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Example - 20 Pa. Cons. Stat. § 5471Legal Research Home > Pennsylvania Statutes Sponsored Links
SUBCHAPTER D
COMBINED FORM
Sec.
5471. Example.
Cross References. Subchapter D is referred to in sections
5433, 5447, 5465 of this title.
§ 5471. Example.
The following is an example of a document that combines a
living will and health care power of attorney:
DURABLE HEALTH CARE POWER OF ATTORNEY
AND HEALTH CARE TREATMENT INSTRUCTIONS
(LIVING WILL)
PART I
INTRODUCTORY REMARKS ON
HEALTH CARE DECISION MAKING
You have the right to decide the type of health care you
want.
Should you become unable to understand, make or
communicate decisions about medical care, your wishes for
medical treatment are most likely to be followed if you
express those wishes in advance by:
(1) naming a health care agent to decide treatment
for you; and
(2) giving health care treatment instructions to
your health care agent or health care provider.
An advance health care directive is a written set of
instructions expressing your wishes for medical treatment. It
may contain a health care power of attorney, where you name a
person called a "health care agent" to decide treatment for
you, and a living will, where you tell your health care agent
and health care providers your choices regarding the
initiation, continuation, withholding or withdrawal of life-
sustaining treatment and other specific directions.
You may limit your health care agent's involvement in
deciding your medical treatment so that your health care
agent will speak for you only when you are unable to speak
for yourself or you may give your health care agent the power
to speak for you immediately. This combined form gives your
health care agent the power to speak for you only when you
are unable to speak for yourself. A living will cannot be
followed unless your attending physician determines that you
lack the ability to understand, make or communicate health
care decisions for yourself and you are either permanently
unconscious or you have an end-stage medical condition, which
is a condition that will result in death despite the
introduction or continuation of medical treatment. You, and
not your health care agent, remain responsible for the cost
of your medical care.
If you do not write down your wishes about your health
care in advance, and if later you become unable to
understand, make or communicate these decisions, those wishes
may not be honored because they may remain unknown to others.
A health care provider who refuses to honor your wishes
about health care must tell you of its refusal and help to
transfer you to a health care provider who will honor your
wishes.
You should give a copy of your advance health care
directive (a living will, health care power of attorney or a
document containing both) to your health care agent, your
physicians, family members and others whom you expect would
likely attend to your needs if you become unable to
understand, make or communicate decisions about medical care.
If your health care wishes change, tell your physician and
write a new advance health care directive to replace your old
one. It is important in selecting a health care agent that
you choose a person you trust who is likely to be available
in a medical situation where you cannot make decisions for
yourself. You should inform that person that you have
appointed him or her as your health care agent and discuss
your beliefs and values with him or her so that your health
care agent will understand your health care objectives.
You may wish to consult with knowledgeable, trusted
individuals such as family members, your physician or clergy
when considering an expression of your values and health care
wishes. You are free to create your own advance health care
directive to convey your wishes regarding medical treatment.
The following form is an example of an advance health care
directive that combines a health care power of attorney with
a living will.
NOTES ABOUT THE USE OF THIS FORM
If you decide to use this form or create your own advance
health care directive, you should consult with your physician
and your attorney to make sure that your wishes are clearly
expressed and comply with the law.
If you decide to use this form but disagree with any of
its statements, you may cross out those statements.
You may add comments to this form or use your own form to
help your physician or health care agent decide your medical
care.
This form is designed to give your health care agent
broad powers to make health care decisions for you whenever
you cannot make them for yourself. It is also designed to
express a desire to limit or authorize care if you have an
end-stage medical condition or are permanently unconscious.
If you do not desire to give your health care agent broad
powers, or you do not wish to limit your care if you have an
end-stage medical condition or are permanently unconscious,
you may wish to use a different form or create your own. YOU
SHOULD ALSO USE A DIFFERENT FORM IF YOU WISH TO EXPRESS YOUR
PREFERENCES IN MORE DETAIL THAN THIS FORM ALLOWS OR IF YOU
WISH FOR YOUR HEALTH CARE AGENT TO BE ABLE TO SPEAK FOR YOU
IMMEDIATELY. In these situations, it is particularly
important that you consult with your attorney and physician
to make sure that your wishes are clearly expressed.
This form allows you to tell your health care agent your
goals if you have an end-stage medical condition or other
extreme and irreversible medical condition, such as advanced
Alzheimer's disease. Do you want medical care applied
aggressively in these situations or would you consider such
aggressive medical care burdensome and undesirable?
You may choose whether you want your health care agent to
be bound by your instructions or whether you want your health
care agent to be able to decide at the time what course of
treatment the health care agent thinks most fully reflects
your wishes and values.
If you are a woman and diagnosed as being pregnant at the
time a health care decision would otherwise be made pursuant
to this form, the laws of this Commonwealth prohibit
implementation of that decision if it directs that life-
sustaining treatment, including nutrition and hydration, be
withheld or withdrawn from you, unless your attending
physician and an obstetrician who have examined you certify
in your medical record that the life-sustaining treatment:
(1) will not maintain you in such a way as to permit the
continuing development and live birth of the unborn child;
(2) will be physically harmful to you; or
(3) will cause pain to you that cannot be alleviated by
medication.
A physician is not required to perform a pregnancy test on
you unless the physician has reason to believe that you may
be pregnant.
Pennsylvania law protects your health care agent and
health care providers from any legal liability for following
in good faith your wishes as expressed in the form or by your
health care agent's direction. It does not otherwise change
professional standards or excuse negligence in the way your
wishes are carried out. If you have any questions about the
law, consult an attorney for guidance.
This form and explanation is not intended to take the
place of specific legal or medical advice for which you
should rely upon your own attorney and physician.
PART II
DURABLE HEALTH CARE POWER OF ATTORNEY
I,........................, of....................
County, Pennsylvania, appoint the person named below to be my
health care agent to make health and personal care decisions
for me.
Effective immediately and continuously until my death or
revocation by a writing signed by me or someone authorized to
make health care treatment decisions for me, I authorize all
health care providers or other covered entities to disclose
to my health care agent, upon my agent's request, any
information, oral or written, regarding my physical or mental
health, including, but not limited to, medical and hospital
records and what is otherwise private, privileged, protected
or personal health information, such as health information as
defined and described in the Health Insurance Portability and
Accountability Act of 1996 (Public Law 104-191, 110 Stat.
1936), the regulations promulgated thereunder and any other
State or local laws and rules. Information disclosed by a
health care provider or other covered entity may be
redisclosed and may no longer be subject to the privacy rules
provided by 45 C.F.R. Pt. 164.
The remainder of this document will take effect when and
only when I lack the ability to understand, make or
communicate a choice regarding a health or personal care
decision as verified by my attending physician. My health
care agent may not delegate the authority to make decisions.
MY HEALTH CARE AGENT HAS ALL OF THE FOLLOWING POWERS
SUBJECT TO THE HEALTH CARE TREATMENT INSTRUCTIONS THAT FOLLOW
IN PART III (CROSS OUT ANY POWERS YOU DO NOT WANT TO GIVE
YOUR HEALTH CARE AGENT):
1. To authorize, withhold or withdraw medical care and
surgical procedures.
2. To authorize, withhold or withdraw nutrition (food)
or hydration (water) medically supplied by tube through my
nose, stomach, intestines, arteries or veins.
3. To authorize my admission to or discharge from a
medical, nursing, residential or similar facility and to make
agreements for my care and health insurance for my care,
including hospice and/or palliative care.
4. To hire and fire medical, social service and other
support personnel responsible for my care.
5. To take any legal action necessary to do what I have
directed.
6. To request that a physician responsible for my care
issue a do-not-resuscitate (DNR) order, including an out-of-
hospital DNR order, and sign any required documents and
consents.
APPOINTMENT OF HEALTH CARE AGENT
I appoint the following health care agent:
Health Care Agent:.............................
(Name and relationship)
Address:.............................................
.....................................................
Telephone Number: Home............. Work............
E-mail:..................................................
IF YOU DO NOT NAME A HEALTH CARE AGENT, HEALTH CARE PROVIDERS
WILL ASK YOUR FAMILY OR AN ADULT WHO KNOWS YOUR PREFERENCES
AND VALUES FOR HELP IN DETERMINING YOUR WISHES FOR TREATMENT.
NOTE THAT YOU MAY NOT APPOINT YOUR DOCTOR OR OTHER HEALTH
CARE PROVIDER AS YOUR HEALTH CARE AGENT UNLESS RELATED TO YOU
BY BLOOD, MARRIAGE OR ADOPTION.
If my health care agent is not readily available or if my
health care agent is my spouse and an action for divorce
is filed by either of us after the date of this document,
I appoint the person or persons named below in the order
named. (It is helpful, but not required, to name
alternative health care agents.)
First Alternative Health Care Agent:.................
(Name and relationship)
Address:.............................................
.....................................................
Telephone Number: Home............. Work............
E-mail:..................................................
Second Alternative Health Care Agent:................
(Name and relationship)
Address:.............................................
.....................................................
Telephone Number: Home............. Work............
E-mail:..................................................
GUIDANCE FOR HEALTH CARE AGENT (OPTIONAL)
GOALS
If I have an end-stage medical condition or other extreme
irreversible medical condition, my goals in making medical
decisions are as follows (insert your personal priorities
such as comfort, care, preservation of mental function,
etc.):................ ......................................
.............................................................
.............................................................
.............................................................
SEVERE BRAIN DAMAGE OR BRAIN DISEASE
If I should suffer from severe and irreversible brain
damage or brain disease with no realistic hope of significant
recovery, I would consider such a condition intolerable and
the application of aggressive medical care to be burdensome.
I therefore request that my health care agent respond to any
intervening (other and separate) life-threatening conditions
in the same manner as directed for an end-stage medical
condition or state of permanent unconsciousness as I have
indicated below.
Initials..............I agree
Initials..............I disagree
PART III
HEALTH CARE TREATMENT INSTRUCTIONS IN THE EVENT
OF END-STAGE MEDICAL CONDITION
OR PERMANENT UNCONSCIOUSNESS
(LIVING WILL)
The following health care treatment instructions exercise
my right to make my own health care decisions. These
instructions are intended to provide clear and convincing
evidence of my wishes to be followed when I lack the capacity
to understand, make or communicate my treatment decisions:
IF I HAVE AN END-STAGE MEDICAL CONDITION (WHICH WILL
RESULT IN MY DEATH, DESPITE THE INTRODUCTION OR CONTINUATION
OF MEDICAL TREATMENT) OR AM PERMANENTLY UNCONSCIOUS SUCH AS
AN IRREVERSIBLE COMA OR AN IRREVERSIBLE VEGETATIVE STATE AND
THERE IS NO REALISTIC HOPE OF SIGNIFICANT RECOVERY, ALL OF
THE FOLLOWING APPLY (CROSS OUT ANY TREATMENT INSTRUCTIONS
WITH WHICH YOU DO NOT AGREE):
1. I direct that I be given health care treatment to
relieve pain or provide comfort even if such treatment might
shorten my life, suppress my appetite or my breathing, or be
habit forming.
2. I direct that all life prolonging procedures be
withheld or withdrawn.
3. I specifically do not want any of the following as
life prolonging procedures: (If you wish to receive any of
these treatments, write "I do want" after the treatment)
heart-lung resuscitation (CPR).......................
mechanical ventilator (breathing machine)............
dialysis (kidney machine)............................
surgery..............................................
chemotherapy.........................................
radiation treatment .................................
antibiotics..........................................
Please indicate whether you want nutrition (food) or
hydration (water) medically supplied by a tube into your
nose, stomach, intestine, arteries, or veins if you have an
end-stage medical condition or are permanently unconscious
and there is no realistic hope of significant recovery.
(Initial only one statement.)
TUBE FEEDINGS
........I want tube feedings to be given
OR
NO TUBE FEEDINGS
........I do not want tube feedings to be given.
HEALTH CARE AGENT'S USE OF INSTRUCTIONS
(INITIAL ONE OPTION ONLY).
........My health care agent must follow these
instructions.
OR
........These instructions are only guidance.
My health care agent shall have final say and may
override any of my instructions. (Indicate any
exceptions)......................................
.................................................
If I did not appoint a health care agent, these
instructions shall be followed.
LEGAL PROTECTION
Pennsylvania law protects my health care agent and health
care providers from any legal liability for their good faith
actions in following my wishes as expressed in this form or
in complying with my health care agent's direction. On behalf
of myself, my executors and heirs, I further hold my health
care agent and my health care providers harmless and
indemnify them against any claim for their good faith actions
in recognizing my health care agent's authority or in
following my treatment instructions.
ORGAN DONATION (INITIAL ONE OPTION ONLY.)
........I consent to donate my organs and tissues at the
time of my death for the purpose of transplant,
medical study or education. (Insert any
limitations you desire on donation of specific
organs or tissues or uses for donation of organs
and tissues.)....................................
.................................................
OR
........I do not consent to donate my organs or tissues
at the time of my death.
SIGNATURE
Having carefully read this document, I have signed it
this.......day of............., 20..., revoking all previous
health care powers of attorney and health care treatment
instructions.
.............................................................
(SIGN FULL NAME HERE FOR HEALTH CARE POWER OF ATTORNEY AND
HEALTH CARE TREATMENT INSTRUCTIONS)
WITNESS:.......................
WITNESS:.......................
Two witnesses at least 18 years of age are required by
Pennsylvania law and should witness your signature in each
other's presence. A person who signs this document on behalf
of and at the direction of a principal may not be a witness.
(It is preferable if the witnesses are not your heirs, nor
your creditors, nor employed by any of your health care
providers.)
NOTARIZATION (OPTIONAL)
(Notarization of document is not required by Pennsylvania
law, but if the document is both witnessed and notarized, it
is more likely to be honored by the laws of some other
states.)
On this..........day of .............., 20...., before me
personally appeared the aforesaid declarant and principal, to
me known to be the person described in and who executed the
foregoing instrument and acknowledged that he/she executed
the same as his/her free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and
affixed my official seal in the County of............., State
of.............. the day and year first above written.
............................... ........................
Notary Public My commission expires
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Last modified: November 27, 2007 |