Pennsylvania Durable Health Care Power of Attorney Form 2
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HEALTH CARE AGENT POWERS
My health care agent has all of the following powers subject to the health care treatment instructions that follow
in PART II (cross out any powers you do not want to give your health care agent):
1.To authorize, withhold orwithdrawmedical care and surgical procedures.
2.Toauthorize, 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 obtain health insurance for my care, including hospice
and/or palliative care.
4. To hire and re medical, social service and other support personnel responsible for my care.
5. To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order,
including an out-of-hospital DNR order, a Physician Order for Life-Sustaining Treatment
(POLST) or other order eectuating my wishes and to sign any required documents and consents.
6. To carry out my wishes regarding funeral, burial, and the disposition of my body.
7. To take any legal action necessary to do what I have directed.
e foregoing powers shall apply with respect to both physical and mental health care as dened under Section
5422 of the Probate, Estates and Fiduciaries Code. I do not have a mental health care power of attorney or
declaration under Chapter 58 of the Probate, Estates and Fiduciaries Code. (Modify or use a dierent form as
needed if you have a mental health care power of attorney or declaration)
I nominate my health care agent as the guardian of my person, should such a guardian be necessary.
GUIDANCE FOR HEALTH CARE AGENT (OPTIONAL) Goals (Leave Blank if Goals Adequately
Expressed in the Rest of this Document):
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 life for as
long as possible, preservation of mental function, care at home, etc.):