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The Illinois health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.
treatment or procedure, even though my death may ensue. My agent shall have the same access
to my medical records that I have, including the right to disclose the contents to others. My agent
shall also have full power to authorize an autopsy and direct the disposition of my remains.
Effective upon my death, my agent has the full power to make an anatomical gift of the
following (initial one):
.... Any organ.
.... Specific organs: .....................................................
(THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS POSSIBLE SO
THAT YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY DECISION YOU
COULD MAKE TO OBTAIN OR TERMINATE ANY TYPE OF HEALTH CARE,
INCLUDING WITHDRAWAL OF FOOD AND WATER AND OTHER LIFE-SUSTAINING
MEASURES, IF YOUR AGENT BELIEVES SUCH ACTION WOULD BE CONSISTENT
WITH YOUR INTENT AND DESIRES. IF YOU WISH TO LIMIT THE SCOPE OF YOUR
AGENT’S POWERS OR PRESCRIBE SPECIAL RULES OR LIMIT THE POWER TO MAKE
AN ANATOMICAL GIFT, AUTHORIZE AUTOPSY OR DISPOSE OF REMAINS, YOU
MAY DO SO IN THE FOLLOWING PARAGRAPHS.)
2.The powers granted above shall not include the following powers or shall be subject to the
following rules or limitations (here you may include any specific limitations you deem
appropriate, such as: your own definition of when life-sustaining measures should be withheld; a
direction to continue food and fluids or life-sustaining treatment in all events; or instructions to
refuse any specific types of treatment that are inconsistent with your religious beliefs or
unacceptable to you for any other reason, such as blood transfusion, electro-convulsive therapy,
amputation, psychosurgery, voluntary
admission to a mental institution, etc.): ....................................
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