A Stitch In Time

My Life In Words

111146125947702093

Posted by debraroby on March 21, 2005

In the spirit of remembering Terry Schaivo, who has existed in limbo for the past many years. If you have not filled out a health care initiative, DO SO NOW. It makes sure that everyone knows your choice if you can’t decide for yourself.

And, to make things easy for you.. so you can’t argue that’s too hard to bother with, I’ve included a basic copy below. Just cut and paste, check a few places, fill in a name or two, print and sign.

And keep the lawyers, judges and politicians out of your life decisions.

PART 1
POWER OF ATTORNEY FOR HEALTH CARE

(1.1) DESIGNATION OF AGENT: I designate the following individual
as my agent to make health care decisions for me:

______________________________________________________________________
(name of individual you choose as agent)

______________________________________________________________________
(address) (city) (state) (ZIP Code)

______________________________________________________________________
(home phone) (work phone)

OPTIONAL: If I revoke my agent’s authority or if my agent is not
willing, able, or reasonably available to make a health care decision for
me, I designate as my first alternate agent:

______________________________________________________________________
(name of individual you choose as first alternate agent)

______________________________________________________________________
(address) (city) (state) (ZIP Code)

______________________________________________________________________
(home phone) (work phone)

(1.2) AGENT’S AUTHORITY: My agent is authorized to make all
health care decisions for me, including decisions to provide, withhold, or
withdraw artificial nutrition and hydration and all other forms of health
care to keep me alive, except as I state here:

______________________________________________________________________

(Add additional sheets if needed.)

(1.3) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s
authority becomes effective when my primary physician determines that I am
unable to make my own health care decisions unless I mark the following
box. If I mark this box (), my agent’s authority to make health care
decisions for me takes effect immediately.

(1.4) AGENT’S OBLIGATION: 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 in my best interest. In determining my best interest,my agent shall consider my personal values to the extent known to my agent.

(1.5) AGENT’S POSTDEATH AUTHORITY: My agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains, except as I state here or in Part 3 of this form:

____________________________________________________________________________

PART 2
INSTRUCTIONS FOR HEALTH CARE

(2.1) END-OF-LIFE DECISIONS: I direct that my health care
providers and others involved in my care provide, withhold, or withdraw
treatment in accordance with the choice I have marked below:
_
|_| (a) Choice Not To Prolong Life
I do not want my life to be prolonged if (1) I have an incurable
And irreversible condition that will result in my death within a
Relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR
_
|_| (b) Choice To Prolong Life
I want my life to be prolonged as long as possible within the
limits of generally accepted health care standards.

(2.2) RELIEF FROM PAIN: Except as I state in the following space,
I direct that treatment for alleviation of pain or discomfort be
Provided at all times, even if it hastens my death.

______________________________________________________________________
(Add additional sheets if needed.)

(2.3) Provide Food and/or Water. I do not want to be put on a feeding tube, if that sustinence is the only thing that keeps me alive. Hydration is acceptable.

PART 3
DONATION OF ORGANS AT DEATH
(OPTIONAL)

(3.1) Upon my death (mark applicable box):
_
|_| (a) I give any needed organs, tissues, or parts, OR
_
|_| (b) I give the following organs, tissues, or parts only.

_____________________________________________________________________

PART 4

(5.1) EFFECT OF COPY: A copy of this form has the same effect as
the original.

(5.2) SIGNATURE: Sign and date the form here:

_______________________________
____________________________________
(date) (sign your name)

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2 Responses to “111146125947702093”

  1. Jen Mullen said

    I have printed this out and will complete and file it. I already have a living will, but this will help make my wishes clearer.

    Thanks!

    Jen

  2. Elle said

    I think these are so important. I know my wishes would be more protected with legal documents like these.

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