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Pennsylvania Durable Health Care Power of Attorney Form 2

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Pennsylvania Durable Health Care Power of Attorney Form 2 Page 2
Pennsylvania Durable Health Care Power of Attorney Form 2
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 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 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 eectuating 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 dened 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 dierent 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.):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Severe Brain Damage or Brain Disease:
If I should suer from severe and irreversible brain damage or brain disease which has made me unable to
recognize or interact with other people and from which my doctors believe there is no realistic hope of signicant
recovery, I would consider such a condition unacceptable and the application of aggressive medical care to extend
my life in this condition to be burdensome. I therefore request that my health care agent respond to any 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. Keep me comfortable and allow natural death to occur.
Initials ________ I disagree. Use all medical treatment that is needed to keep me alive.
ADVANCE HEALTH CARE DIRECTIVE PAGE 2
APPROVED BY: Allegheny County Bar Association
Pennsylvania Durable Health Care Power of Attorney Form 2