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Statutory Short Form
Durable Power of Attorney for Health Care
Durable Power of Attorney made this [Day] [Month], [Year]
1. I, [Principal's Name] residential address, [Full Address] hereby appoint: my, [RELATIONSHIP], APPOINTEE, as my attorney-in-fact (my "agent") to act for me and in my name in any way I could act in person, to make any and all decisions for me concerning my personal care, medical treatment, hospitalization and health care and to require, withhold or withdraw any type of medical treatment or procedure, even though my death may ensue. My agent shall have the same access to my medical records that I have, including the right to discuss the contents with others. My agent shall also have full power to make a disposition of any part or all of my body for medical purposes, authorize an autopsy of my body and direct the disposition of my remains.
2. The powers granted above shall not include the following powers or shall be subject to the following rules or limitations (here you may include any specific limitations you deem appropriate, such as your own definition of when life-sustaining or death-delaying measures should be withheld; a direction to continue nourishment and fluids or other life-sustaining or death-delaying treatment in all events; or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs or unacceptable to you for any other reason, such as blood transfusion, electroconvulsive therapy, amputation, etc.):
I do not want my life to be prolonged nor do I want life-sustaining or death-delaying treatment to be provided or continued if my agent believes the burdens of the treatment outweigh the expected suffering, the expense involved and the quality as well as the possible extension of my life in making decisions concerning life-sustaining or death-delaying treatment.
I want my life to be prolonged and I want life-sustaining or death-delaying treatment to be provided or continued unless I am in a coma, including a persistent vegetative state, which my attending physician believes to be irreversible, in accordance with reasonable medical standards at the time of reference. If and when I have suffered such an irreversible coma, I want life-sustaining or death-delaying treatment to be withheld or discontinued.
I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the procedures.
3. ( ) This power of attorney shall become effective on (insert a future date or event during your lifetime, such as court determination of your disability, incapacity or incompetency, when you want this power to first take effect).
4. ( ) This power of attorney shall terminate on (insert a future date or event, such court determination of your disability, incapacity or incompetency, when you want this power to terminate prior to your death).
5. If any agent named by me shall die, become legally disabled, incapacitated or incompetent, or resign, refuse to act or be unavailable, I name the following (each to act successively in the order named) as successors to such agent:
6. If a guardian of my person is to be appointed, I nominate the following to serve as such guardian:
7. I am fully informed as to all the contents of this form and understand the full import of this grant of powers to my agent.
The principal has had an opportunity to read the above form and has signed the above form in our presence. We, the undersigned, each being over eighteen years of age, hereby witness the principal's signature at the request and in the presence of the principal, and in the presence of each other, the day and year above set out.