Combined Living Will And Health Care Power Of Attorney (Page 2 of 5) in pdf

II.

HEALTH CARE POWER OF ATTORNEY

________________________________________________________________________________________(name)

of _________________________________________ County, Pennsylvania, am a Catholic from the Diocese of

______________________________ and believe that life is a precious gift from God. I believe that God

intended for my life to be lived for His glory and my salvation. I know too that my earthly goal is to be united

with God for eternal life. Therefore, I do not need to resist death if medical treatment is futile or disproportionately

burdensome. My duly appointed health care agent may refuse medical treatments, as long as doing so is

consistent with the authoritative teaching of the Catholic Church such as that set forth in documents such as

The Gospel of Life (Pope John Paul II, March 25, 1995); Declaration on Euthanasia (Congregation for the

Doctrine of the Faith, 1980); Patients in a “Permanent” Vegetative State (Pope John Paul II, March 20, 2004);

Nutrition and Hydration: Moral Considerations (The Catholic Bishops of Pennsylvania, Revised Edition, 1999);

Ethical and Religious Directives for Catholic Health Care Services (U.S. Conference of Catholic Bishops,

2001);and

Responses to Certain Questions Concerning Artificial Nutrition and Hydration (Congregation for

the Doctrine of the Faith,

2007).

Medical treatments may be foregone, or withdrawn, if they do not offer me reasonable hope of benefit or are

disproportionately burdensome, meaning the treatments will impose serious risks, excessive pain, excessive

expense on the family or the community, or other extreme burden. My health care agent (or health care

representative as designated by the law) is to presume in favor of providing me with nutrition and hydration,

including medically assisted nutrition and hydration if they are capabale of sustaining my life.

This health care power of attorney will take effect when, and only when, I lack the ability to understand,

make or communicate a choice regarding a health or personal care decision and that inability is verified by my

attending physician.

My health care agent may not delegate the authority to make decisions to anyone else, unless I specifically

authorize that by additional written instructions which I set forth below.

I recognize that the civil law gives my health care agent certain powers. These powers are to be exercised

according to my wishes and religious beliefs as expressed above.

POWERS OF HEALTH CARE AGENT UNDER PENNSYLVANIA LAW

To authorize or direct withholding or withdrawal of medical care and surgical procedures.

To authorize my admission to or discharge from a medical, nursing, residential or similar facility, and to

make arrangements for my care, including hospice and/or palliative care.

To hire and discharge medical, social service and other support personnel responsible for my care.

To authorize, withhold or withdraw nutrition (food) or hydration (water) medically supplied by tube

through my nose, stomach, intestines, arteries or veins.

To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order, including an

out-of-hospital DNR order as authorized in law, and sign any required documents and consents.

1 Effective immediately and continuously until my death, or revocation by a writing signed by me or someone authorized by law to revoke this

document, I authorize all health care providers or other covered entities to disclose to my health care agent, upon the agent’s request, any information,

oral or written, regarding my physical or mental health.

The information includes, but is not limited to, medical and hospital records and what is

otherwise private, privileged, protected or personal health information (such as that described or defined in the Health Insurance Portability and

Accountability Act of 1996 (Public Law 104-91, 100 Stat. 1936) and the regulations promulgated thereunder and any other State or local laws and

rules).

Page 2

Combined Living Will And Health Care Power Of Attorney Page 2

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