Form Mtl0801-12 - Durable Power Of Attorney For Healthcare Decisions (Page 3 of 8) in pdf

MTL0801-12/17/2010

Division of Child and Family Services

Section 0801

Family Programs Office: Statewide Policy Manual

Subject: Youth Independent Living Program

__________________________________________________________________________

5. DURATION

I understand that this Power of Attorney will exist indefinitely from the date I execute this document

unless I establish a shorter time. If I am unable to make health care decisions for myself when this Power

of Attorney expires, the authority I have granted my agent will continue to exist until the time when I

become able to make health care decisions for myself.

(IF APPLICABLE)

I wish to have this Power of Attorney end on the following date: ___________________

6. STATEMENT OF DESIRES

(With respect to decisions to withhold or withdraw life-sustaining treatment, your agent must make

health care decisions that are consistent with your known desires. You can, but are not required to,

indicate your desires below. If your desires are unknown, your agent has the duty to act in your best

interests; and, under some circumstances, a judicial proceeding may be necessary so that a court can

determine the health care decision that is in your best interest. If you wish to indicate your desires, you

may INITIAL the statement or statements that reflect your desires and/or write your own statements in

the space below.)

1. I desire that my life be prolonged to the greatest extent possible, without

regard to my condition, the chances I have for recovery or long-term

survival, or the cost of the procedures.

__________

2. If I am in a coma which my doctors have reasonable concluded is irreversible,

I desire that life sustaining or prolonging treatments not be used. (Also should

utilize provisions of NRS 449.535 to 449.690, inclusive, if this subparagraph

is initialed).

__________

3. If I have an incurable or terminal condition or illness and no reasonable hope

of long-term recovery or survival, I desire that life-sustaining or prolonging

treatments not be used. (Also should utilize provisions of NRS 449.535

to 449.690, inclusive, and sections 2 to 12, inclusive, if this subparagraph

is initialed).

__________

4. Withholding or withdrawal of artificial nutrition and hydration may result

in death by starvation or dehydration. I want to receive or continue receiving

artificial nutrition and hydration by way of the gastro-intestinal tract after all

other treatment is withheld

__________

5. I do not desire treatment to be provided and/or continue if the burdens of the

treatment outweigh the expected benefits. My agent is to consider

relief of suffering, the preservation or restoration of functioning, and the

quality as well as the extent of the possible extension of my life.

__________

(If you wish to change your answer, you may do so by drawing an “X” through the answer you do not

want, and circling the answer you prefer.)

Date: 12/17/2010

YOUTH INDEPENDENT LIVING PROGRAM

Section 0801, Page 3 of 8

FPO 0801C - Durable Power Of Attorney

For Healthcare Decisions

Form Mtl0801-12 - Durable Power Of Attorney For Healthcare Decisions Page 3

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