Fillable Durable Power Of Attorney For Health Care printable pdf download

- Warning to person executing this document -

This is an important legal document. Before executing

that you include in this document. You may state in this

this document you should know these important facts:

document any types of treatment that you do not desire. In

addition, a court can take away the power of your agent to

This document gives the person you designate as your

make health care decisions for you if your agent: (1) authorizes

agent (your attorney in fact) the power to make health care

anything that is illegal; or (2) acts contrary to your desires as

decisions for you. Your agent must act consistently with your

stated in this document.

desires as stated in this document.

You have the right to revoke the authority of your agent

Except as you otherwise specify in this document, this

by notifying your agent or your treating physician, hospital

document gives your agent the power to consent to your doctor

or other health care provider orally or in writing of the

not giving treatment or stopping treatment necessary to keep

revocation.

you alive.

Your agent has the right to examine your medical

Notwithstanding this document, you have the right to

records and to consent to their disclosure unless you limit this

make medical and other health care decisions for yourself so

right in this document.

long as you can give informed consent with respect to the

particular decision. In addition, no treatment may be given to

Unless you otherwise specify in this document, this

you over your objection, and health care necessary to keep you

document gives your agent the power after you die to: (1)

alive may not be stopped or withheld if you object at the time.

authorize an autopsy; (2) donate your body or parts thereof

for transplant or therapeutic or educational or scientific

This document gives your agent authority to consent, to

purposes; and (3) direct the disposition of your remains.

refuse to consent, or to withdraw consent to any care, treatment,

service, or procedure to maintain, diagnose or treat a physical

If there is anything in this document that you do not

or mental condition. This power is subject to any limitations

understand, you should ask an attorney to explain it to you.

[Tennessee Code Annotated, § 34-6-205; Durable Power Of Attorney For Health Care]

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

By signing this document, I appoint the

that I need to keep me comfortable and

person I name on page 2 to make health care

relieve pain.

decisions for me if I am ever unable to make

them for myself. I intend for this person to

In the situation described here,

ensure that my living will is honored and

I authorize

do not authorize

that decisions about my medical care respect

this person to approve a treatment or

my wishes as far as they are known. I intend

medicine to keep me comfortable and out of

for this person to have the broadest discretion

pain, even if it may cause permanent physical

and power allowed by law to approve, refuse

damage or addiction or hasten my death.

or stop medical care for me.

If I cannot take food and/or liquids by

If I should ever reach the point at which

mouth in the situation described here,

my doctor believes I am going to die no

I authorize

do not authorize

matter what is done, I direct this person to

this person to refuse or stop artificial feeding,

ensure that I am allowed to die naturally.

such as giving me nourishment or fluids

That means not starting or continuing to use

through a tube or a vein.

machines or treatments that would only

prolong my dying.

At that point, this person should ensure

that I have only the medicine or treatment

8/98 - Legal Aid Society of Middle Tennessee

Durable Power Of Attorney For Health Care - page 1 of 2

Durable Power Of Attorney For Health Care

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