ADVANCE HEALTH CARE DIRECTIVE

Name: ##GRANTORNAME||Name of Grantor##

Address: ##GRANTORADDRESS||Full Address of Grantor##

PART 1.  Durable Power of Attorney for Health Care 

I hereby appoint the following person to act as my agent and to make decisions about my medical care on my behalf. 

Name: 

 ##AGENT1NAME||Name of 1st Agent##

Telephone: 

##AGENT1PHN||1st Agent Number##
 
Address: 

##AGENT1ADDRESS||1st Agent Full Address##

If for any reason whatsoever, I revoke my agent's authority or if my agent is not willing, able, or available to make a health care decision for me, I designate as my first alternate agent

Name: 

 ##AGENT2NAME||Name of 2nd Agent##
 
Telephone: 

##AGENT2PHN||2nd Agent Number##

Address: 

##AGENT2ADDRESS||2nd Agent Full Address##

 I hereby declare that I have not appointed any other person to make any health care decisions on behalf of me in any other document.  

My agent is authorized to:

(a) make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of healthcare to keep me alive, 

(b) to choose a particular physician or health care facility, and 

(c) to receive or consent to the release of medical information and records, except as I state here: ##NORELEASE||Information not to be released##

My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

PART 2. My Living Will 

The following are my wishes for my future medical care to be taken on my behalf: 

A. The following are my wishes if I have an End of life condition. 

(i) Life-sustaining treatments 

______ I do not want life-sustaining treatment (including CPR) started. If life-sustaining treatments are started, I want them stopped.
 
______ I want the life-sustaining treatments that my doctors think are best for me.
 
______ Other wishes

(ii) Artificial nutrition and hydration 

______  I do not want artificial nutrition and hydration started if they would be the main treatments keeping me alive. If artificial nutrition and hydration are started, I want them stopped. 
 
______  I want artificial nutrition and hydration even if they are the main treatments keeping me alive.
 
______  Other wishes

(iii) Comfort care 

______  I want to be kept as comfortable and free of pain as possible, even if such care prolongs my dying or shortens my life. 
 
______   Other wishes

B. These are my wishes if I am ever in a persistent critical condition. 

(i) Life-sustaining treatments 

______   I do not want life-sustaining treatment (including CPR) started. If life-sustaining treatments are started, I want them stopped.
 
______ 
 I want the life-sustaining treatments that my doctors think are best for me.
 
______  Other wishes

(ii) Artificial nutrition and hydration 

______   I do not want artificial nutrition and hydration started if they would be the main treatments keeping me alive. If artificial nutrition and hydration are started, I want them stopped. 
 
______   I want artificial nutrition and hydration even if they are the main treatments keeping me alive.
 
______   Other wishes

(iii) Comfort care 

______   I want to be kept as comfortable and free of pain as possible, even if such care prolongs my dying or shortens my life. 
 
______   Other wishes

PART 3. Other Wishes 

A. Organ donation 

______   I do not wish to donate any of my organs or tissues. 
 
______   I want to donate all of my organs and tissues.
 
______   I only want to donate these organs and tissues:

______  Other wishes

B. Autopsy 

______   I do not want an autopsy. 
 
______   I agree to an autopsy if my doctors wish it. 
 
______   Other wishes

C. Other statements about my medical care 

________________________________________________________________________ 

PART 4. Signatures 

By my signature below, I show that I understand the purpose and the effect of this document. 

Signature: 

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 Date: 

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Address: 

##GRANTORADDRESS||Full Address of Grantor##

B. Witnesses' signatures 

Witness #1 

Signature: 

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 Date: 

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Address: 

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Witness #2 

Signature: 

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 Date: 

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Address: