Power of Attorney Form Instructions
1. Read the "Questions & Answers" section and the "Power of Attorney for Health Care " form.
2. If you have questions, talk a family member, your physician, pastor, attorney, hospital chaplain, care coordinator or social worker.
3. Discuss you health care preferences with the persons you have chosen to be your Health Care Agent and Alternate Health Care Agent.
4. To complete this form:
- fill in the day, month (i.e. January) and year of the day you are having the form witnessed
- fill in your legal name, address and date of birth
- fill in the names, relationships, addresses and telephone numbers of your health care agent and alternate health care agent
- check the "Yes-No" options on the form to indicate your desires about nursing home admission, community-based residential facility admission, and provision of a feeding tube.
- for the "Yes-No" option regarding health care decisions for pregnant women, you may write "Not Applicable" for a male or woman over child-bearing age.
- make any additions to your form in the "Statement of Desires, Special Provisions or Limitations Section."
5. Sign the completed form in the presence of your two witnesses and then have these witnesses sign the form. Witnesses cannot be:
- related to you through blood , marriage or adoption
- heirs to your estate
- directly financially responsible for your health care
- your health care providers (hospital chaplains and social workers may witness).
6. 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.
Make copies of the signed "Power of Attorney for Health Care" 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
7. Bring the "Power of Health Care" 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 Waukesha Memorial's Social Work Services at (262) 928-2300, Pastoral Care at (262) 928-2419, contact the Care Coordinator on your individual care unit or your local hospital.
Now, you can relax and enjoy the peace of mind that comes from knowing you have taken care of an important health issue.
It can be helpful to review examples of language to include in your Power of Attorney for Health Care "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.
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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.
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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, and no emergency medical services for life-threatening conditions.
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Organ Donations
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 or 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.
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Nursing Home Placement
1. Nursing home placement should be used only when home care alternatives have proved unworkable.
2. I only want to go to a nursing home if no other alternatives are available.
3. I would prefer not to be placed in a nursing home 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 nursing home rather than impose on my children.
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Preferred Physicians and/or Long-Term Care Facilities
1. If consistent with my medical treatment, I would prefer to be treated at Hospital or nursing home.
2. I prefer to be treated by Physician, Dr. _______________________, if at all possible.
3. My agent may not authorized treatment in ______________________ Hospital or treatment by Dr. ________________________ .
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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.
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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 orexperimental procedures if these procedures would only serve to prolong the dying process or maintain me in a vegetative state.
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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.)
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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 measure, including narcotics, to the extent necessary to alleviate all of my pain, regardless of the possibility of addiction or shortening of my life expectancy.
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Religious Preferences
1. I wish to be treated at a (Catholic, Lutheran, etc.) nursing home/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).
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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.
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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.
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