State Of West Virginia Combined Medical Power Of Attorney And Living Will Page 2

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This appointment shall extend to, but not be limited to, health care decisions
relating to medical treatment, surgical treatment, nursing care, medication,
hospitalization, care and treatment in a nursing home or other facility, and
home health care. The representative appointed by this document is
specifically authorized to be granted access to my medical records and other
health information and to act on my behalf to consent to, refuse or withdraw
any and all medical treatment or diagnostic procedures, or autopsy if my
representative determines that I, if able to do so, would consent to, refuse or
withdraw such treatment or procedures. Such authority shall include, but not
be limited to, decisions regarding the withholding or withdrawal of life-
prolonging interventions.
I appoint this representative because I believe this person understands my
wishes and values and will act to carry into effect the health care decisions
that I would make if I were able to do so, and because I also believe that this
person will act in my best interest when my wishes are unknown. It is my
intent that my family, my physician and all legal authorities be bound by the
decisions that are made by the representative appointed by this document, and
it is my intent that these decisions should not be the subject of review by any
health care provider or administrative or judicial agency.
It is my intent that this document be legally binding and effective and that this
document be taken as a formal statement of my desire concerning the method
by which any health care decisions should be made on my behalf during any
period when I am unable to make such decisions.
In exercising the authority under this medical power of attorney, my
representative shall act consistently with my special directives or limitations
as stated below.
THIS POWER: (Comments about tube feedings, breathing machines,
cardiopulmonary resuscitation, dialysis, mental health treatment, funeral
arrangements, autopsy, and organ donation may be placed here. My failure to
provide special directives or limitations does not mean that I want or refuse
certain treatments).
1. If I am very sick and not able to communicate my wishes for myself and I
am certified by one physician who has personally examined me, to have a
terminal condition or to be in a persistent vegetative state (I am unconscious


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