Durable Health Care Power Of Attorney And Health Care Treatment Template (Page 3 of 8) in pdf

NOTES ABOUT THE USE OF

allows or if you wish for your

withdrawn from you, unless your

THIS FORM

health care agent to be able to speak

attending physician and an obstetri-

for you immediately. In these situa-

cian who have examined you certi-

If you decide to use this form or

tions, it is particularly important

fy in your medical record that the

create your own advance health

that you consult with your attorney

life-sustaining treatment:

care directive, you should consult

and physician to make sure that

with your physician and your attor-

(1) will not maintain you in such

your wishes are clearly expressed.

ney to make sure that your wishes

a way as to permit the con-

are clearly expressed and comply

This form allows you to tell your

tinuing development and live

with the law.

health care agent your goals if you

birth of the unborn child;

have an end-stage medical condi-

If you decide to use this form but

(2) will be physically harmful to

tion or other extreme and irre-

disagree with any of its statements,

you; or

versible medical condition, such as

you may cross out those statements.

(3) will cause pain to you that

advanced Alzheimer’s disease. Do

You may add comments to this

cannot be alleviated by med-

you want medical care applied

form or use your own form to help

ication.

aggressively in these situations or

your physician or health care agent

A physician is not required to

would you consider such aggres-

decide your medical care.

perform a pregnancy test on you

sive medical care burdensome and

This form is designed to give

unless the physician has reason to

undesirable?

your health care agent broad pow-

believe that you may be pregnant.

You may choose whether you

ers to make health care decisions

Pennsylvania law protects your

want your health care agent to be

for you whenever you cannot make

health care agent and health care

bound by your instructions or

them for yourself. It is also designed

providers from any legal liability

whether you want your health care

to express a desire to limit or

for following in good faith your

agent to be able to decide at the

authorize care if you have an end-

wishes as expressed in the form or

time what course of treatment the

stage medical condition or are per-

by your health care agent’s direc-

health care agent thinks most fully

manently unconscious.

tion. It does not otherwise change

reflects your wishes and values.

If you do not desire to give your

professional standards or excuse

If you are a woman and diag-

health care agent broad powers, or

negligence in the way your wishes

nosed as being pregnant at the time

you do not wish to limit your care if

are carried out. If you have any

a health care decision would other-

you have an end-stage medical con-

questions about the law, consult an

wise be made pursuant to this form,

dition or are permanently uncon-

attorney for guidance.

the laws of this Commonwealth

scious, you may wish to use a dif-

This form and explanation is not

prohibit implementation of that

ferent form or create your own. You

intended to take the place of specif-

decision if it directs that life-sus-

should also use a different form if

ic legal or medical advice for which

taining treatment, including nutri-

you wish to express your prefer-

you should rely upon your own

tion and hydration, be withheld or

ences in more detail than this form

attorney and physician.

Reprinted 6/08

Durable Health Care Power Of Attorney And Health Care Treatment Template Page 3

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