Durable Power Of Attorney For Health Care Form (Dpoah)
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1
2DURABLE POWER OF ATTORNEY FOR HEALTH CARE
(usually referred to as DPOAH)
I, _____________________________________, hereby appoint _____________________________________
(Name)
(Name of Health Care Agent)
of _________________________________________________________________________________________
(Health Care Agent’s address and phone #)
as my health care agent to make any and all health care decisions for me, except if I state otherwise
in this document, or as prohibited by law. This Durable Power of Attorney for Health Care shall take
effect in the event I become unable to make my own health care decisions.
In the event the person I choose as health care agent is unable, unwilling, unavailable or ineligible
to act as my health care agent, I choose _______________________________________________
(Name of alternate health care agent)
of ____________________________________________________________ as alternate health care agent.
(Address and phone # of alternate health care agent)
Statement of Desires, Special Provisions, and Limitations about Health Care Decisions
Some general statements about the withholding or removal of life-sustaining treatment are used
in this document. Life-sustaining treatment is defined as procedures without which a person would
die. Some of these are: cardiopulmonary resuscitation, mechanical respiration, kidney dialysis or the
use of other external mechanical and technological devices, drugs to maintain blood pressure, blood
transfusions and antibiotics.
If I wish to indicate my agreement or disagreement with each of the following statements I will
circle my choice and initial the line beside it, and give my health care agent power to act in these
specific circumstances.
1.
If I become permanently incompetent to make health care decisions, and if I am also suffering
from a terminal illness, I authorize my health care agent to direct that life-sustaining
treatment be discontinued. (Circle your choice and initial beside it.)
YES __________
NO __________
(Initials)
(Initials)
2.
Whether terminally ill or not, if I become permanently unconscious, I authorize my health
care agent to direct that life-sustaining treatment be discontinued. (Circle your choice and
initial beside it.)
YES __________
NO __________
(Initials)
(Initials)
3.
I realize that situations could arise in which the only way to allow me to die would be to
discontinue artificial nutrition and hydration. In carrying out any instructions I have given in
this document, I authorize my health care agent to direct that my choices indicated below be
respected.
I wish to have my life continued with artificial feeding or artificial hydration.
YES __________
NO __________
(Initials)
(Initials)
If artificial feeding and hydration have been started, I want them:
STOPPED __________
CONTINUED __________
(Initials)
(Initials)
I understand that if I do not complete item number 3, my health care agent will NOT have the
power to stop artificial feeding and hydration.
DURABLE POWER OF ATTORNEY FOR HEALTH CARE – FRONT
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