Health Care Power Of Attorney Page 7
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12E. Pain Relief
No matter what my condition, give me the medicine or other treatment I need to relieve
pain.
F. In Case of Pregnancy
(Optional, for women of child‐bearing years only; form valid if left blank)
If I am pregnant, my decision concerning life‐sustaining procedures shall be modified
as follows:
G. Effect of Stated Preferences
(Read both of these statements carefully. Then, initial one only.)
1. I realize I cannot foresee everything that might happen after I can no longer decide
for myself. My stated preferences are meant to guide whoever is making decisions
on my behalf and my health care providers, but I authorize them to be flexible in
applying these statements if they feel that doing so would be in my best interest.
✎______________
>>OR <<
2. I realize I cannot foresee everything that might happen after I can no longer decide
for myself. Still, I want whoever is making decisions on my behalf and my health
care providers to follow my stated preferences exactly as written, even if they think
that some alternative is better.
✎______________
Page 7 of 8
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