Durable Health Care Power Of Attorney And Health Care Treatment Instructions Page 7

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end-stage medical condition or are permanently unconscious and there is no realistic
hope of significant recovery.
(Initial only one statement.)
TUBE FEEDINGS
_____I want tube feedings to be given.
OR
NO TUBE FEEDINGS
_____I do not want tube feedings to be given.
HEALTH CARE AGENT'S USE OF INSTRUCTIONS
(INITIAL ONE OPTION ONLY.)
_____My health care agent must follow these instructions.
OR
_____These instructions are only guidance.
My health care agent shall have final say and may override any of my instructions.
(Indicate any exceptions)
If I did not appoint a health care agent, these instructions shall be followed.
LEGAL PROTECTION
Pennsylvania law protects my health care agent and health care providers from any
legal liability for their good faith actions in following my wishes as expressed in this form
or in complying with my health care agent's direction. On behalf of myself, my
executors and heirs, I further hold my health care agent and my health care providers
harmless and indemnify them against any claim for their good faith actions in
recognizing my health care agent's authority or in following my treatment instructions.
ORGAN DONATION (INITIAL ONE OPTION ONLY.)
7

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