WILLIAM DONALD SCHAEFER, Governor                            Ch. 372

B. EMPLOY AND DISCHARGE MY HEATH CARE PROVIDERS;

C. AUTHORIZE MY ADMISSION TO OR DISCHARGE FROM (INCLUDING
TRANSFER TO ANOTHER FACILITY) ANY HOSPITAL, HOSPICE, NURSING HOME,
ADULT HOME, OR OTHER MEDICAL CARE FACILITY; AND

D. CONSENT TO THE PROVISION, WITHHOLDING, OR WITHDRAWAL OF
HEALTH CARE, INCLUDING, IN APPROPRIATE CIRCUMSTANCES, LIFE-SUSTAINING
PROCEDURES.

(3) THE AUTHORITY OF MY AGENT IS SUBJECT TO THE FOLLOWING PROVISIONS
AND LIMITATIONS:

(4) MY AGENT'S AUTHORITY BECOMES OPERATIVE (INITIAL THE OPTION THAT
APPLIES):

WHEN MY ATTENDING PHYSICIAN AND A SECOND PHYSICIAN DETERMINE
THAT I AM INCAPABLE OF MAKING AN INFORMED DECISION REGARDING MY
HEALTH CARE; OR

WHEN THIS DOCUMENT IS SIGNED.

(5)    MY AGENT IS TO MAKE HEALTH CARE DECISIONS FOR ME BASED ON THE
HEALTH CARE INSTRUCTIONS I GIVE IN THIS DOCUMENT AND ON MY WISHES AS
OTHERWISE KNOWN TO MY AGENT. IF MY WISHES ARE UNKNOWN OR UNCLEAR, MY
AGENT IS TO MAKE HEALTH CARE DECISIONS FOR ME IN ACCORDANCE WITH MY
BEST INTEREST, TO BE DETERMINED BY MY AGENT AFTER CONSIDERING THE
BENEFITS, BURDENS, AND RISKS THAT MIGHT RESULT FROM A GIVEN TREATMENT
OR COURSE OF TREATMENT, OR FROM THE WITHHOLDING OR WITHDRAWAL OF A
TREATMENT OR COURSE OF TREATMENT.

(6)    MY AGENT SHALL NOT BE LIABLE FOR THE COSTS OF CARE BASED SOLELY ON
THIS AUTHORIZATION.

BY SIGNING BELOW, I INDICATE THAT I AM EMOTIONALLY AND MENTALLY
COMPETENT TO MAKE THIS APPOINTMENT OF A HEALTH CARE AGENT AND THAT I
UNDERSTAND ITS PURPOSE AND EFFECT.

____________(DATE)_____________________________________(SIGNATURE OF DECLARANT)

THE DECLARANT SIGNED OR ACKNOWLEDGED SIGNING THIS APPOINTMENT
OF A HEALTH CARE AGENT IN MY PRESENCE AND BASED UPON MY PERSONAL
OBSERVATION APPEARS TO BE A COMPETENT INDIVIDUAL.

(WITNESS)______________________________________________(WITNESS)

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