Power of Attorney for Health Care Form Instructions

  1. Read the "Questions & Answers" section and the "Power of Attorney for Health Care" form.
     
  2. If you have questions, talk to a family member, your physician, pastor, attorney, hospital chaplain, care coordinator or social worker.
     
  3. Discuss your health care preferences with the person(s) you have chosen to be your Health Care Agent and Alternate Health Care Agent.
     
  4. Have your agent and alternate agent sign the form after you have discussed it thoroughly with them. They do not need to be present when the witnesses sign. The form can be mailed to the agents for their signatures.
     
  5. After you complete the document, keep the original in a safe place that you can access easily. A photo or fax copy is as legally valid as the original. Make copies of the signed Power of Attorney for Health Care (POAHC) form and distribute as follows:
  • Original to your agent
  • 1 copy in a safe place at home

  • 1 copy to your alternate

  • 1 copy to your physician

  • 1 copy to your hospital

  • 1 copy to each close family member or friend

6. Bring the POAHC form with you when you are admitted to the hospital. Your nurse will make a copy of this document, return your document to you and place a copy in your medical record. On any future admissions to the hospital, your nurse will review the copy of the document in your medical record with you.

If you have questions regarding this procedure, you may call 262-928-2450 or contact the care coordinator on your individual care unit or your local hospital.

You can find comfort in knowing that you have taken care of an important health issue.

It can be helpful to review examples of language to include in your POAHC "Special Provision" section. (The staff at the Center for Public Representation in Madison, WI uses these statements when they assist individuals.) Click a heading to see sample statements regarding:

We encourage you to spend time in considering what wishes you want to specify and encourage you to feel comfortable in expressing your wishes clearly in the "Special Provision" section of the document. These examples are only tools to use in developing your ideas and wishes.


The Removal of Life-Sustaining Procedures

  1. Life-sustaining procedures, including non-orally ingested nutrition and hydration, may be withheld or withdrawn when my agent agrees to it.
  2. I do not wish to be kept alive by life-sustaining procedures. My health care agent may determine the timing of the discontinuation of any and all treatment.
  3. I do not want to be kept alive on artificial life-sustaining equipment, including non-orally ingested nutrition or hydration, if these procedures would only serve to prolong the dying process or maintain me in a persistent vegetative state.
  4. Non-orally ingested nutrition or hydration should only be withdrawn or withheld if my condition is stable and I am not expected to improve.
  5. I trust my agent(s) to decide the timing of the continuation and/or discontinuation of any or all treatment and/or procedures.

[Back to Top]

The Continued Use of Life-Sustaining Equipment and Procedures

  1. I wish that all life-sustaining equipment and non-oral nutrition and hydration be used for as long as possible.
  2. I wish that any medical treatment that will prolong my life be used, including chemotherapy, radiation treatment, kidney dialysis, and non-oral nutrition and hydration.
  3. I want any and all medical treatment used that will keep me comfortable (even if it results in addiction).
  4. I trust my agent(s) to decide the timing of the continuation and/or discontinuation of any or all treatment and/or procedures.

[Back to Top]

Resuscitation and Other Heroic Measures

  1. Do not continue life-sustaining procedures if my condition is stable and full independent functional capacity is not expected to return.
  2. If death is imminent, I want respiration discontinued and no CPR.
  3. I wish no heroic measures, including 9-1-1, and no emergency medical services for life-threatening conditions.

[Back to Top]

Organ Donation

  1. My agent may not donate my organs under any circumstances.
  2. I prefer not to participate in any organ donation programs.
  3. I would like to donate my body, organs, medical tissue or blood that can be used.
  4. My agent may authorize organ donations and autopsy.
  5. I wish to donate my entire body to medical research.

[Back to Top]

Skilled Nursing Facility Placement

  1. Skilled nursing facility placement should be used only when home care alternatives have proved unworkable.
  2. I only want to go to a skilled nursing facility if no other alternatives are available.
  3. I would prefer not to be placed in a skilled nursing facility and/or community-based residential facility unless it is absolutely necessary and all community resources have been exhausted.
  4. I prefer to stay in my own home as long as possible.
  5. I prefer to go to a skilled nursing facility rather than impose on my children.

[Back to Top]

Preferred Physicians and/or Long-Term Care Facilities

  1. If consistent with my medical treatment, I would prefer to be treated at  ______________________ Hospital or  ______________________ skilled nursing facility .
  2. I prefer to be treated by, Dr. _______________________, if at all possible.
  3. My agent may not authorize treatment in ______________________ Hospital or treatment by Dr. ________________________ .

[Back to Top]

Revocation of Prior Living Wills

  1. I revoke my prior executed living will executed on _________ (date, if available).
  2. I authorize my prior health care agent to make all decisions not already covered in my living will so as to cover those conditions where I am not terminally ill and/or my death is not imminent, as well as all procedures not covered by my living will.
  3. I authorize my health care agent to make all decisions allowed in a living will, with the authority to discontinue or refuse any and all life-sustaining procedures.

[Back to Top]

Use Of Experimental Treatment, Including Considerations For Patients Who Are HIV Positive

  1. I wish my health care agent to authorize all available experimental drugs and treatment which are supervised by a licensed health care professional.
  2. I wish no AZT, experimental drugs, experimental procedures, antibiotics, etc., when my condition is stable and full independent functional capacity is not expected to return.
  3. I wish no AZT or other experimental drugs or experimental procedures if these procedures would only serve to prolong the dying process or maintain me in a vegetative state.

[Back to Top]

Abortion

  1. My health care agent may not authorize an abortion under any circumstances.
  2. My health care agent may authorize an abortion only if it is necessary to save my life.
  3. My health care agent may only authorize an abortion in the case of incest or rape or if necessary to save my life.
  4. My health care agent has the authority to authorize an abortion.
  5. My health care agent may authorize an abortion but only after consulting _______________ (spouse, religious advisor, etc.)

[Back to Top]

Alleviation of Pain

  1. My desire is that pain should be alleviated to the extent possible, even though this may lead to physical damage, addiction, or may hasten death.
  2. I authorize my health care agent to authorize all comfort measures, including narcotics, to the extent necessary to alleviate all of my pain, regardless of the possibility of addiction or shortening of my life expectancy.

[Back to Top]

Religious Preferences

  1. I wish to be treated at a (Catholic, Lutheran, etc.) skilled nursing facility/hospital if at all possible.
  2. I wish to have religious services provided to me once a week, even if I am unable to fully participate.
  3. In the event of a terminal or life threatening situation, I wish to receive the last rites of _____________ (name of religion).

[Back to Top]

Visitation

  1. I wish that only _______ (list names of individuals) be allowed to visit me.
  2. I do not want any visitors during my incapacitation, other than my agent, alternate agent or _______________ (list people).
  3. I want all visitors to be able to visit with me, unless inconsistent with my medical treatment.
  4. I wish that only _____________ (list names of individuals) be permitted to visit me while I am incapacitated.

[Back to Top]

Consultation and Information Sharing

  1. I would like my health care agent to consult with _______________ before making any of my health care decisions.
  2. I wish my health care agent to keep my children informed of my health care condition.
  3. My health care agent need only consult with ___________ before making any of my health care decisions and no one else.
  4. I do not want _________________ (list names of individuals) to be informed of the nature of my health care condition.
  5. I authorize my health care agent to disclose my condition and prognosis only to my health care providers and _______________________ (list names of individuals),
  6. I would like my agent to keep informed of my condition.

[Back to Top]


www.ProHealthCare.org
http://www.prohealthcare.org/patient-guest-services-advance-directives-power-of-attorney-form-instructions.aspx