Fillable Printable Combined Medical Power of Attorney and Living Will - West Virginia

Combined Medical Power of Attorney and Living Will - West Virginia

STATE OF WEST VIRGINIA

COMBINED

MEDICAL POWER OF ATTORNEY

AND LIVING WILL

Dated: , 20

I, , hereby

(Insert your name and address)

appoint as my representative to act on my behalf to give, withhold or withdraw informed

consent to health care decisions in the event that I am not able to do so myself

The person I choose as my representative is:

(Insert the name, address, area code and telephone number of the person you wish to

designate as your representative)

The person I choose as my successor representative is:

If my representative is unable, unwilling or disqualified to serve, then I appoint

(Insert the name, address, area code and telephone number of the person you wish to

designate as your successor representative)

The Person I Want to Make Health Care Decisions

For Me When I Can't Make Them for Myself

And

The Kind of Medical Treatment I Want and Don't Want

If I Have a Terminal Condition or Am In a Persistent Vegetative State

Opt In

INITIAL box if you agree to have

this advance directive submitted to the WV

e-Directive

Registry, and released to treating health care providers.

Complete information to RIGHT.

REGISTRY FAX: 304-293-7442

Last Name/First/Middle

Address

City/State/Zip

Date of Birth (mm/dd/yyyy) ______/______/_________

Last 4 SSN ___ ___ ___ ___ Gender M___ F___

This appointment shall extend to, but not be limited to, health care decisions relating to

medical treatment, surgical treatment, nursing care, medication, hospitalization, care and

treatment in a nursing home or other facility, and home health care. The representative

appointed by this document is specifically authorized to be granted access to my medical

records and other health information and to act on my behalf to consent to, refuse or

withdraw any and all medical treatment or diagnostic procedures, or autopsy if my

representative determines that I, if able to do so, would consent to, refuse or withdraw

such treatment or procedures. Such authority shall include, but not be limited to,

decisions regarding the withholding or withdrawal of life-prolonging interventions.

I appoint this representative because I believe this person understands my wishes and

values and will act to carry into effect the health care decisions that I would make if I

were able to do so, and because I also believe that this person will act in my best interest

when my wishes are unknown. It is my intent that my family, my physician and all legal

authorities be bound by the decisions that are made by the representative appointed by

this document, and it is my intent that these decisions should not be the subject of review

by any health care provider or administrative or judicial agency.

It is my intent that this document be legally binding and effective and that this document

be taken as a formal statement of my desire concerning the method by which any health

care decisions should be made on my behalf during any period when I am unable to make

such decisions.

In exercising the authority under this medical power of attorney, my representative shall

act consistently with my special directives or limitations as stated below.

I am giving the following SPECIAL DIRECTIVES OR LIMITATIONS ON THIS

POWER: (Comments about tube feedings, breathing machines, cardiopulmonary

resuscitation, dialysis, mental health treatment, funeral arrangements, autopsy, and organ

donation may be placed here. My failure to provide special directives or limitations does

not mean that I want or refuse certain treatments).

1. If I am very sick and not able to communicate my wishes for myself and I am certified

by one physician who has personally examined me, to have a terminal condition or to be

in a persistent vegetative state (I am unconscious and am neither aware of my

environment nor able to interact with others,) I direct that life-prolonging medical

intervention that would serve solely to prolong the dying process or maintain me in a

persistent vegetative state be withheld or withdrawn. I want to be allowed to die naturally

and only be given medications or other medical procedures necessary to keep me

comfortable. I want to receive as much medication as is necessary to alleviate my pain.

2. Other directives:

THIS MEDICAL POWER OF ATTORNEY SHALL BECOME EFFECTIVE ONLY

UPON MY INCAPACITY TO GIVE, WITHHOLD OR WITHDRAW INFORMED

CONSENT TO MY OWN MEDICAL CARE.

_______________________________________ DATE _________________

Signature of the Principal

I did not sign the principal's signature above. I am at least eighteen years of age and am

not related to the principal by blood or marriage. I am not entitled to any portion of the

estate of the principal or to the best of my knowledge under any will of the principal or

codicil thereto, or legally responsible for the costs of the principal's medical or other care.

I am not the principal's attending physician, nor am I the representative or successor

representative of the principal.

Witness _______________________________ DATE _________________

STATE OF ___________________________________

COUNTY OF _________________________________

I, ______________________, a Notary Public of said County, do certify

that_____________________, as principal, and ____________________ and

____________________, as witnesses, whose names are signed to the writing above

bearing date on the _____ day of ______________, 20___,

have this day acknowledged the same before me.

Given under my hand this _______ day of ___________________, 20___.

My commission expires:_______________________________

______________________________________

Signature of Notary Public