Fillable Durable Power Of Attorney For Health Care

Durable Power Of Attorney For Health Care - Vermont

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Durable Power of Attorney for Health Care Vermont

Standard Form

(Please print clearly, except where signature is required)

I, ………………………………………………………….. of ……………………………....……., hereby appoint

…………………………………………………… of ………………………………….., as my agent to make any

and all health care decisions for me, except to the extent I state otherwise in this document. This durable

power of attorney for health care shall take effect in the event I become unable to make my own health

care decisions. Should the person I have appointed be unable, unwilling or unavailable to act as my

health care agent, I hereby appoint

..................................................................................... of ……………………………………………. as my

alternate agent.

STATEMENT OF DESIRES, SPECIAL PROVISIONS AND LIMITATIONS REGARDING HEALTH

CARE DECISIONS. Here you may include any specific desires or limitations you feel are appropriate,

such as when or what life-sustaining measures should be started or withheld; directions whether or not to

use artificial nutrition and hydration; or instructions to refuse any specific types of treatment that are

inconsistent with your religious beliefs or unacceptable to you for any other reason. (If you want to include

instructions about life-sustaining treatment, read Part B before filling out this section.) (attach additional

worksheets or pages as necessary)

THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR IMPORTANCE. For

your convenience in dealing with this subject, some general statements concerning life-sustaining

treatment are set forth below. IF YOU AGREE WITH ONE OF THE STATEMENTS, YOU MAY COPY IT

IN THE SPACE PROVIDED ABOVE.

1. If I suffer a condition from which there is no reasonable prospect of regaining my ability to think

and act for myself, I want only care directed to my comfort and dignity, and authorize my agent to

decline all treatment (including artificial nutrition and hydration) the primary purpose of which is to

prolong life.

2. If I suffer a condition from which there is no reasonable prospect of regaining the ability to think

and act for myself, I want care directed to my comfort and dignity and also want artificial nutrition

and hydration, if needed, but authorize my agent to decline all other treatment the primary purpose

of which is to prolong my life.

3. I want my life sustained by any reasonable medical measures, regardless of my condition.

Durable Power Of Attorney For Health Care - Vermont

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