Mississippi Power Of Attorney For Health Care Template Page 5
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8PART 2
INSTRUCTIONS FOR HEALTH CARE
I
f you are satisfied to allow your agent to determine what is best for you in making
end-of-life decisions, you need not fill out this part of the form. If you do fill out this part of
the form, you may strike any wording you do not want.
(6) END-OF-LIFE DECISIONS:
I direct that my health-care providers and others
involved in my care provide, withhold or withdraw treatment in accordance with the
choice I have marked below:
[ ] (a) Choice Not To Prolong Life
I do not want my life to be prolonged if (i) I have an incurable and irreversible condition
that will result in my death within a relatively short time, (ii) I become unconscious and,
to a reasonable degree of medical certainty, I will not regain consciousness, or (iii) the
likely risks and burdens of treatment would outweigh the expected benefits, or
[ ] (b) Choice To Prolong Life
I want my life to be prolonged as long as possible within the limits of generally
accepted health-care standards.
(7) ARTIFICIAL NUTRITION AND HYDRATION:
Artificial nutrition and hydration
must be provided, withheld or withdrawn in accordance with the choice I have made in
paragraph (6) unless I mark the following box. If I mark this box [ ], artificial nutrition and
hydration must be provided regardless of my condition and regardless of the choice I
have made in paragraph (6).
(8) RELIEF FROM PAIN:
Except as I state in the following space, I direct that
treatment for alleviation of pain or discomfort be provided at all
times, even if it hastens my death: __________________________________________
________________________________________________________________________
(9) OTHER WISHES:
(If you do not agree with any of the optional choices above and
wish to write your own, or if you wish to add to the instructions you have given above,
you may do so here.) I direct that:
________________________________________________________________________
________________________________________________________________________
(Add additional sheets if needed.)
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