The Minnesota Health Care Directive Page 11
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If I WANT my agent to have any of the following powers, I must initial
powers of my
the line in front of the statement.
agent
I also authorize my agent to:
______ Make health care decisions for me even if I am able to decide or
speak for myself.
______ Carry out my wishes regarding a funeral, burial, or what will
happen to my body when I die.
______ Make decisions about mental health treatment including
electroconvulsive therapy and antipsychotic medication,
including neuroleptics.
______ In the event I am pregnant, determine whether to attempt to
continue my pregnancy to delivery based upon my agent’s
understanding of my values, preferences, or instructions.
______ Continue as my health care agent even if a dissolution,
annulment, or termination of our marriage or domestic
partnership is in process or has been completed.
Limiting the
I wish to limit the powers of my health care agent in the following
powers of my
way(s): _________________________________________________
agent
_______________________________________________________
PART II: Health Care Instructions
• I give the following instructions about my health care (my values and beliefs, what I
do and do not want, views about medical treatments or situations) ______________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
• I am attaching additional instructions concerning my health care values and
preferences. Initial one line: ______ Yes ______ No
• I authorize donation of organs, tissue, or other body parts after my death.
Initial one line: ______ Yes ______ No
Minnesota Health Care Directive / 3 of 4 pages
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