Sample Sample: Appendix B1

APPENDIX B1
Health Care Proxy
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I, ____________, hereby appoint _______________,

_______, as my health
cisions for me, exc
care agent, to make any and all health care
except to
re decisions
the extent I state otherwise. This Health
effect in
roxy shall take effe
ealth Care Proxy
wn health care decisions.
the event I become unable to make my own
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a
I make the following

my
en declaration as a set of ins
owing written
instructions to m
health care agent, and, furthermore, as a statement of my wishes
wishe and
intentions
g future care:
care
ions regarding
substantia and irreversible

In the event that I sustain substantial
loss of mental capacity, and there is doubt as to whether
treatment is to be administered to
life-sustain
or not life-sustaining
treatm
care agent, and all physicians,
me, I direct that my health
he
h
hospitals
and oother health care providers, abide by my
decision that my life not be artificially extended by
mechanical means, and to resolve any such doubt in
me
favor of withholding or withdrawing life-sustaining
treatment.
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Without limiting the generality of the unrestricted

icted
authority conferred by my health care proxy,
y,, I affirm
that I do not draw a distinction between
utrition and
en nutrition
hydration and any other kind of life-sustaining
ife-sustaining treatment,
and I expressly authorize my health care
re agent, in his or
her unrestricted discretion,
ect that nutrition and
retion, to direct
hydration be withdrawn orr withheld from me when m
my
agent believes
elieves that it is in my best interest to do so.
Furthermore,
urthermore, I hereby state my instructions, and direct
that my health care agent communicate said instructions,
instru
that if there is no reasonable hope that I will regain
treatment
(including,
lifemental capacity, all life-sustaining
tre
of nourishment and
without limitation, administration
administrat
uids intravenously
intrave
liquids
or by tubes connected to my
tract) shall
digest
digestive
sha be withheld or withdrawn, whether
or not I am conscious or free from pain, and that no
cardiopulmonary resuscitation shall thereafter be
cardiop
administered to me if I sustain cardiac or pulmonary
arrest. I recognize that when life-sustaining treatment is
withheld or withdrawn from me, I will surely die of
m
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dehydration and malnutrition within days or weeks. I

further state and direct my said health care agent to
communicate my instructions that all available
vailabl
medication for the relief of pain and for my comfort
shall be administered to me after
fterr life-sustaining
treatment is withheld or withdrawn
wn even if I am rendered
unconscious and my life is shortenedd thereby. I also wish
to donate any needed
eded organss or tissues to an eligible
donee organization
on my death.
death
ization upon
I have made this instrument while in ful
full command of
o
my faculties in order to state my intentions, and to
in
writt instructions,
furnish my health care agent with written
i
clear and convincing language, oof the strength and
urability of my determination
durability
determinatio to forgo life-sustaining
described herein, and in
treatment in the circumstances
circum
whereby my health care agent
cir
any circumstances
circumstanc
determines that I would wish to do so. It is my firm and
settled conviction that I am entitled to forgo such
settle
treatment in the exercise of my right to determine the
course of my medical treatment, and my belief that my
right to forgo such treatment is paramount to any
responsibility of any health care provider or the authority
rity
of any court or judge to attempt to force unwanted
medical care upon me.
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I direct my agent to make health care

ns in accordance with my
are decisions
wishes as stated above, or as otherwise
own to him or her. I also direct
herwise known
my agent to abide by any limitations on his or her authority as stated above
a
or as otherwise known
wn to him or her.
m
a
In the event the person I appoint above is unable,

u
uunwilling or
unavailable to act as my health care agent, I hereby appoint
as my health
a
app
care agent __________________.
_____________.
__________________
I understand that, unless

unles I revoke it, this proxy shall remain in effect
indefinitely.
definitely.
ndefinitely.
Signed
th ______ day of ________, ____.
gnedd this
________________________
Name of Principal
I declare that the person who signed or asked another to sign this
document is personally known to me, that he or she signed or asked
another to sign this document in my presence, and that he or she
sh appears
to be of sound mind and under no duress, fraud or undue influence.
influen I am
not the person appointed as agent by this document.
ent.
ument.
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First Witness:_______________________________________________
________________
_____________________________
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a
Address: _________________________________________________
________________________
________________________________________
_________________________________________________
_______________________
_________________________________________
Second Witness:____________________________________________
Witness:_________________________
Witness:______________________________
Address: __________________________
_________________________________________________
_________________
_________________________________________________
_____
_____________
Attorney:
_________________________________________________
Attorne _______
Address:
Addres _________________________________________________
Tel.:
_________________________________________________
m
a
e
l
p

Sample Sample: Appendix B1

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APPENDIX B1

Health Care Proxy

I, , hereby appoint ___,

I make the following

substantia and irreversible

Without limiting the generality of the unrestricted

dehydration and malnutrition within days or weeks. I

I direct my agent to make health care

In the event the person I appoint above is unable,

I understand that, unless

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