North Carolina Statutory Form Health Care Power Of Attorney Page 3
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11A. To request, review, and receive any information, verbal or written, regarding my
physical or mental health, including, but not limited to, medical and hospital records, and
to consent to the disclosure of this information.
B. To employ or discharge my health care providers.
C. To consent to and authorize my admission to and discharge from a hospital, nursing or
convalescent home, or other institution.
D. To consent to and authorize my admission to and retention in a facility for the care or
treatment of mental illness.
E. To consent to and authorize the administration of medications for mental health
treatment and electroconvulsive treatment (ECT) commonly referred to as "shock
treatment.”
F. To give consent for, to withdraw consent for, or to withhold consent for, X ray,
anesthesia, medication, surgery, and all other diagnostic and treatment procedures ordered
by or under the authorization of a licensed physician, dentist, or podiatrist. This
authorization specifically includes the power to consent to measures for relief of pain.
G. To authorize the withholding or withdrawal of life-sustaining procedures when and if
my physician determines that I am terminally ill, permanently in a coma, suffer severe
dementia, or am in a persistent vegetative state. Life-sustaining procedures are those
forms of medical care that only serve to artificially prolong the dying process and may
include mechanical ventilation, dialysis, antibiotics, artificial nutrition and hydration, and
other forms of medical treatment which sustain, restore or supplant vital bodily functions.
Life-sustaining procedures do not include care necessary to provide comfort or alleviate
pain.
I DESIRE THAT MY LIFE NOT BE PROLONGED BY LIFE-SUSTAINING
PROCEDURES IF I AM TERMINALLY ILL, PERMANENTLY IN A COMA, SUFFER
SEVERE DEMENTIA, OR AM IN A PERSISTENT VEGETATIVE STATE.
H. To exercise any right I may have to make a disposition of any part or all of my body for
medical purposes, to donate my organs, to authorize an autopsy, and to direct the
disposition of my remains.
I. To take any lawful actions that may be necessary to carry out these decisions, including
the granting of releases of liability to medical providers.
4. Special provisions and limitations.
(Notice: The above grant of power is intended to be as broad as possible so that your
health care agent will have authority to make any decisions you could make to obtain or
terminate any type of health care. If you wish to limit the scope of your health care agent's
powers, you may do so in this section.)
A. In exercising the authority to make health care decisions on my behalf, the authority of
my health care agent is subject to the following special provisions and limitations (Here you
may include any specific limitations you deem appropriate such as: your own definition of
when life-sustaining treatment should be withheld or discontinued, or instructions to refuse
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