Indiana - Rest Of Your Life (Page 3 of 4) in pdf

Indiana - Rest Of Your Life Page 3

INDIANA APPOINTMENT OF

A HEALTH C A R E REPRESENTATIVE

.. of

(Name)

(Address)

hereby voluntarily appoint

.. of

(Name of Health Care Representative)

(Address & Telephone Number)

as my health care representative.

In the event that the person I appoint above as health care representative is unable, unwilling or unavailable to serve, I hereby

as my substitute representative hereunder.

I authorize my health care representative to make decisions in my best interest concerning my health care including the

consent to health care, as well as the withdrawal or withholding of health care. I understand health care to include medical

care, treatment, service, or procedure to maintain, diagnose, treat or provide for my physical or mental well-being. Pursuant

to the Indiana Health Care Consent Act, I authorize my health care representative to make decisions to withhold or withdraw

artificial nutrition and hydration to the extent it is in my best interest to do so. If at any time, based on my previously

expressed preferences and the diagnosis and prognosis, my health care representative is satisfied that certain health care

is not or would not be beneficial, or that such health care is or would be excessively burdensome, my health care

representative may express my will that such health care be withheld or withdrawn and consent on my behalf that any and

all health care be discontinued or not instituted, even if death may result.

My health care representative must try to discuss this decision with me. However, if I am unable to communicate, my health

care representative may make such a decision for me, after consultation with my physician or physicians and other relevant

health care givers. To the extent appropriate, my health care representative may also discuss this decision with my family

and others, to the extent that they are available.

This appointment becomes effective and remains effective if I am incapable of consenting to my health care.

I DO, DO NOT

(circle one)

authorize my health care representative hereby appointed to delegate decision making power

to another.

appoint

(Name of Successor Health Care Representative)

(Address & Telephone Number)

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Indiana - Rest Of Your Life Page 3