"Durable Power of Attorney Form for Health Care (Designation of Health Care Surrogate)"

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PLEASE COMPLETE ALL FIELDS
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
(DESIGNATION OF HEALTH CARE SURROGATE)
In the event that I, Name_______________________________ Age_________ have been determined by my physician(s) to
be incompetent/incapacitated (lack the ability) to provide informed consent for medical treatment and surgical and diagnostic
procedures including but not limited to the withholding, withdrawal, or continuation of life prolonging procedures, I wish to designate
as my decision maker (surrogate) to make health care decisions:
Name: _________________________________ / ______________________Phone# (w) ___________________________
(h) ___________________________
relationship
Address:_____________________________________________________________
If my surrogate is unwilling or unable to perform his/her duties, I wish to designate as my alternate decision maker:
Name: _________________________________ / ______________________Phone# (w) ___________________________
relationship
(h) ___________________________
Address:_____________________________________________________________
I fully understand that this designation will permit my decisionmaker to make all health care decisions on my behalf until I regain
the ability to make health care decisions. The healthcare decisions may also include if necessary, the decisions to withhold,
withdraw, or continue life prolonging procedures. My decisionmaker may also authorize my admission to or transfer from a health
care facility and also apply for public assistance on my behalf. This designation is to remain in effect during any incapacity or
incompetency I may experience.
Additional instructions (optional): __________________________________________________________________________
I further affirm that this designation is not being made as a condition of treatment or admission to a health care facility.
Witness: ____________________________________________
Signature: ____________________________________
Witness: ____________________________________________
Date: ________________________________________
LIVING WILL
I, willfully and voluntarily make known my desire that my dying not be prolonged under the following circumstances. If at any
time I have a terminal condition and/or am in a persistent vegetative state, and if my attending/treating physician and a consulting
physician have determined that there is no medical probability of my recovery from such condition(s), I direct that life prolonging
procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of
dying. I request to be permitted to die naturally with only the administration of medication or the performance of medical procedure
deemed necessary to provide me with comfort care or to alleviate pain.
I also desire to have life prolonging procedures withheld/withdrawn when: (optional)
_______
Due to a debilitating disease condition in which I have no reasonable probability of recovering, I cannot
_______
Initial
communicate or interact purposely with others.
_______
Specify other condition: ________________________________________________________________
Initial
In addition, I do ____ or I do not ____ want to be given nutrition (food) and/or hydration (water) artificially by a feeding tube or
by
Initial
Initial
intravenous feedings when it would serve only to prolong artificially the process of dying.
Additional instructions (optional): __________________________________________________________________________
I request that my Living Will be honored by my family and physician(s) as the final expression of my legal right to refuse medical
or surgical treatment and to accept the consequences for such refusal.
If I am pregnant and this is known to my physician(s), this Living Will shall have no force or effect during the course of
my pregnancy.
I understand the full meaning of this Living Will, and I am emotionally and mentally competent to make these declarations.
Witness: ____________________________________________
Signature: ____________________________________
Witness: ____________________________________________
Date: ________________________________________
FK5502 Back (02/11)
PLEASE COMPLETE ALL FIELDS
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
(DESIGNATION OF HEALTH CARE SURROGATE)
In the event that I, Name_______________________________ Age_________ have been determined by my physician(s) to
be incompetent/incapacitated (lack the ability) to provide informed consent for medical treatment and surgical and diagnostic
procedures including but not limited to the withholding, withdrawal, or continuation of life prolonging procedures, I wish to designate
as my decision maker (surrogate) to make health care decisions:
Name: _________________________________ / ______________________Phone# (w) ___________________________
(h) ___________________________
relationship
Address:_____________________________________________________________
If my surrogate is unwilling or unable to perform his/her duties, I wish to designate as my alternate decision maker:
Name: _________________________________ / ______________________Phone# (w) ___________________________
relationship
(h) ___________________________
Address:_____________________________________________________________
I fully understand that this designation will permit my decisionmaker to make all health care decisions on my behalf until I regain
the ability to make health care decisions. The healthcare decisions may also include if necessary, the decisions to withhold,
withdraw, or continue life prolonging procedures. My decisionmaker may also authorize my admission to or transfer from a health
care facility and also apply for public assistance on my behalf. This designation is to remain in effect during any incapacity or
incompetency I may experience.
Additional instructions (optional): __________________________________________________________________________
I further affirm that this designation is not being made as a condition of treatment or admission to a health care facility.
Witness: ____________________________________________
Signature: ____________________________________
Witness: ____________________________________________
Date: ________________________________________
LIVING WILL
I, willfully and voluntarily make known my desire that my dying not be prolonged under the following circumstances. If at any
time I have a terminal condition and/or am in a persistent vegetative state, and if my attending/treating physician and a consulting
physician have determined that there is no medical probability of my recovery from such condition(s), I direct that life prolonging
procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of
dying. I request to be permitted to die naturally with only the administration of medication or the performance of medical procedure
deemed necessary to provide me with comfort care or to alleviate pain.
I also desire to have life prolonging procedures withheld/withdrawn when: (optional)
_______
Due to a debilitating disease condition in which I have no reasonable probability of recovering, I cannot
_______
Initial
communicate or interact purposely with others.
_______
Specify other condition: ________________________________________________________________
Initial
In addition, I do ____ or I do not ____ want to be given nutrition (food) and/or hydration (water) artificially by a feeding tube or
by
Initial
Initial
intravenous feedings when it would serve only to prolong artificially the process of dying.
Additional instructions (optional): __________________________________________________________________________
I request that my Living Will be honored by my family and physician(s) as the final expression of my legal right to refuse medical
or surgical treatment and to accept the consequences for such refusal.
If I am pregnant and this is known to my physician(s), this Living Will shall have no force or effect during the course of
my pregnancy.
I understand the full meaning of this Living Will, and I am emotionally and mentally competent to make these declarations.
Witness: ____________________________________________
Signature: ____________________________________
Witness: ____________________________________________
Date: ________________________________________
FK5502 Back (02/11)