Health-Care Power Of Attorney Form Page 2
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4Nebraska State Unit on Aging
Surrogate Decision Making in Nebraska
Paragraph 2
You can make your preferences known about specific treatment decisions, such as:
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amputations
•
blood transfusions
•
chemotherapy
•
transplants
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organ donation
•
exploratory procedures and surgeries
See the Appendix for sample wording you can use.
Paragraph 4
If you wish to have artificial nutrition and hydration withheld or withdrawn, you must indicate that
wish in this paragraph. You may describe your wishes as follows:
“If I am in a terminal condition, I want artificial nutrition and hydration withheld and if started, I want
it withdrawn.”
Before signing this document, make sure of the following:
•
review all of the information carefully
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make sure that you have clearly expressed your wishes
•
if you make any errors in filling out the form, correct them in ink and put your initials and date
next to the correction
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make sure you have had detailed discussions with your attorney-in-fact
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and your doctor
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the document can be signed either in the presence of two witnesses or in the presence of a
notary public.
IF YOU DO NOT UNDERSTAND OR HAVE QUESTIONS ABOUT THE USE OF THIS
FORM, CONTACT A LAWYER, HEALTH-CARE PROVIDER, OR SOCIAL WORKER
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