Health Care Power Of Attorney Page 6
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12C. Preference in Case of Persistent Vegetative State
(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 I am in a persistent vegetative state, that is, if I am not
conscious and am not aware of myself or my environment or able to interact with
others, and there is no reasonable expectation that I will ever regain consciousness:
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.
✎______________
D. Preference in Case of End‐Stage 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 I am in an end‐state condition, that is, an incurable
condition that will continue in its course until death and that has already resulted in
loss of capacity and complete physical dependency:
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 6 of 8
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