Living Will And Durable Power Of Attorney For Health Care Page 4
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72.
CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE
By this portion of this Directive, I create a durable power of attorney for health care.
This power of attorney shall not be affected by my subsequent incapacity. This power
shall be effective only when I am unable to communicate rationally.
3.
GENERAL STATEMENT OF AUTHORITY GRANTED
I hereby grant to my agent full power and authority to make health care decisions for me
to the same extent that I could make such decisions for myself if I had the capacity to do
so. In exercising this authority, my agent shall make health care decisions that are
consistent with my desires as stated in this Directive or otherwise made known to my
agent including, but not limited to, my desires concerning obtaining or refusing or
withdrawing artificial life-sustaining care, treatment, services and procedures, including
such desires set forth in a living will, Physician Orders for Scope of Treatment (POST)
form, or similar document executed by me, if any.
(If you want to limit the authority of your agent to make health care decisions for you,
you can state the limitations in paragraph 4, "Statement of Desires, Special Provisions,
and Limitations", below. You can indicate your desires by including a statement of your
desires in the same paragraph.)
4.
STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS
(Your agent must make health care decisions that are consistent with your known
desires. You can, but are not required to, state your desires in the space provided
below. You should consider whether you want to include a statement of your desires
concerning artificial life-sustaining care, treatment, services and procedures. You can
also include a statement of your desires concerning other matters relating to your health
care, including a list of one or more persons whom you designate to be able to receive
medical information about you and/or to be allowed to visit you in a medical institution.
You can also make your desires known to your agent by discussing your desires with
your agent or by some other means. If there are any types of treatment that you do not
want to be used, you should state them in the space below. If you want to limit in any
other way the authority given your agent by this Directive, you should state the limits in
the space below. If you do not state any limits, your agent will have broad powers to
make health care decisions for you, except to the extent that there are limits provided by
law.)
In exercising the authority under this durable power of attorney for health care, my
agent shall act consistently with my desires as stated below and is subject to the special
provisions and limitations stated in my Physician Orders for Scope of Treatment (POST)
form, a living will, or similar document executed by me, if any. Additional statement of
desires, special provisions, and limitations:
Living Will and Durable Power of Attorney for Health Care
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