Durable Health Care Power Of Attorney And Health Care Treatment Instructions (Page 6 of 9) in pdf

Durable Health Care Power Of Attorney And Health Care Treatment Instructions Page 6

If I should suffer from severe and irreversible brain damage or brain disease with no

realistic hope of significant recovery, I would consider such a condition intolerable and

the application of aggressive medical care to be burdensome.

I therefore request that my health care agent respond to any intervening (other and

separate) life-threatening conditions in the same manner as directed for an end-stage

medical condition or state of permanent unconsciousness as I have indicated below.

Initials________I agree

Initials_________I disagree

PART III

HEALTH CARE TREATMENT INSTRUCTIONS IN THE EVENT OF END-STAGE MEDICAL

CONDITION OR PERMANENT UNCONSCIOUSNESS (LIVING WILL)

The following health care treatment instructions exercise my right to make my own

health care decisions. These instructions are intended to provide clear and convincing

evidence of my wishes to be followed when I lack the capacity to understand, make,

or communicate my treatment decisions:

If I have an end-stage medical condition (which will result in my death, despite the

introduction or continuation of medical treatment) or am permanently unconscious

such as in an irreversible coma or irreversible vegetative state and there is no realistic

hope of significant recovery, all of the following apply (cross out any treatment

instructions with which you do not agree):

1. I direct that I be given health care treatment to relieve pain or provide

comfort even if such treatment might shorten my life, suppress my appetite or

my breathing, or be habit forming.

2. I direct that all life prolonging procedures be withheld or withdrawn.

3. I specifically do not want any of the following as life prolonging procedures:

(If you wish to receive any of these treatments, write "I do want" after the

treatment)

heart-lung resuscitation (CPR) _______________________________________

mechanical ventilator (breathing machine) __________________________

dialysis (kidney machine) ___________________________________________

surgery _____________________________________________________________

chemotherapy radiation treatment __________________________________

antibiotics __________________________________________________________

Please indicate whether you want nutrition (food) or hydration (water) medically

supplied by a tube into your nose, stomach, intestine, arteries, or veins if you have an

Durable Health Care Power Of Attorney And Health Care Treatment Instructions Page 6