HEALTH CARE TREATMENT DIRECTIVE AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
HEALTH CARE TREATMENT DIRECTIVE (LIVING WILL)
I make this Health Care Treatment Directive to exercise my right to determine the course of my health care to provide clear and convincing proof of my treatment decisions when I lack the capacity to make or communicate my decisions.
If my physician believes that a certain life prolonging procedure or other health care treatment may provide me with comfort, relieve pain, or lead to a significant recovery, I direct my physician to try the treatment for a reasonable period of time. However, if such treatment proves to be ineffective, I direct the treatment be withdrawn, even if so doing may shorten my life.
[If there is a statement in paragraph 1 or 2 below with which you do not agree draw a line through it and add your initials]
I direct I be given health care treatment to relieve pain or to provide comfort even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit-forming.
(1) I direct all life prolonging procedures be withheld or withdrawn when there is no realistic hope of significant recovery, and I have:
-a terminal condition, or
-a condition, disease, or injury without hope of a significant recovery and there is no reasonable expectation that I will regain an acceptable quality of life, or
-substantial brain damage or brain disease which cannot be significantly reversed, or
-other____________________________________________________________________________________
(2) When the above conditions exist, life prolonging procedures I choose to have withheld or withdrawn include: (You should assume that any item crossed out would be administered to you)
-surgery -heart-lung resuscitation (CPR) -antibiotics
-dialysis -mechanical ventilator (respirator) -tube feeding (food/water via tube in vein, nose, or stomach)
(3) I make other instructions as follows: (You may describe what a minimally acceptable quality of life is for you.)
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
[If you do not wish to name an agent, initial here________ and skip next section]
DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
General Statement: I hereby execute the following Durable Power of Attorney for Health Care Decisions to be effective WHEN AND ONLY WHEN my physician and my agentagree that I lack capacity to make or communicate my health decisions and my above Health Care Treatment Directive does not adequately cover circumstances. This is a Durable Power of Attorney for Health Care Decisions, and the authority of my agent shall not terminate if I become incapacitated.
Agent's Powers: I grant to my agent full authority for Health Care Decisions for me regarding my health care; however, in exercising this authority, my agent shall follow my desires as stated in my Health Care Treatment Directive or otherwise known to my agent. My agent's authority to interpret my desires is intended to be as broad as possible and any expenses incurred should be paid by my resources.. My agent may not delegate the authority to make decisions. My agent is authorized as follows to:
[If you wish a statement in A to F deleted, draw a line through it and initial]
A. Consent, refuse, or withdraw consent to any care, treatment, service or procedure. (including tube feeding of food or water) used to maintain, diagnose, or treat a physical or mentalcondition;
B. Have the same access to health care records and information that I could have, including the right to disclose the contents to others and to discuss the treatment decisions with them;
C. Make all necessary arrangements for health care, including admission/discharge for health care service, and to choose or discharge medical personnel responsible for my care;
D. Move me into or out of any state for the purpose of complying with my health Care Treatment Directive or the decisions of my agents;
E. Take any legal action reasonably necessary to do what I have directed;
F. Make decisions regarding organ donation, autopsy, and the disposition of my body.
Agent and Alternates Named: I appoint the following person to be my agent to make health care decisions for me WHEN AND ONLY WHEN I lack the capacity to make or communicate a choice regarding a particular health care decision.
Name:______________________________________________________________________________________________
Address:___________________________________________________________________________________________
Only an agent named by me may act under this document. If any agent named by me is not available or not willing to make health care decisions for me, or is my spouse and legally separated or divorced from me, I appoint the person or persons named below (in the order named if more than one is listed) as my agent. (It is not necessary to name an alternate agent)
First Alternate Agent Second Alternate Agent
Name:______________________________________ Name:______________________________________
Address:____________________________________ Address:_____________________________________
Telephone:___________________________________ Telephone:___________________________________
Protections of Persons Who Rely on My Agent: I and my estate hold my agent and caregivers harmless and protect them against any claim for following this directive.
Severability: If any part of this document is held to be uneforceable under law, I direct that all of the other provisions of the document shall remain in force and effect.
I have executed this document this day of ______________________, 200_____
X______________________________________________________
Signature
Witnesses
The person executing this document is personally known to me, is 18 years of age or older, of sound mind and voluntarily signed this document in my presence. I am 18 years of age or older and not related to the signer by blood, marriage, or adoption, am not entitled (to my knowledge) to any portion of the estate of the signer, and am not directly financially responsible for signer's medical care.
WITNESS WITNESS
Signature:________________________________ Signature______________________________
Notarization
STATE OF ________________________________ COUNTY OF ______________________________
on this _____________day of _______________________, 200____, before me personally appeared the aforesaid declarant, to me known to be the person described in and who executed theforegoing instrument and acknoweledged that he/she executed the same as his/her free act and deed.
IN WINESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County of______________________State of _________________________
______________________________ ______________________________________
My commission expires Notary Public
Acceptance (Optional)
I have discussed this document with the person making this directive and I accept the responsibility designated to me as stated above.
___________________________________ _______________________
First Agent Date