Health-Care Power Of Attorney Form Page 3
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4Nebraska State Unit on Aging
Surrogate Decision Making in Nebraska
Nebraska
Power of Attorney for Health Care
1. I appoint ______________________________________________________, whose address is
_____________________________________________________________ and whose telephone
number is ________________________________________ as my attorney-in-fact for health care. I
appoint ________________________________, whose address is __________________________,
and whose telephone number is ___________________, as my successor attorney-in-fact for health
care. I authorize my attorney-in-fact appointed by this document to make health care decisions for
me when I am determined to be incapable of making my own health care decisions. I have read the
warning which accompanies this document and understand the consequences of executing a power
of attorney for health care.
2. I direct that my attorney-in-fact comply with the following instructions or limitations: ________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. I direct that my attorney-in-fact comply with the following instructions on life-sustaining
treatment: (optional) ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. I direct that my attorney-in-fact comply with the following instructions on artificially
administered nutrition and hydration: (optional) __________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND
THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR
ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND
THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY
TIME BY NOTIFYING MY ATTORNEY-IN-FACT, MY PHYSICIAN, OR THE FACILITY
IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN
REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF
MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN.
_________________________________________________________________________________
(Signature of person making designation)
(date)
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