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Fillable Printable Combined Living Will and Health Care Power of Attorney - Pennsylvania

Fillable Printable Combined Living Will and Health Care Power of Attorney - Pennsylvania

Combined Living Will and Health Care Power of Attorney - Pennsylvania

Combined Living Will and Health Care Power of Attorney - Pennsylvania

Commonwealth of Pennsylvania – Act 169 of 2006
Combined Living Will & Health Care Power of Attorney
Example Form from Pennsylvania Act 169 of 2006
PART I
Introductory Remarks on Health Care Decision Making
You have the right to decide the type of health care you want.
Should you become unable to understand, make or communicate decisions about medical care, your wishes for
medical treatment are most likely to be followed if you express those wishes in advance by:
(1) naming a health care agent to decide treatment for you; and
(2) giving health care treatment instructions to your health care agent or health care provider.
An advance health care directive is a written set of instructions expressing your wishes for medical treatment. It may
contain a health care power of attorney, where you name a person called a “health care agent” to decide treatment
for you, and a living will, where you tell your health care agent and health care providers your choices regarding the
initiation, continuation, withholding or withdrawal of life-sustaining treatment and other specific directions.
You may limit your health care agents involvement in deciding your medical treatment so that your health care
agent will speak for you only when you are unable to speak for yourself or you may give your health care agent the
power to speak for you immediately. This combined form gives your health care agent the power to speak for you
only when you are unable to speak for yourself. A living will cannot be followed unless your attending physician
determines that you lack the ability to understand, make or communicate health care decisions for yourself, and you
are either permanently unconscious or you have an end-stage medical condition, which is a condition that will result
in death despite the introduction or continuation of medical treatment. You, and not your health care agent, remain
responsible for the cost of your medical care.
If you do not write down your wishes about your health care in advance, and if later you become unable to
understand, make or communicate these decisions, those wishes may not be honored because they may remain
unknown to others.
A health care provider who refuses to honor your wishes about health care must tell you of its refusal and help to
transfer you to a health care provider who will honor your wishes.
You should give a copy of your advance health care directive (a living will, health care power of attorney or a
document containing both) to your health care agent, your physicians, family members and others whom you expect
would likely attend to your needs if you become unable to understand, make or communicate decisions about
medical care. If your health care wishes change, tell your physician and write a new advance health care directive to
replace your old one. It is important in selecting a health care agent that you choose a person you trust who is likely
to be available in a medical situation where you cannot make decisions for yourself. You should inform that person
that you have appointed him or her as your health care agent and discuss your beliefs and values with him or her so
that your health care agent will understand your health care objectives.
You may wish to consult with knowledgeable, trusted individuals such as family members, your physician or clergy
when considering an expression of your values and health care wishes. You are free to create your own advance health
care directive to convey your wishes regarding medical treatment. The following form is an example of an advance
health care directive that combines a health care power of attorney with a living will.
Commonwealth of Pennsylvania – Act 169 of 2006
Notes About the Use of this Form
If you decide to use this form or create your own advance health care directive, you should consult with your
physician and your attorney to make sure that your wishes are clearly expressed and comply with the law.
If you decide to use this form but disagree with any of its statements, you may cross out those statements.
You may add comments to this form or use your own form to help your physician or health care agent decide your
medical care.
This form is designed to give your health care agent broad powers to make health care decisions for you whenever
you cannot make them for yourself. It is also designed to express a desire to limit or authorize care if you have an
end-stage medical condition or are permanently unconscious. If you do not desire to give your health care agent
broad powers, or you do not wish to limit your care if you have an end-stage medical condition or are permanently
unconscious, you may wish to use a different form or create your own. You should also use a different form if you
wish to express your preferences in more detail than this form allows or if you wish for your health care agent to
be able to speak for you immediately. In these situations, it is particularly important that you consult with your
attorney and physician to make sure that your wishes are clearly expressed.
This form allows you to tell your health care agent your goals if you have an end-stage medical condition or other
extreme and irreversible medical condition, such as advanced Alzheimers disease. Do you want medical care applied
aggressively in these situations or would you consider such aggressive medical care burdensome and undesirable?
You may choose whether you want your health care agent to be bound by your instructions or whether you want
you health care agent to be able to decide at the time what course of treatment the health care agent thinks most
fully reflects your wishes and values.
If you are a woman and diagnosed as being pregnant at the time a health care decision would otherwise be made
pursuant to this form, the laws of this Commonwealth prohibit implementation of that decision if it directs that
life-sustaining treatment, including nutrition and hydration, be withheld or withdrawn from you, unless your
attending physician and an obstetrician who have examined you certify in your medical record that the life-
sustaining treatments:
will not maintain you in such a way as to permit the continuing development and live birth of the unborn child;
will be physically harmful to you; or
will cause pain to you that cannot be alleviated by medication.
A physician is not required to perform a pregnancy test on you unless the physician has reason to believe that you
may be pregnant.
Pennsylvania law protects your health care agent and health care providers from any legal liability for following in
good faith your wishes as expressed in the form or by your health care agents direction. It does not otherwise change
professional standards or excuse negligence in the way your wishes are carried out. If you have any questions about
the law, consult an attorney for guidance.
This form and explanation is not intended to take the place of specific legal or medical advice for which you should
rely upon your own attorney and physician.
Commonwealth of Pennsylvania – Act 169 of 2006
PART II
Durable Health Care Power of Attorney
I ____________________________, of _____________________________ County,
Pennsylvania, appoint the person named below to be my health care agent to make health and personal care
decisions for me.
Effective immediately and continuously until my death or revocation by a writing signed by me or someone
authorized to make health care treatment decisions for me, I authorize all health care providers or other covered
entities to disclose to my health care agent, upon my agents request, any information, oral or written, regarding
my physical or mental health, including, but not limited to, medical and hospital records and what is otherwise
private, privileged, protected or personal health information, such as health information as defined and described
in the Health Insurance Portability and Accountability Act of 1996 (Public Law 104—191, 110 Stat. 1936), the
regulations promulgated thereunder and any other State or local laws and rules. Information disclosed by a health
care provider or other covered entity may be redisclosed and may no longer be subject to the privacy rules provided
by 45 C.F.R. Pt. 164.
The remainder of this document will take effect when and only when I lack the ability to understand, make or
communicate a choice regarding a health or personal care decision as verified by my attending physician. My health
care agent may not delegate the authority to make decisions.
My health care agent has all of the following powers subject to the health care treatment instructions that follow in
Part III (cross out any powers you do not want to give your health care agent):
1. To authorize, withhold or withdraw medical care and surgical procedures.
2. To authorize, withhold or withdraw nutrition (food) or hydration (water) medically supplied
by tube through my nose, stomach, intestines, arteries or veins.
3. To authorize my admission to or discharge from a medical, nursing, residential or similar
facility and to make agreements for my care and health insurance for my care, including
hospice and/or palliative care.
4. To hire and fire medical, social service and other support personnel responsible for my care.
5. To take any legal action necessary to do what I have directed.
6. To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order,
including an out-of-hospital DNR order, and sign any required documents and consents.
Appointment of Health Care Agent
I appoint the following health care agent:
Health Care Agent (Name and relationship):
Address:
Telephone Number: Home Work
E-Mail:
Commonwealth of Pennsylvania – Act 169 of 2006
If you do not name a health care agent, health care providers will ask your family or an adult who knows your
preferences and values for help in determining your wishes for treatment. Note that you may not appoint your
doctor or other health care provider as your health care agent unless related to you by blood, marriage or adoption.
If my health care agent is not readily available or if my health care agent is my spouse and an action for divorce
is filed by either of us after the date of this document, I appoint the person or persons named below in the order
named. (It is helpful, but not required, to name alternative health care agents.)
First Alternative Health Care Agent (name and relationship):
Address:
Telephone Numbers: Home Work
E-Mail:
Second Alternative Health Care Agent (name and relationship):
Address:
Telephone Number: Home Work
E-Mail:
Guidance for Health Care Agent (optional)
Goals
If I have an end-stage medical condition or other extreme irreversible medical condition, my goals in making
medical decisions are as follows (insert your personal priorities such as comfort, care, preservation of mental
function, etc.):
Severe Brain Damage or Brain Disease
If I should suffer from severe and irreversible brain damage or brain disease with no realistic hope of significant
recovery, I would consider such a condition intolerable and the application of aggressive medical care to be
burdensome. I therefore request that my health care agent respond to any intervening (other and separate) life-
threatening conditions in the same manner as directed for an end-stage medical condition or state of permanent
unconsciousness as I have indicated below.
Initials I agree
Initials I disagree
Commonwealth of Pennsylvania – Act 169 of 2006
PART III
Health Care Treatment Instructions in the Event of End-Stage
Medical Condition or Permanent Unconsciousness
(Living Will)
The following health care treatment instructions exercise my right to make my own health care decisions. These
instructions are intended to provide clear and convincing evidence of my wishes to be followed when I lack the
capacity to understand, make or communicate my treatment decisions:
If I have an end-stage medical condition (which will result in my death, despite the introduction or continuation of
medical treatment) or am permanently unconscious such as an irreversible coma or an irreversible vegetative state
and there is no realistic hope of significant recovery, all of the following apply (cross out any treatment instructions
with which you do not agree):
1. I direct that I be given health care treatment to relieve pain or provide comfort even if such
treatment might shorten my life, suppress my appetite or my breathing, or be habit forming.
2. I direct that all life-prolonging procedures be withheld or withdrawn.
3. I specifically do not want any of the following as life prolonging procedures: (If you wish to
receive any of these treatments, write “I do want” after the treatment)
heart-lung resuscitation (CPR)
mechanical ventilator (breathing machine)
dialysis (kidney machine)
surgery
chemotherapy
radiation treatment
antibiotics
Please indicate whether you want nutrition (food) or hydration (water) medically supplied by a tube into your nose,
stomach, intestine, arteries, or veins if you have an end-stage medical condition or are permanently unconscious and
there is no realistic hope of significant recovery. (Initial only one statement).
Tube Feedings
I want tube feedings to be given
OR
No Tube Feedings
I do not want tube feedings to be given.
Commonwealth of Pennsylvania – Act 169 of 2006
Health Care Agent’s Use of Instructions
(Initial one option only)
My health care agent must follow these instructions.
OR
These instructions are only guidance. My health care agent shall have final say and may override any
of my instructions. (Indicate any exceptions)
If I did not appoint a health care agent, these instructions shall be followed.
Legal Protection
Pennsylvania law protects my health care agent and health care providers from any legal liability for their good faith
actions in following my wishes as expressed in this form or in complying with my health care agent’s direction. On
behalf of myself, my executors and heirs, I further hold my health care agent and my health care providers harmless
and indemnify them against any claim for their good faith actions in recognizing my health care agents authority or
in following my treatment instructions.
Organ Donation (Inital one option only.)
I consent to donate my organs and tissues at the time of my death for the purpose of transplant,
medical study or education. (Insert any limitations you desire on donation of specific organs or
tissues or uses for donation of organs and tissues.)
OR
I do not consent to donate my organs or tissues at the time of my death.
Signature
Having carefully read this document, I have signed it this day of
, 20 , revoking all previous health care powers of attorney and health care
treatment instructions.
(Sign full name here for health care power of attorney and health care treatment instructions.)
WITNESS:
WITNESS:
Commonwealth of Pennsylvania – Act 169 of 2006
Two witnesses at least 18 years of age are required by Pennsylvania law and should witness your signature in each
others presence. A person who signs this document on behalf of and at the direction of a principal may not be a
witness. (It is preferable if the witnesses are not your heirs, nor your creditors, nor employed by any of your health
care providers.)
Notarization (optional)
(Notarization of document is not required by Pennsylvania law, but if the document is both witnessed and notarized,
it is more likely to be honored by the laws of some other states.)
On this day of , 20 , before me personally appeared
the aforesaid declarant and principal, to me known to be the person described in and who executed the foregoing
instrument and acknowledged that he/she executed the same as his/her free act and deed.
In witness whereof, I have hereunto set my hand and affixed my official seal in the County of
, State of the day and year first above written.
Notary Public My commission expires
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