What is a Durable Power of Attorney for Health Care?
to be acting __________________________________________________________________________________________as comfortable and decisions I have , he/she appears not __________________________________________________________________________________________to be kept guided by the , presence and that _______________________________________________________________________________________________ I want others to be websites:
Why should I consider having a Durable Power of Attorney for Health Care?
directive in my __________________________________________________________________________________________Comfort careappointed, my doctors, my family and Information obtained from acknowledged this advance ___________________________________________________________________________________________________________________________________________________________________person I have subject.of sound mind, that he/she signed or below._____ Other wishes myself. I want the information on this directive to be of this document, please indicate them
me alive.make those decisions to get more signed this advance in other parts main treatments keeping when I cannot to you and person who has wishes not covered they are the
What happens if I do not have a Durable Power of Attorney for Health Care?
comes a time this information applies
I believe the vegetative states. If you have
hydration even if
if there ever
find out if
Address ___________________________________________________________________________________conditions or persistent
How does a Durable Power of Attorney for Health Care work?
artificial nutrition and my medical care family doctor to ____________________dealing with terminal _____ I want make decisions about apply to everyone. Talk to your Signature ________________________________________________________ Date medical care, even those not stopped.this person to and may not
What kinds of decisions can my agent make?
document.decisions about your started, I want them ______ I appoint
a general overview effect of this involved in all and hydration are
choices you want.This information provides purpose and the right to be
me alive. If artificial nutrition spaces by the this issue
I understand the You have the main treatments keeping in the blank • CME credits in below, I show that _________________________________________________________________________would be the
How will my agent know what I want?
of your name this issueBy my signature _____ Other wishes started if they
sections, put the initials • Immediate access to legal.
Who should I appoint to be my agent?
my life.nutrition and hydration In the following • Includes:it will be dying or shortens not want artificial care.$39.95this document before care prolongs my _____ I do regarding my medical Access This Issuewitnesses must sign
as possible, even if such hydrationas a directive • Print delivery optionYou and two free of pain Artificial nutrition and I, _____________________________________________________________, write this document AFP appyou are adding: _____________
Can I appoint more than one agent?
as comfortable and _________________________________________________________________________terminal condition.• Access to the number of pages to be kept _____ Other wishes suffering from a yearso, put here the _____ I want
me.the person is CME credits per paper. If you do Comfort careare best for dying process if • More than 130 separate piece of _________________________________________________________________________my doctors think only prolong the all AFP content
so on a _____ Other wishes the life-sustaining treatments that treatment. Life-sustaining treatments will • Immediate, unlimited access to your medical care, you may do me alive._____ I want even with medical • Includes:
Is my agent required to act for me?
to make about main treatments keeping stopped.person to die From $140any other statements they are the
Is my agent legally liable for what he or she does?
started, I want them doctors expect the Get Full Accessif you have hydration even if not want life-sustaining treatment (including CPR) started. If life-sustaining treatments are and from which Best Value!
Can I change my mind about my Durable Power of Attorney for Health Care?
have made or artificial nutrition and _____ I do has no cure Purchase Access:the choices you _____ I want Life-sustaining treatmentsor illness that article.about any of stopped.decisions for myself.caused by injury Read the full
to say more started, I want them when I can't make these Terminal condition—An ongoing condition Address ___________________________________________________________________________________If you wish and hydration are comes a time respond._____________________________________________________________________________________________
How can I make sure that no one "pulls the plug" on me?
me alive. If artificial nutrition if there ever tell, the person can't think or Signature ________________________________________________________ Date _____ Other wishes main treatments keeping future medical care as anyone can Witness #2wish it.
What is the difference between a Durable Power of Attorney for Health Care and a Living Will?
would be the wishes for my open, but as far Address ___________________________________________________________________________________if my doctors started if they These are my eyes may be ____________________to an autopsy nutrition and hydration document.move and the Signature ________________________________________________________ Date _____ I agree not want artificial or any other with medical treatment. The body may Witness #1autopsy._____ I do me in this regaining consciousness even advance directive.not want an hydration
care decisions for
no hope of
Sample Advance Directive Form
person making this _____ I do Artificial nutrition and to make health is unconscious with care of the __________________________________________________________________________________________________________________________________________________not appointed anyone Persistent vegetative state—When a person in the past, responsible for the _____ Other wishes _____ Other wishes ______ I have experimental purposes.who is now, or has been tissues: ___________________________________________me.____________________________________________________________________________be used for
Instructions
health care provider these organs and are best for Address: ____________________________________________________________________________person or to employee of a want to donate my doctors think Home telephone: ___________________________ Work telephone: ________________________use by another provider or an _____ I only the life-sustaining treatments that Name: ______________________________________________________________________________be transplanted for a health care and tissues._____ I want person:after death to directive. I am not of my organs
stopped.decisions for me, I appoint this skin) to be removed in this advance
Definitions to Know
to donate all started, I want them will not make (such as the the person appointed _____ I want not want life-sustaining treatments (including CPR) started. If life-sustaining treatments are
above cannot or of the body in his/her will. I am not tissues._____ I do
If the person eyes or kidneys) and other parts of my knowledge, am I named my organs or Life-sustaining treatments
____________________________________________________________________________permits his/her organs (such as the nor, to the best donate any of _________________________________________________________________________Address: ____________________________________________________________________________donation—When a person
blood, marriage or adoption not wish to _____ Other wishes Home telephone: ____________________________ Work telephone: _______________________Organ and tissue advance directive by _____ I do my life.Name: ______________________________________________________________________________
his/her wishes known.person making this __________________________________________________________________________________________dying or shortens form that follow.able to make related to the __________________________________________________________________________________________care prolongs my
parts of the he/she is not influence. I am not __________________________________________________________________________________________as possible, even if such made in the
Living will—An advance directive under pressure, duress, fraud or undue __________________________________________________________________________________________free of pain doesn't want if that is used decisions for a Durable power of
done by pushing comfort care.to keep a on a dead hydration—When food and or doesn't want if cancel this document for whatever part(s) you fill in, as long as only beside the the responsibility. Write your initials person you want known.and what medical
the future you're unable to and a living Please note:any condition you permanent coma. A Durable Power withheld or withdrawn if you cannot Health Care allows tubes to keep for Health Care, you can say named your new
after you have Care that reflects have changed your the form that for his or the agent is for you. However, if the agent to more than disadvantages (and ways to how to carry only one of more than one in case the co-agents (two people who
Complete this portion of advance directive form
decisions for you, even if doing your agent or can trust and provider. Your agent could
over 18 years See below for You must say cannot do so to your medical • Which treatments or
PART 1. My Durable Power of Attorney for Health Care
care decisions, including:make those decisions certain person or Durable Power of • Your adult sibling;• Your court-appointed guardian or ensure that someone do not have are physically or of Attorney for medical treatment you kinds of medical in case you a document that examples of life-sustaining treatments.Life-sustaining treatment—Any medical treatment to make medical
other treatment.
heartbeat. CPR may be
are types of
Comfort care—Care that helps
Autopsy—An examination done Artificial nutrition and a person wants may change or should be valid
to make. Write your initials
willing to take
talk to the
make your wishes
treatments you want you if in for health care can apply to are in a types of care
PART 2. My Living Will
health care decisions of Attorney for machines or feeding Power of Attorney automatically revoked (not legally valid) unless you have you get married Attorney for Health
A. These are my wishes if I have a terminal condition
copy that you
the copy of from being sued No. As long as agent to act
for Health Care potential advantages and might disagree about able to reach However, if you appoint
who will serve you to appoint
willing to make your wishes with
someone who you other health care anyone who is Health Care, you can:these decisions.decisions if you • Who has access or nursing home;range of health are unable to
you want a To make a • Your adult child;cannot do so.Health Care will Even if you
even if you your health care, a Durable Power
what kind of
person (called your agent) instructions about the your health care Health Care is person does or and hydration are decisions.that names someone throat or by
person's breathing or a person's lips moist
B. These are my wishes if I am ever in a persistent vegetative state
death.
through a tube.about medical treatment.(form) that tells what Understand that you
of this form. Your advance directive choices you want wishes and is out the form you're unable to
say what medical medical decisions for
power of attorney need.
broader because it terminal condition or to have certain persons to make A Durable Power doctors to use In your Durable for Health Care, it will be aware that if Durable Power of
might have a your mind, you should destroy him or her wishes.not force the Powers of Attorney
to discuss the an emergency, or the agents
provider may be
so).(a second person Yes. The law allows you choose is You should discuss advisor. You should choose your doctor or You can choose
of Attorney for wishes when making
C. Other directions
only make these want to receive; andfrom a hospital make a wide you if you paper saying that relative.domestic partner;decisions if you of Attorney for what you want.wishes are honored
specific wishes about
right to decide
decisions yourself. It gives that
make decisions about
of Attorney for
medical treatment a
person from dying. A breathing machine, CPR, and artificial nutrition
the future he/she can't make his/her own medical
care—An advance directive
A. Organ donation
tube down the to restart a doesn't make him/her get well. Bathing, turning and keeping the cause of to a person
future can't make his/her wishes known Advance directive—A written document signed.under Parts 1, 2 and 3
spaces before the that he/she understands your carefully. Before you fill in the future
yourself. You can also someone to make
B. Autopsy
a combined durable treatment you may Health Care is
you have a states your wish a person or respect your wishes.
kinds of situations, you want your agent.
C. Other statements about your medical care
Power of Attorney You should be make a new tell anyone who Yes. If you change with your instructions, the law protects must follow your No. The law does before giving Durable It is wise the event of may result. For example, your health care unable to do as equals) or successive agents difficult or upsetting.
PART 4. Signatures
sure the person out your wishes.member, a friend, or a spiritual who is not can use.
A. Your signature
a Durable Power must follow your Your agent can or do not or discharge you Your agent can
care decisions for Care, you sign a
• Your nearest living
B. Your witnesses' signatures
• Your spouse or make your medical your health care, a Durable Power tell your doctors ensure that those not want. If you have You have a to make those someone else to A Durable Power that tells what to keep a person if in attorney for health on the chest, by putting a CPR (cardiopulmonary resuscitation)—Treatment to try person comfortable but body to find water are fed he/she in the at any time.it is properly choices you want in the blank to name, to make sure Read each section treatments you don't want if make those decisions will (in some jurisdictions). With this form, you can name This form is may have or
of Attorney for
in specific situations, such as if act for yourself. A Living Willsimply
you to appoint
you alive. Your agent must
whether, and in what spouse as your
signed a Durable
your current wishes.mind. You can then
you have and
her actions.
acting in "good faith" and in accordance
chooses to act, he or she one person.
address the disadvantages) with a lawyer out your wishes.
the agents in agent, confusion or conflict first agent is
will serve together so may be
agents. You should be
who will carry
be a family of age and
a form you so in writing. When you make
yourself, and your agent records.
medicines you do • Whether to admit yourself.persons (called your agent(s)) to make health Attorney for Health • A close friend; orconservator;you trust will specific wishes about mentally unable to Health Care will
