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Document made this.... day of.... (month),.... (year).
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CREATION OF POWER OF ATTORNEY
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FOR HEALTH CARE
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I,.... (print name, address and date of birth), being of sound mind, intend by this
15document to create a power of attorney for health care. My executing this power of
16attorney for health care is voluntary. Despite the creation of this power of attorney
17for health care, I expect to be fully informed about and allowed to participate in any
18health care decision for me, to the extent that I am able. For the purposes of this
19document, “health care decision" means an informed decision to accept, maintain,
20discontinue or refuse any care, treatment, service or procedure to maintain, diagnose
21or treat my physical or mental condition.
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In addition, I may, by this document, specify my wishes with respect to making
23an anatomical gift upon my death.
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DESIGNATION OF HEALTH CARE AGENT
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1If I am no longer able to make health care decisions for myself, due to my
2incapacity, I hereby designate.... (print name, address and telephone number) to be
3my health care agent for the purpose of making health care decisions on my behalf.
4If he or she is ever unable or unwilling to do so, I hereby designate.... (print name,
5address and telephone number) to be my alternate health care agent for the purpose
6of making health care decisions on my behalf. Neither my health care agent nor my
7alternate health care agent whom I have designated is my health care provider, an
8employee of my health care provider, an employee of a health care facility in which
9I am a patient or a spouse of any of those persons, unless he or she is also my relative.
10For purposes of this document, “incapacity" exists if 2 physicians or a physician and
11a psychologist who have personally examined me sign a statement that specifically
12expresses their opinion that I have a condition that means that I am unable to receive
13and evaluate information effectively or to communicate decisions to such an extent
14that I lack the capacity to manage my health care decisions. A copy of that statement
15must be attached to this document.
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GENERAL STATEMENT OF AUTHORITY GRANTED
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Unless I have specified otherwise in this document, if I ever have incapacity I
18instruct my health care provider to obtain the health care decision of my health care
19agent, if I need treatment, for all of my health care and treatment. I have discussed
20my desires thoroughly with my health care agent and believe that he or she
21understands my philosophy regarding the health care decisions I would make if I
22were able. I desire that my wishes be carried out through the authority given to my
23health care agent under this document.
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If I am unable, due to my incapacity, to make a health care decision, my health
25care agent is instructed to make the health care decision for me, but my health care
1agent should try to discuss with me any specific proposed health care if I am able to
2communicate in any manner, including by blinking my eyes. If this communication
3cannot be made, my health care agent shall base his or her decision on any health
4care choices that I have expressed prior to the time of the decision. If I have not
5expressed a health care choice about the health care in question and communication
6cannot be made, my health care agent shall base his or her health care decision on
7what he or she believes to be in my best interest.
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LIMITATIONS ON MENTAL HEALTH TREATMENT
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My health care agent may not admit or commit me on an inpatient basis to an
10institution for mental diseases, an intermediate care facility for persons with an
11intellectual disability, a state treatment facility or a treatment facility. My health
12care agent may not consent to experimental mental health research or
13psychosurgery, electroconvulsive treatment or drastic mental health treatment
14procedures for me.
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ADMISSION TO NURSING HOMES OR
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COMMUNITY-BASED RESIDENTIAL FACILITIES
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My health care agent may admit me to a nursing home or community-based
18residential facility for short-term stays for recuperative care or respite care.
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If I have checked “Yes" to the following, my health care agent may admit me for
20a purpose other than recuperative care or respite care, but if I have checked “No" to
21the following, my health care agent may not so admit me:
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1. A nursing home — Yes.... No....
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2. A community-based residential facility — Yes.... No....
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If I have not checked either “Yes" or “No" immediately above, my health care
25agent may admit me only for short-term stays for recuperative care or respite care.
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1PROVISION OF A FEEDING TUBE
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If I have checked “Yes" to the following, my health care agent may have a
3feeding tube withheld or withdrawn from me, unless my physician has advised that,
4in his or her professional judgment, this will cause me pain or will reduce my comfort.
5If I have checked “No" to the following, my health care agent may not have a feeding
6tube withheld or withdrawn from me.
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My health care agent may not have orally ingested nutrition or hydration
8withheld or withdrawn from me unless provision of the nutrition or hydration is
9medically contraindicated.
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Withhold or withdraw a feeding tube — Yes.... No....
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If I have not checked either “Yes" or “No" immediately above, my health care
12agent may not have a feeding tube withdrawn from me.
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HEALTH CARE DECISIONS FOR
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PREGNANT WOMEN
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If I have checked “Yes" to the following, my health care agent may make health
16care decisions for me even if my agent knows I am pregnant. If I have checked “No"
17to the following, my health care agent may not make health care decisions for me if
18my health care agent knows I am pregnant.
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Health care decision if I am pregnant — Yes.... No....
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If I have not checked either “Yes" or “No" immediately above, my health care
21agent may not make health care decisions for me if my health care agent knows I am
22pregnant.