Durable Power Of Attorney Form For Health Care Choices & Health Care Choices Directive (Page 3 of 6) in pdf

Durable Power Of Attorney Form For Health Care Choices & Health Care Choices Directive Page 3

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3 of 6

DURABLE POWER OF ATTORNEY FOR HEALTH CARE & HEALTH CARE DIRECTIVE

Part II. Health care choices directive

I want those involved in my health care to understand my wishes if I cannot communicate or

make decisions on my own. I make this directive to provide clear and convincing proof of

my wishes and instructions about my health care and treatment.

If my doctor believes medical treatment will lead to my recovery, I want to have the

treatment. I also want to have care and treatment for pain or discomfort even if this

treatment might shorten my life, affect my appetite, slow my breathing or be habit-forming.

If I have a terminal illness or condition and there is no reasonable hope I will

recover, or if I am persistently unconscious, I direct all of the life-prolonging

procedures I have initialed below to be withheld or withdrawn.

I direct the following treatments to be withheld or withdrawn:

Surgery or other invasive procedures

Cardiopulmonary resuscitation (CPR) to restart my heart or breathing

Antibiotics

Dialysis

Mechanical ventilator (respirator)

Chemotherapy

Radiation therapy

All other “life-prolonging” medical treatments or surgeries that are merely intended to

keep me alive without reasonable hope of making me better or curing my illness or injury.

I direct the donation of my organs or tissues. I realize my body may need to be maintained

Yes

I do not want to address this question now.

COMMUNICATING ABOUT THE END OF LIFE

Durable Power Of Attorney Form For Health Care Choices & Health Care Choices Directive Page 3