Va Advance Directive: Durable Power Of Attorney For Health Care And Living Will Page 3
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7VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
B - ALTERNATE HEALTH CARE AGENT
Fill out this section if you want to appoint a second person to make health care decisions for you,
in case the first person isn’t available.
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If the person named above can't or doesn't want to make decisions for me, I appoint the person
named below to act as my Health Care Agent.
Name (Last, First, Middle):
Relationship to Me:
City, State, Zip:
Street Address:
Home Phone with Area Code:
Work Phone with Area Code:
Mobile Phone with Area Code:
PART III: LIVING WILL
This section of the advance directive form is called a Living Will. This section of it lets you write down how
you want to be treated in case you aren't able to decide for yourself anymore. Its purpose is to help others
decide about your care.
A - SPECIFIC PREFERENCES ABOUT LIFE-SUSTAINING TREATMENTS
In this section, you can indicate your preferences for life-sustaining treatments in certain situations. Some
examples of life-sustaining treatments are:
CPR (cardiopulmonary resuscitation)
•
a breathing machine (mechanical ventilation)
•
kidney dialysis
•
a feeding tube (artificial nutrition and hydration)
•
Think about each situation described on the left and ask yourself, “In that situation, would I want to have
life-sustaining treatments?” Place your initials in the box that best describes your treatment preference. You
may complete some, all, or none of this section. Choose only one box for each statement.
Yes.
I'm not sure. It
No.
I would want
would depend
I would not want
life-sustaining
on the
life-sustaining
treatments.
circumstances.
treatments.
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If I am unconscious, in a coma, or in a vegetative
state and there is little or no chance of recovery.
If I have permanent, severe brain damage that
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makes me unable to recognize my family or friends
(for example, severe dementia).
VA FORM
10-0137
Page 3 of 7
JUL 2012
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