Health-Care Power Of Attorney Form
Download a blank fillable Health-Care Power Of Attorney Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Health-Care Power Of Attorney Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Nebraska State Unit on Aging
Surrogate Decision Making in Nebraska
Instructions
Health-Care Power of Attorney Form
How to use this form:
•
Read this guide carefully.
•
Read the instructions on these pages.
•
Neatly print or type all information except where a signature is required.
Paragraph 1
Neatly print or type your name and the name, address and telephone number of your attorney-in-fact
and successor attorney-in-fact.
Paragraphs 2, 3, and 4
These sections are where you must indicate what specific instructions you have, if any, about future
health care.
If you fill in “none” or “no limitations,” remember that your attorney-in-fact will have authority to
make all lawful health-care decisions except those involving the withholding or withdrawal of life-
sustaining treatment. If you want to have life-sustaining treatment withheld or withdrawn, you must
indicate your wish in Paragraph 3. If you want to have artificial nutrition and hydration withheld or
withdrawn, you must indicate your wish in Paragraph 4.
Paragraph 3
Some examples of life-sustaining treatment are:
•
mechanical respirators which aid or replace normal breathing
•
cardiopulmonary resuscitation (CPR)
•
kidney dialysis
•
antibiotic therapy to treat or prevent infections
•
major surgery
If there are specific types of life-sustaining treatment you want or don’t want, you may describe your
wishes as follows:
“If I am in a persistent vegetative state, I do not want to be put on a respirator”
or
“If I am in a terminal condition, I do not want life-sustaining treatment.”
For more samples of wording you can use, see the Appendix.
26
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal