Durable Health Care Power Of Attorney And Health Care Treatment Template (Page 5 of 8) in pdf

Durable Health Care Power Of Attorney And Health Care Treatment Template Page 5

FOR HELP IN DETERMINING YOUR WISHES FOR TREATMENT.

NOTE THAT YOU MAY NOT APPOINT YOUR DOCTOR OR OTHER HEALTH CARE

PROVIDER AS YOUR HEALTH CARE AGENT, UNLESS RELATED TO YOU BY BLOOD,

MARRIAGE OR ADOPTION.

If my health care agent is not readily available or if my health care agent is my spouse and an

action for divorce is filed by either of us after the date of this document, I appoint the person or

persons named below in the order named. (It is helpful, but not required, to name alternative

health care agents.)

First Alternative Health Care Agent: ________________________________________________

(Name and relationship)

Address: ______________________________________________________________________

Telephone Number: Home _________________________ Work ________________________

E-mail: _______________________________________________________________________

Second Alternative Health Care Agent: ______________________________________________

(Name and relationship)

Address: ______________________________________________________________________

Telephone Number: Home _________________________ Work ________________________

E-mail: _______________________________________________________________________

GUIDANCE FOR HEALTH CARE AGENT (OPTIONAL)

GOALS

If I have an end-stage medical condition or other extreme irreversible medical condition, my

goals in making medical decisions are as follows (insert your personal priorities such as com-

fort, care, preservation of mental function, etc.):

SEVERE BRAIN DAMAGE OR BRAIN DISEASE

If I should suffer from severe and irreversible brain damage or brain disease with no realistic

hope of significant recovery, I would consider such a condition intolerable and the application

of aggressive medical care to be burdensome.

I therefore request that my health care agent respond to any intervening (other and separate)

lifethreatening conditions in the same manner as directed for an end-stage medical condition or

state of permanent unconsciousness as I have indicated below.

Initials _______ I agree

Initials _______ I disagree

Durable Health Care Power Of Attorney And Health Care Treatment Template Page 5