Durable Power Of Attorney For Health Care Template Page 6
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11Here are my desires about my health care to guide my agent and health care providers.
1. If I am close to death and life support would only prolong my dying:
INITIAL ONLY ONE:
I want to receive a feeding tube.
I DO NOT WANT a feeding tube.
INITIAL ONLY ONE:
I want all life support that may apply.
I want NO life support.
2. If I am unconscious and it is very unlikely that I will ever become conscious again:
INITIAL ONLY ONE:
I want to receive a feeding tube.
I DO NOT WANT a feeding tube.
INITIAL ONLY ONE:
I want all other life support that may apply.
I want NO life support.
3. If I have a progressive illness that will be fatal and is in an advanced stage, and I am
consistently and permanently unable to communicate by any means, swallow food and water
safely, care for myself and recognize my family and other people, and it is very unlikely that my
condition will substantially improve:
INITIAL ONLY ONE:
I want to receive a feeding tube.
I DO NOT WANT a feeding tube.
INITIAL ONLY ONE:
I want all life support that may apply.
I want NO life support.
Additional statement of desires, special provisions, and limitations regarding health
care decisions (More space is available on page 8):
ORGAN DONATION
_____ In the event of my death, I request that my agent inform my family or next of kin of my
desire to be an organ and tissue donor for transplant. (Initial if applicable)
_____ In the event of my death, I request that my agent inform my family or next of kin of my
desire to be an organ and tissue donor for research. (Initial if applicable)
_____ My Initials
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