my alternate health care agent (attorney-in-fact).
GENERAL STATEMENT OF AUTHORITY GRANTED
Subject to the directions and limitations in this document, I hereby grant my agent full authority
to make health care decisions for me if I am unable to receive and evaluate information
effectively or to communicate decisions to such an extent that I lack the capacity to manage my
health care decisions. I expect to be fully informed about and allowed to participate in any
health care decisions for me to the extent that I am able.
Nothing in this document shall authorize anyone to approve or commit any action or
omission which will cause my death. While certain forms of care and treatment may be futile
in curing a disease or injury, care or treatment which sustains life is not futile. I reject both
euthanasia and assisted suicide, which are contrary to my belief that human bodily life is
inherently good and not merely instrumental to other goods.
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