[THIS SECTION IS FOR YOUR INFORMATION ONLY. IT WILL NOT BE PRINTED.]
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record. It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate. The Health Care Power of Attorney should be reviewed: if the Agent or the Alternate Agent is no longer able to serve; if the Agent is your spouse and you become separated or divorced; or if you wish to revise your desires as stated in the document.
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This section explains the purpose and consequences of this Power of Attorney for Health Care, as well as the rights and obligations of the person making the document (the "Principal") and the person appointed to make health care decisions for the Principal (the "Attorney-in-Fact"). This section will appear on the printed document and must be read and understood by the Principal before he or she signs the Power of Attorney for Health Care.
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Name: |
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@Who is this Power of Attorney for Health Care being created for?
FWhat is the Attorney-in-Fact's relationship, if any, to the Principal?
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Limitations:#|
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yWhat limitations, if any, will there be on the Attorney-in-Fact's authority to make decisions on behalf of the Principal?
If desired, specify any limitations on the Attorney-in-Fact's authority. For example, the Principal may wish to prohibit the Attorney-in-Fact from authorizing certain procedures. Press [Ctrl+F1] for more information.
Enter the Principal's city or edit the information as desired.
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Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
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2What are the names and addresses of the witnesses?
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Agent to follow Living WillAgent to decide treatmentComfort care treatment onlyAll treatment requested[Enter desires in your own words]
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MWhat are your desires concerning life-sustaining treatment and/or procedures?
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining procedures.
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If I have an incurable conditionIf I am permanently unconsciousEither of the above
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aUnder what circumstances should life-sustaining treatment or procedures be withheld or withdrawn?
Enter an X to withhold life-sustaining procedures if the condition of the Principal is incurable or irreversible and is expected to result in death within a relatively short time without such procedures.
Enter an X to withhold life-sustaining procedures if the Principal is in a permanently unconscious condition.
Enter an X to withhold life-sustaining procedures if the Principal's condition is incurable and is expected to result in death within a relatively short time (without such procedures) or if the Principal is in a permanently unconscious state.
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Specific desires:#|
HCP_DC05
VWhat are your specific desires concerning life-sustaining treatment and/or procedures?
IGN04022
Yes, include nutrition and fluids paragraph.
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LDo you wish to state your desires regarding artificial nutrition and fluids?
IGN04023
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YesNo
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Will artificially administered nutrition and fluids be included in the "life-sustaining procedures" that may be withheld or withdrawn?
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Yes, include life-sustaining procedures section.
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GDo you wish to state your desires regarding life-sustaining procedures?
IGN04003
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Special provisions:#|
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IWhat special provisions, if any, do you wish to include in this document?
If desired, enter any special health care provisions that you would like to include in the document. For example, describe any types of treatment you wish or wish not to receive. Press [Ctrl+F1] for more information.
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Values and preferences:#|
HCP_DC07
DWhat personal values, if any, do you wish to state in this document?
If desired, specify any values and preferences about health care. For example, describe values or religious preferences, or your desires regarding the location of treatment. Press [Ctrl+F1] for more information.
=Who, if anyone, will be designated as Second Alternate Agent?
If desired, enter the Second Alternate Agent's name or use the P.I. Manager to select and paste a record. You do not have to name a second Alternate Agent.
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