Power of Attorney for Health Care - State of Illinois

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2. The powers granted above shall not include the following powers or shall be subject to thefollowing rules or limitations:(NOTE: Here you may include any specific limitations you deem appropriate, such as: yourown definition of when life-sustaining measures should be withheld; a direction to continue foodand fluids or life-sustaining treatment in all events; or instructions to refuse any specific typesof treatment that are inconsistent with your religious beliefs or unacceptable to you for anyother reason, such as blood transfusion, electro-convulsive therapy, amputation, psychosurgery,voluntary admission to a mental institution, etc.)_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(NOTE: The subject of life-sustaining treatment is of particular importance. For yourconvenience in dealing with that subject, some general statements concerning the withholding orremoval of life-sustaining treatment are set forth below. If you agree with one of these statements,you may initial that statement; but do not initial more than one. These statements serve asguidance for your agent, who shall give careful consideration to the statement you initial whenengaging in health care decision-making on your behalf.)I do not want my life to be prolonged nor do I want life-sustaining treatment to be provided orcontinued if my agent believes the burdens of the treatment outweigh the expected benefits. Iwant my agent to consider the relief of suffering, the expense involved and the quality as well asthe possible extension of my life in making decisions concerning life-sustaining treatment.Initialed __________I want my life to be prolonged and I want life-sustaining treatment to be provided or continued,unless I am, in the opinion of my attending physician, in accordance with reasonable medicalstandards at the time of reference, in a state of “permanent unconsciousness” or suffer froman “incurable or irreversible condition” or “terminal condition”, as those terms are defined inSection 4-4 of the Illinois Power of Attorney Act. If and when I am in any one of these states orconditions, I want life-sustaining treatment to be withheld or discontinued.Initialed __________I want my life to be prolonged to the greatest extent possible in accordance with reasonablemedical standards without regard to my condition, the chances I have for recovery or the cost ofthe procedures.B-3Initialed __________
(NOTE: This power of attorney may be amended or revoked by you in the manner provided inSection 4-6 of the Illinois Power of Attorney Act. )3. This power of attorney shall become effective on:_______________________________________________________________________________________________________________(NOTE: In Line 3 above, insert a future date or event during your lifetime, such as a courtdetermination of your disability or a written determination by your physician that you areincapacitated, when you want this power to first take effect.)(NOTE: If you do not amend or revoke this power, or if you do not specify a specific ending datein paragraph 4, it will remain in effect until your death; except that your agent will still have theauthority to donate your organs, authorize an autopsy, and dispose of your remains after yourdeath, if you grant that authority to your agent.)4. This power of attorney shall terminate on:_____________________________________________________________________________________________________________________(NOTE: In Line 4 above, insert a future date or event, such as a court determination that youare not under a legal disability or a written determination by your physician that you are notincapacitated, if you want this power to terminate prior to your death.)(NOTE: You cannot use this form to name co-agents. If you wish to name successor agents, insertthe names and addresses of the successors in paragraph 5.)5. If any agent named by me shall die, become incompetent, resign, refuse to accept the officeof agent or be unavailable, I name the following (each to act alone and successively, in theorder named) as successors to such agent:_____________________________________________________________________________(insert name and address of successor agent)_____________________________________________________________________________(insert name and address of successor agent)For purposes of this paragraph 5, a person shall be considered to be incompetent if and while theperson is a minor, or an adjudicated incompetent or disabled person, or the person is unable to giveprompt and intelligent consideration to health care matters, as certified by a licensed physician.(NOTE: If you wish to, you may name your agent as guardian of your person if a court decidesthat one should be appointed. To do this, retain paragraph 6, and the court will appoint youragent if the court finds that this appointment will serve your best interests and welfare. Strike outparagraph 6 if you do not want your agent to act as guardian.)6. If a guardian of my person is to be appointed, I nominate the agent acting under this powerof attorney as such guardian, to serve without bond or security.7. I am fully informed as to all the contents of this form and understand the full import of thisgrant of powers to my agent.Dated:____________________Signed:___________________________________________(principal’s signature or mark)B-4
Page 1 and 2: NOTICE TO THE INDIVIDUAL SIGNING TH
Page 3: D. I intend for the person named as

Power of Attorney for Health Care - State of Illinois

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