Living Will And Durable Power Of Attorney For Healthcare Form

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LIVING WILL
You must be an adult (age 18 or older) and of
These documents are valid as long as you do
and
sound mind when completing these forms. In
not rescind them or declare them void. These
documents will continue indefinitely unless you
DURABLE POWER OF
order for these documents to be valid, they
provide for an expiration date. These documents
must be signed by you in the presence of two
ATTORNEY FOR HEALTH-
will become void at time of death. If you decide at
witnesses. Only one witness may be your
any time to revoke any portion of these documents,
CARE
spouse or relative. The person you designate
immediately tell this to your attending/treating
as your Durable Power for Healthcare cannot
physician. Also, retrieve and destroy all copies
FORMS
be a witness. These documents do not need to
given to others and complete a new document(s).
be notarized.
and
You should keep the original completed documents.
INSTRUCTIONS
The Durable Power of Attorney for Healthcare
Copies should be given to:
document allows you to appoint another person to
◆ individual designated as Durable Power of
make healthcare decisions on your behalf when
The Designation of Durable Power of Attorney
Attorney for Healthcare
you are unable to do so. It is recommended that
for Healthcare and Living Will are legal
◆ family member(s), friends, as appropriate
you appoint an adult who knows your wishes
documents you may complete to help ensure that
◆ family physician or primary health care
and will carry them out. It is suggested that
your wishes are carried out when you are unable
provider
you choose a person who has exhibited special
to speak for yourself. It is very important that
◆ the hospital each time your are admitted
your wishes expressed in these documents
care and concern for you and has maintained
be discussed with your physician and family/
regular contact and is familiar with your personal,
◆ nursing home or assisted living facility if this
significant other.
religious, moral and cultural beliefs. Your Durable
is your home
Power of Attorney for Healthcare will have the
◆ clergy, and/or attorney (optional)
authority to make all medical decisions on your
You may at sometime lose the ability to make
behalf according to your wishes, including but
sound judgements concerning medical treatment
The Durable Power of Attorney for Healthcare,
not limited to the withholding / withdrawal of life
for reasons that may range from confusion caused
Living Will and these instructions are based on
prolonging procedures.
by medication to coma following a major accident.
Florida law. These instructions are intended to
When you cannot make decisions about your
be general guidelines only. If further guidance
medical care, others, such as family members
is needed or questions arise regarding these
The Living Will document lets your physician(s)
and physicians will need to take responsibility for
documents, your physician, clergy, or attorney
and others know your choices regarding the use
these decisions. Often, it is difficult for them to
should be contacted.
of life prolonging procedures if you are unable to
know what your wishes are. The decision process
in these complex situations is made easier when
make decisions for yourself. Your physician and
you have previously expressed wishes about your
Note: If you are a Florida Hospital inpatient, you
your Durable Power of Attorney for Healthcare
medical care, including the withholding and/or
may receive additional information by watching the
are to follow the directives of the Living Will. Your
withdrawal of life prolonging procedures.
hospital’s educational TV channel at 11 am and 7
physician is required to make a reasonable effort
pm. If you would like assistance after reviewing
to transfer your care to another physician if he/
the information, please ask your nurse to contact
she is unable or unwilling to carry out your wishes
the Chaplain, Case Management, or a Patient
specified in the Living Will.
Relations Representative.
FK5502 Front (02/11)

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