Durable Power Of Attorney For Health Care Decisions Page 5
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12Under this authority, "best interest" means that the benefits to you resulting from a
treatment outweigh the burdens to you resulting from that treatment after assessing
(A) the effect of the treatment on your physical, emotional, and cognitive
functions;
(B) the degree of physical pain or discomfort caused to you by the treatment or the
withholding or withdrawal of treatment;
(C) the degree to which your medical condition, the treatment, or the withholding
or withdrawal of treatment, results in a severe and continuing impairment;
(D) the effect of the treatment on your life expectancy;
(E) your prognosis for recovery, with and without the treatment;
(F) the risks, side effects, and benefits of the treatment or the withholding of
treatment; and
(G) your religious beliefs and basic values, to the extent that these may assist in
determining benefits and burdens.
(3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE.
Except in the case of mental illness, 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.
In the case of mental illness, unless I mark the following box, my agent's authority
becomes effective when a court determines I am unable to make my own decisions, or, in an
emergency, if my primary physician or another health care provider determines I am unable to
make my own decisions.
If I mark this box [ ], my agent's authority to make health care decisions for me
takes effect immediately.
(4) AGENT'S OBLIGATION.
My agent shall make health care decisions for me in accordance with this durable
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.
(5) NOMINATION OF GUARDIAN.
If a guardian of my person needs to be appointed for me by a court, I nominate the
agent designated in this form. If that agent is not willing, able, or reasonably available to act
as guardian, I nominate the alternate agents whom I have named under (1) above, in the order
designated.
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