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Living Will Form - Health Care Power of Attorney Form

The purpose of a Living Will declaration is to document your wish that life-sustaining treatment, including artificially or technologically supplied nutrition and hydration, be withheld or withdrawn if you are unable to make informed medical decisions and are in a terminal condition or in a permanently unconscious state.

1. Life-sustaining treatment means any health care, including artificially or technologically supplied nutrition and hydration, that will serve mainly to prolong the process of dying.

2. Terminal condition or terminal illness means an irreversible, incurable and untreatable condition caused by disease, illness or injury. Your physician and one other physician will have examined you and believe that you cannot recover and that death is likely to occur within a relatively short time if you do not receive life-sustaining treatment.

3. Permanently unconscious state means an irreversible condition in which you are permanently unaware of yourself and your surroundings. Your physician and one other physician must examine you and agree that the total loss of higher brain function has left you unable to feel pain or suffering. Having a Living Will does not affect the responsibility of health care personnel to provide comfort care to you. Comfort care means any measure taken to diminish pain or discomfort, but not to postpone death. In most states, a Living Will is applicable only to individuals in a terminal condition or a permanently unconscious state. If you wish to direct medical treatment in other circumstances, you should prepare a Health Care Power of Attorney. The Health Care Power of Attorney form gives the person you designate (agent or attorney-in-fact) the authority to make most health care (including dental, nursing, psychological, and surgical) decisions for you if you lose the capacity to make informed health care decisions for yourself. This authority is effective only when your attending physician determines that you have lost the capacity to make informed health care decisions for yourself. As long as you have the capacity to make informed health care decisions for yourself, you retain the right to make all medical and other health care decisions. You may also limit the health care decisions that your agent will have the authority to make. The authority of the agent to make health care decisions for you generally will include the authority to give informed consent, to refuse to give informed consent, or to withdraw informed consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.


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