Pennsylvania Durable Health Care Power of Attorney Form 1
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Commonwealth of Pennsylvania – Act 169 of 2006
Combined Living Will & Health Care Power of Attorney
Example Form from Pennsylvania Act 169 of 2006
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 agent’s 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.
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