Durable Health Care Power Of Attorney And Health Care Treatment Instructions (Page 4 of 9) in pdf

Durable Health Care Power Of Attorney And Health Care Treatment Instructions Page 4

The remainder of this document will take effect when and only when I lack the ability to

understand, make or communicate a choice regarding a health or personal care

decision as verified by my attending physician. My health care agent may not

delegate the authority to make decisions.

MY HEALTH CARE AGENT HAS ALL OF THE FOLLOWING POWERS SUBJECT TO THE HEALTH

CARE TREATMENT INSTRUCTIONS THAT FOLLOW IN PART III (Cross out any powers you do

not want to give your health care agent):

1. To authorize, withhold or withdraw medical care and surgical procedures.

2. To authorize, withhold or withdraw nutrition (food) or hydration (water)

medically supplied by tube through my nose, stomach, intestines, arteries or

veins.

3. To authorize my admission to or discharge from a medical, nursing, residential

or similar facility and to make agreements for my care and health insurance

for my care, including hospice and/or palliative care.

4. To hire and fire medical, social service and other support personnel

responsible for my care.

5. To take any legal action necessary to do what I have directed.

6. To request that a physician responsible for my care issue a do-not-resuscitate

(DNR) order, including an out-of-hospital DNR order, and sign any required

documents and consents.

APPOINTMENT OF HEALTH CARE AGENT

I appoint the following health care agent:

Health Care Agent _________________________________________________

(Name and relationship)

Address:____________________________________________________________________

Telephone Number: Home____________________Work_________________________

E-MAIL:_____________________________________

IF YOU DO NOT NAME A HEALTH CARE AGENT, HEALTH CARE PROVIDERS WILL ASK YOUR

FAMILY OR AN ADULT WHO KNOWS YOUR PREFERENCES AND VALUES FOR HELP IN

DETERMINING YOUR WISHES FOR TREATMENT.

NOTE THAT YOU MAY NOT APPOINT YOUR DOCTOR OR OTHER HEALTH CARE PROVIDER

AS YOUR HEALTH CARE AGENT, UNLESS RELATED TO YOU BY BLOOD, MARRIAGE OR

ADOPTION.

Durable Health Care Power Of Attorney And Health Care Treatment Instructions Page 4