Logan County Advance Directive Form (Page 2 of 4) in pdf

APPOINTMENT OF HEALTH CARE AGENT AND

ATTORNEY-IN-FACT FOR HEALTH CARE DECISIONS

I appoint _______________________________ to be my health care agent and my attorney-in-fact

for health care decisions. If my attending physician concludes that I am unable to comprehend and

appreciate the nature and consequences of health care decisions and that I am unable to formulate

and communicate an informed decision regarding treatment, ________________________________

is authorized,

As My Health Care Agent to:

(1) convey my wishes concerning the withholding or removal of life support systems to my

physician; and

(2) take whatever actions are necessary to ensure that my wishes are implemented.

As My Attorney-In-Fact to:

(1) act in my name, place, and stead in any way which I myself could do, if I were personally

present and under no disability, with respect to health care decisions as defined in the

Illinois Statutory Short Form Power of Attorney For Health Care Act to the extent that I am

permitted by law to act through an agent; and

(2) consent, refuse, or withdraw consent to any medical treatment other than that designated

solely for the purpose of maintaining physical comfort, withdrawal of life support systems,

or withdrawal of nutrition or hydration.

If _________________________________ is unwilling or unable to serve as my health care agent

and my attorney-in-fact for health care decisions, I appoint __________________________________

to be my alternate health care agent and my attorney-in-fact for health care decisions.

These Advanced Directives may be amended or revoked by me in the manner provided in Section 4-

6 of the Illinois Powers of Attorney for Health Care Law. Absent amendment or revocation, the

authority granted in these Advanced Directives will become effective at the time the documents are

signed and will continue until my death and beyond if anatomical gift, autopsy, or disposition of

remains is authorized, unless a limitation on the beginning date and duration is made by completing

and initialing either or both of the following.

1. (

) These Advanced Directives become effective on__________________________________

Initial

(insert a future date/event such as a court determination of

your disability when you want this power to take effect)

) These Advanced Directives shall terminate on____________________________________

2. (

Initial

(insert a future date/event such as a court determination of

your disability when you want this power to terminate prior

to your death)

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Logan County Advance Directive Form Page 2