Durable Power Of Attorney For Health Care Decisions Page 8
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12PART 3
ANATOMICAL GIFT AT DEATH
(OPTIONAL)
If you are satisfied to allow your agent to determine whether to make an
anatomical gift at your death, you do not need to fill out this part of the form.
(8) UPON MY DEATH: (mark applicable box)
[ ] (A) I give any needed organs, tissues, or other body parts,
OR
[ ] (B) I give the following organs, tissues, or other body parts only:
______________________________________________________________________________
My gift under (A) or (B) above is for the following purposes (mark any of the following
you want):
[ ] transplant;
[ ] therapy;
[ ] research;
[ ] education.
[ ] (C) I refuse to make an anatomical gift.
PART 4
MENTAL HEALTH TREATMENT
(OPTIONAL)
This part of the declaration allows you to make decisions in advance about mental
health treatment.
The instructions that you include in this declaration will be followed only if a court,
two physicians that include a psychiatrist, or a physician and a professional mental
health clinician believe that you are not competent and cannot make treatment
decisions. Otherwise, you will be considered to be competent and to have the capacity to give
or withhold consent for the treatments.
If you are satisfied to allow your agent to determine what is best for you in
making these mental health decisions, you do not need to 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.
(9) PSYCHOTROPIC MEDICATIONS.
If I do not have the capacity to give or
withhold informed consent for mental health treatment, my wishes regarding psychotropic
medications are as follows:
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