Durable Health Care Power Of Attorney And Health Care Treatment Template (Page 6 of 8) in pdf

Durable Health Care Power Of Attorney And Health Care Treatment Template Page 6

PART III

HEALTH CARE TREATMENT INSTRUCTIONS

IN THE EVENT OF END-STAGE MEDICAL CONDITION

OR PERMANENT UNCONSCIOUSNESS (LIVING WILL)

The following health care treatment instructions exercise my right to make my own health care

decisions. These instructions are intended to provide clear and convincing evidence of my wish-

es to be followed when I lack the capacity to understand, make, or communicate my treatment

decisions:

If I have an end-stage medical condition (which will result in my death, despite the introduction

or continuation of medical treatment) or am permanently unconscious such as in an irreversible

coma or irreversible vegetative state and there is no realistic hope of significant recovery, all of

the following apply (cross out any treatment instructions with which you do not agree):

1. I direct that I be given health care treatment to relieve pain or provide comfort even

if such treatment might shorten my life, suppress my appetite or my breathing, or be

habit forming.

2. I direct that all life prolonging procedures be withheld or withdrawn.

3. I specifically do not want any of the following as life prolonging procedures: (If you

wish to receive any of these treatments, write “I do want” after the treatment.)

•

heart-lung resuscitation (CPR) _____________________________________

•

mechanical ventilator (breathing machine) ____________________________

•

dialysis (kidney machine) _________________________________________

•

surgery ________________________________________________________

•

chemotherapy radiation treatment ___________________________________

•

antibiotics ______________________________________________________

Please indicate whether you want nutrition (food) or hydration (water) medically supplied by a

tube into your nose, stomach, intestine, arteries, or veins if you have an end-stage medical con-

dition or are permanently unconscious and there is no realistic hope of significant recovery.

(Initial only one statement.)

TUBE FEEDINGS

_____ I want tube feedings to be given.

NO TUBE FEEDINGS

_____ I do not want tube feedings to be given.

HEALTH CARE AGENT’S USE OF INSTRUCTIONS

(Initial one option only.)

_____ My health care agent must follow these instructions.

_____ These instructions are only guidance.

Durable Health Care Power Of Attorney And Health Care Treatment Template Page 6