Health Care Power Of Attorney Page 5
Download a blank fillable Health Care Power Of Attorney in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Health Care Power Of Attorney with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12P
II: T
P
(“L
W
”)
ART
REATMENT
REFERENCES
IVING
ILL
A. Statement of Goals and Values
(Optional: Form valid if left blank)
I want to say something about my goals and values, and especially what’s most
important to me during the last part of my life:
B. Preference in Case of Terminal Condition
(If you want to state what your preference is, initial one only. If you do not want to state
a preference here, cross through the whole section.)
If my doctors certify that my death from a terminal condition is imminent, even if
life‐sustaining procedures are used:
1. Keep me comfortable and allow natural death to occur. I do not want any medical
interventions used to try to extend my life. I do not want to receive nutrition and
fluids by tube or other medical means.
✎______________
>>OR<<
2. Keep me comfortable and allow natural death to occur. I do not want medical
interventions used to try to extend my life. If I am unable to take enough
nourishment by mouth, however, I want to receive nutrition and fluids by tube or
other medical means.
✎______________
>>OR<<
3. Try to extend my life for as long as possible, using all available interventions that in
reasonable medical judgment would prevent or delay my death. If I am unable to
take enough nourishment by mouth, I want to receive nutrition and fluids by tube
or other medical means.
✎______________
Page 5 of 8
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal