Health Care Power Of Attorney Page 3
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12This power is subject to the following conditions or limitations:
(Optional; form valid if left blank)
D. How my Agent is to Decide Specific Issues
I trust my agent’s judgment. My agent should look first to see if there is anything in
Part II of this advance directive that helps decide the issue. Then, my agent should think
about the conversations we have had, my religious and other beliefs and values, my
personality, and how I handled medical and other important issues in the past. If what I
would decide is still unclear, then my agent is to make decisions for me that my agent
believes are in my best interest. In doing so, my agent should consider the benefits,
burdens, and risks of the choices presented by my doctors.
E. People My Agent Should Consult
(Optional; form valid if left blank)
In making important decisions on my behalf, I encourage my agent to consult with the
following people. By filling this in, I do not intend to limit the number of people with
whom my agent might want to consult or my agent’s power to make decisions.
Name(s)
Telephone Number(s):
F. In Case of Pregnancy
(Optional, for women of child‐bearing years only; form valid if left blank)
If I am pregnant, my agent shall follow these specific instructions:
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