WHAT DOES A LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE SAY

WHAT DOES A LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE SAY?

Death is as much a reality as birth, growth, maturity and old age- it is the one certainty of life. There may come a time when I am unable, due to physical or mental incapacity, to make my own health care decisions. In these circumstances, those caring for me will need direction and they will turn to someone who knows my values and health care wishes. By writing this durable power of attorney for health care I appoint a health care representative with the legal authority to make health care decisions on my behalf and to consult with my physician and others. If the time comes when I am physically and/or mentally unable to make decisions for my own future, let this statement stand as an expression of my wishes and directions, while I am still of sound mind. I understand that as a competent adult, I have the right to make decisions about my health care.

If at such a time the situation should arise in which there is no reasonable expectation of my recovery from physical or mental disability, I direct that I be allowed to die and not be kept alive by medications, artificial means or extraordinary life sustaining medical procedures. I do, however, ask that medication be administered to me to alleviate suffering even though this may shorten my remaining life.

A. Fluids and Nutrition.
I request that artificially provided fluids and nutrition, such as by feeding tube or intravenous infusion (initial one, not both)

1. ______ shall be withheld or withdrawn as "Life Sustaining Treatment."

2. ______ shall be provided to the extent medically appropriate even if other "Life Sustaining Treatment" is withheld or withdrawn.

B. Directive as to Medical Treatment.
I request that "Life Sustaining Treatment" be withheld or withdrawn from me in each of the following circumstances: (Initial all that apply. Most people initial 1-4, all of them)

1. ______ If the "life sustaining treatment" is experimental and not a proven therapy, or is likely to be ineffective or futile in prolonging my life, or is likely to merely prolong an imminent dying process;
2. ______ If I am permanently unconscious (total and irreversible loss of consciousness and capacity for interaction with the environment);
3. ______ If I am in a terminal condition (terminal stage of an irreversibly fatal illness, disease, or condition); or
4. ______ If I have a serious irreversible illness or condition, and the likely risks and burdens associated with the medical intervention to be withheld or withdrawn outweigh the likely benefits to me from such intervention.
______ None of the above. I direct that all medically appropriate measures be provided to sustain my life, regardless of my physical or mental condition. I want to be kept alive for as long as possible.

Life Sustaining Treatment. "Life Sustaining Treatment" means the use of any medical device or procedure, artificially provided fluids and nutrition, drugs, surgery or therapy that uses mechanical or other artificial means to sustain, restore or supplant a vital bodily function, and thereby increase the expected life span of a patient.

DURABLE POWER OF ATTORNEY FOR MEDICAL DECISIONS

I hereby designate p1 to serve as my attorney-in-fact for the purpose of making medical treatment decisions. In the event p1 predeceases me or is unable or unwilling to act as my attorney-in-fact for the purpose of making medical treatment decisions, then I select __

MEDICAL RECORDS ACCESS UNDER HIPAA: My attorney-in-fact shall be able to access my medical and hospital records under Federal Law HIPAA and make decisions under POLST. Healthcare providers shall release medical information to my agent. This authorization expires upon my death.

If I lack decision-making capacity, my Health Care Representative shall have authority to make health care decisions on my behalf, in good faith and within the bounds of the authority granted herein and by law. My Health Care Representative shall exercise my right to be informed of my medical condition, prognosis and treatment options, and to give informed consent to, or refusal of, health care.