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Sample of Nebraska Health Care PoA
with Will to Live Language

Sample of Nebraska Power of Attorney for Health Care with Will to Live Language

(put out by Nebraska Right to Life)

POWER OF ATTORNEY FOR HEALTH CARE

I, ______________________________ appoint,

 

 ___________________________whose

 

address is _______________________________________________________________,

 

and whose telephone number is ___________________________________________, as

 

my attorney in fact for health care. I appoint ___________________________________,

 

whose address is_________________________________________________________ ,

 

and whose telephone number is_____________________________________________ , as my successor attorney in fact for health care. I authorize my attorney in fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions. I have read the warning which accompanies this document and understand the consequences of executing a power of attorney for health care.

I direct that my attorney in fact comply with the following instructions or limitations:

GENERAL PRESUMPTION FOR LIFE

I direct my health care provider(s) and attorney in fact to make health care decisions consistent with my general desire for the use of medical treatment that would preserve my life, as well as for the use of medical treatment that can cure, improve, or reduce or prevent deterioration in, any physical or mental condition. Food and water are not medical treatment, but basic necessities. I direct my health care provider(s) and attorney in fact to provide me with food and fluids orally, intravenously, by tube, or by other means to the full extent necessary both to preserve my life and to assure me the optimal health possible.

I direct that medication to alleviate my pain be provided, as long as the medication is not used in order to cause my death.

I direct that the following be provided:

* the administration of medication;

* cardiopulmonary resuscitation (CPR); and

* the performance of all other medical procedures, techniques, and technologies, including surgery,

-- all to the full extent necessary to correct, reverse, or alleviate life-threatening or health-impairing conditions, or complications arising from those conditions.

I also direct that I be provided basic nursing care and procedures to provide comfort care.

I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of an unborn or newborn child, who has been subject to an induced abortion. This rejection does not apply to the use of tissues or organs obtained in the course of the removal of an ectopic pregnancy.

I also reject any treatments that use an organ or tissue of another person obtained in a manner that causes, contributes to, or hastens that person's death.

The instructions in this document are intended to be followed even if suicide is alleged to be attempted at some point after it is signed.

I request and direct that medical treatment and care be provided to me to preserve my life without discrimination based on my age or physical or mental disability or the "quality" of my life. I reject any action or omission that is intended to cause or hasten my death.

I direct my health care provider(s) and attorney in fact to follow the above policy, even if I am judged to be incompetent.

During the time I am incompetent, my agent, as named above or below, is authorized to make medical decisions on my behalf, consistent with the above policy, after consultation with my health care provider(s), utilizing the most current diagnoses and/or prognosis of my medical condition, in the following situations with the written special conditions.

WHEN MY DEATH IS IMMINENT

1. If I have an incurable terminal illness or injury, and I will die imminently--meaning that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only a week or less even if lifesaving treatment or care is provided to me--the following may be withheld or withdrawn:

(Be as specific as possible):

 

________________________________________________________________________

 

________________________________________________________________________

(Cross off any remaining blank lines.)

WHEN I AM TERMINALLY ILL

2. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even though death is not imminent I am in the final stage of that terminal condition--meaning that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only three months or less, even if lifesaving treatment or care is provided to me--the following may be withheld or withdrawn:

(Be as specific as possible.):

________________________________________________________________________

 

________________________________________________________________________

(Cross off any remaining blank lines.)

3. OTHER SPECIAL CONDITIONS:

(Be as specific as possible):

 

________________________________________________________________________

 

________________________________________________________________________

(Cross off any remaining blank lines.)

IF I AM PREGNANT

4. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and attorney in fact(s) to use all lifesaving procedures for myself, with none of the above special conditions applying, if there is a chance that prolonging my life might allow my child to be born alive. I also direct that lifesaving procedures be used even if I am legally determined to be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I specify by writing my signature in the box below, no one is authorized to consent to any procedure for me that would result in the death of my unborn child.

I direct that my attorney in fact comply with the following instructions on life-sustaining treatment: (optional)

See above instructions and limitations.

I direct that my attorney in fact comply with the following instructions on artificially administered nutrition and hydration: (optional)

See above instructions and limitations.

I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY ATTORNEY IN FACT, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN.

 

______________________________________________________________________

(Signature of person making designation/date)

DECLARATION OF WITNESSES

We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care in our presence, that the principal appears to be of sound mind and not under duress or under influence, and that neither of us nor the principal's attending physician is the person appointed as attorney in fact by this document.

Witnessed By:

 

____________________________________________________________________

 (Signature of Witness/Date)                                               (Printed Name of Witness)

 

____________________________________________________________________

(Signature of Witness/Date)                                                 (Printed Name of Witness)

Form Prepared 1998

 

For more information, contact Nebraska Right to Life www.nebraskarighttolife.org