Durable Power Of Attorney For Healthcare Decisions Form (Page 2 of 2) in pdf

Healthcare Treatment Directive

If you only want to name a Durable Power of Attorney for Healthcare Decisions, draw a large X through this page.

I, ________________________ , SS# _________________ want everyone who cares for me to know what healthcare I want.

(optional)

I always expect to be given care and treatment for pain or discomfort even if such care may affect how I sleep, eat, or breathe.

I would consent to, and want my agent to consider my participation in federally regulated research related to my disorder or

condition.

I want my doctor to try treatments/interventions on a time-limited basis when the goal is to restore my health or help me

experience a life in a way consistent with my values and wishes. I want such treatments/interventions withdrawn when they

cannot achieve this goal or become too burdensome to me.

I want my dying to be as natural as possible. Therefore, I direct that no treatment (including food or water by tube) be given

just to keep my body functioning when I have

• a condition that will cause me to die soon, or

• a condition so bad (including substantial brain damage or brain disease) that I have no reasonable hope of achieving

a quality of life that is acceptable to me.

An acceptable quality of life to me is one that includes the following capacities and values. (Describe here the things that are

most important to you when you are making decisions to choose or refuse life-sustaining treatments.)

_______________________________________________________________________________________________

_______________________________________________________________________________________________.

Examples:

• recognize family or friends

• make decisions

• communicate

• feed myself

• take care of myself

• be responsive to my environment

If you do not agree with one or other of the above statements, draw a line through the statement and put your initials

at the end of the line.

In facing the end of my life, I expect my agent (if I have one) and my caregivers to honor my wishes, values, and directives.

For further clarification, please refer to my Caring Conversations Workbook, which is located at ____________________.

Be sure to sign the reverse side of this page even if you do not wish

to appoint a Durable Power of Attorney for Healthcare Decisions

Talk about this form and your ideas about your healthcare with the person you have chosen to make

decisions for you, your doctors, family, friends, and clergy. Give each of them a completed copy.

You may cancel or change this form at any time. You should review it often. Each time you review it, put your initials and

the date here. _____________

This document is provided as a service by the Center for Practical Bioethics.

For more information, call the Center for Practical Bioethics at 816-221-1100

Email – • Website –

Durable Power Of Attorney For Healthcare Decisions Form Page 2