Fillable Combined Medical Power Of Attorney And Living Will (Page 2 of 3) in pdf

Principal Name

:_________________________________________________

(person for whom form is being completed)

This appointment shall extend to, but not be limited to, health care decisions relating to

medical treatment, surgical treatment, nursing care, medication, hospitalization, care and

treatment in a nursing home or other facility, and home health care. The representative

appointed by this document is specifically authorized to be granted access to my medical

records and other health information and to act on my behalf to consent to, refu

se or

withdraw any and all medical treatment or diagnostic procedures, or autopsy if my

representative determines that I, if able to do so, would consent to, refuse or withdraw

to,

such treatment or procedures. Such authority shall include, but not be limited

decisions regarding the withholding or withdrawal of life-prolonging interventions.

I appoint this representative because I believe this person understands my wishes and

values and will act to carry into effect the health care decisions that I would make if I

were able to do so, and because I also believe that this person will act in my best interest

when my wishes are unknown. It is my intent that my family, my physician and all legal

authorities be bound by the decisions that are made by the representative appointed by

this document, and it is my intent that these decisions should not be the subject of review

by any health care provider or administrative or judicial agency.

It is my intent that this document be legally binding and effective and that this document

be taken as a formal statement of my desire concerning the method by which any health

care decisions should be made on my behalf during any period when I am unable to make

such decisions.

In exercising the authority under this medical power of attorney, my representative shall

act consistently with my special directives or limitations as stated below.

I am giving the following SPECIAL DIRECTIVES OR LIMITATIONS ON THIS

POWER: (Comments about tube feedings, breathing machines, cardiopulmonary

resuscitation, dialysis, mental health treatment, funeral arrangements, autopsy, and organ

donation may be placed here. My failure to provide special directives or limitations does

not mean that I want or refuse certain treatments).

1. If I am very sick and not able to communicate my wishes for myself and I am certified

by one physician who has personally examined me, to have a terminal condition or to be

in a persistent vegetative state (I am unconscious and am neither aware of my

environment nor able to interact with others,) I direct that life-prolonging medical

intervention that would serve solely to prolong the dying process or maintain me in a

persistent vegetative state be withheld or withdrawn. I want to be allowed to die naturally

and only be given medications or other medical procedures necessary to keep me

comfortable. I want to receive as much medication as is necessary to alleviate my pain.

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Combined Medical Power Of Attorney And Living Will Page 2