2010 Pennsylvania Code
Title 20 - DECEDENTS, ESTATES AND FIDUCIARIES
Chapter 54 - Health Care
5471 - Example.

                               SUBCHAPTER D
                              COMBINED FORM

     Sec.
     5471.  Example.

        Cross References.  Subchapter D is referred to in sections
     5433, 5447, 5465 of this title.
     § 5471.  Example.
        The following is an example of a document that combines a
     living will and health care power of attorney:
                    DURABLE HEALTH CARE POWER OF ATTORNEY
                   AND HEALTH CARE TREATMENT INSTRUCTIONS
                                (LIVING WILL)
                                   PART I
                           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.
                      NOTES ABOUT THE USE OF THIS FORM
            If you decide to use this form or create your own advance
        health care directive, you should consult with your physician
        and your attorney to make sure that your wishes are clearly
        expressed and comply with the law.
            If you decide to use this form but disagree with any of
        its statements, you may cross out those statements.
            You may add comments to this form or use your own form to
        help your physician or health care agent decide your medical
        care.
            This form is designed to give your health care agent
        broad powers to make health care decisions for you whenever
        you cannot make them for yourself. It is also designed to
        express a desire to limit or authorize care if you have an
        end-stage medical condition or are permanently unconscious.
        If you do not desire to give your health care agent broad
        powers, or you do not wish to limit your care if you have an
        end-stage medical condition or are permanently unconscious,
        you may wish to use a different form or create your own. YOU
        SHOULD ALSO USE A DIFFERENT FORM IF YOU WISH TO EXPRESS YOUR
        PREFERENCES IN MORE DETAIL THAN THIS FORM ALLOWS OR IF YOU
        WISH FOR YOUR HEALTH CARE AGENT TO BE ABLE TO SPEAK FOR YOU
        IMMEDIATELY. In these situations, it is particularly
        important that you consult with your attorney and physician
        to make sure that your wishes are clearly expressed.
            This form allows you to tell your health care agent your
        goals if you have an end-stage medical condition or other
        extreme and irreversible medical condition, such as advanced
        Alzheimer's disease. Do you want medical care applied
        aggressively in these situations or would you consider such
        aggressive medical care burdensome and undesirable?
            You may choose whether you want your health care agent to
        be bound by your instructions or whether you want your health
        care agent to be able to decide at the time what course of
        treatment the health care agent thinks most fully reflects
        your wishes and values.
            If you are a woman and diagnosed as being pregnant at the
        time a health care decision would otherwise be made pursuant
        to this form, the laws of this Commonwealth prohibit
        implementation of that decision if it directs that life-
        sustaining treatment, including nutrition and hydration, be
        withheld or withdrawn from you, unless your attending
        physician and an obstetrician who have examined you certify
        in your medical record that the life-sustaining treatment:
            (1)  will not maintain you in such a way as to permit the
        continuing development and live birth of the unborn child;
            (2)  will be physically harmful to you; or
            (3)  will cause pain to you that cannot be alleviated by
        medication.
        A physician is not required to perform a pregnancy test on
        you unless the physician has reason to believe that you may
        be pregnant.
            Pennsylvania law protects your health care agent and
        health care providers from any legal liability for following
        in good faith your wishes as expressed in the form or by your
        health care agent's direction. It does not otherwise change
        professional standards or excuse negligence in the way your
        wishes are carried out. If you have any questions about the
        law, consult an attorney for guidance.
            This form and explanation is not intended to take the
        place of specific legal or medical advice for which you
        should rely upon your own attorney and physician.
                                   PART II
                    DURABLE HEALTH CARE POWER OF ATTORNEY
            I,........................, of....................
        County, Pennsylvania, appoint the person named below to be my
        health care agent to make health and personal care decisions
        for me.
            Effective immediately and continuously until my death or
        revocation by a writing signed by me or someone authorized to
        make health care treatment decisions for me, I authorize all
        health care providers or other covered entities to disclose
        to my health care agent, upon my agent's request, any
        information, oral or written, regarding my physical or mental
        health, including, but not limited to, medical and hospital
        records and what is otherwise private, privileged, protected
        or personal health information, such as health information as
        defined and described in the Health Insurance Portability and
        Accountability Act of 1996 (Public Law 104-191, 110 Stat.
        1936), the regulations promulgated thereunder and any other
        State or local laws and rules. Information disclosed by a
        health care provider or other covered entity may be
        redisclosed and may no longer be subject to the privacy rules
        provided by 45 C.F.R. Pt. 164.
            The remainder of this document will take effect when and
        only when I lack the ability to understand, make or
        communicate a choice regarding a health or personal care
        decision as verified by my attending physician. My health
        care agent may not delegate the authority to make decisions.
            MY HEALTH CARE AGENT HAS ALL OF THE FOLLOWING POWERS
        SUBJECT TO THE HEALTH CARE TREATMENT INSTRUCTIONS THAT FOLLOW
        IN PART III (CROSS OUT ANY POWERS YOU DO NOT WANT TO GIVE
        YOUR HEALTH CARE AGENT):
            1.  To authorize, withhold or withdraw medical care and
        surgical procedures.
            2.  To authorize, withhold or withdraw nutrition (food)
        or hydration (water) medically supplied by tube through my
        nose, stomach, intestines, arteries or veins.
            3.  To authorize my admission to or discharge from a
        medical, nursing, residential or similar facility and to make
        agreements for my care and health insurance for my care,
        including hospice and/or palliative care.
            4.  To hire and fire medical, social service and other
        support personnel responsible for my care.
            5.  To take any legal action necessary to do what I have
        directed.
            6.  To request that a physician responsible for my care
        issue a do-not-resuscitate (DNR) order, including an out-of-
        hospital DNR order, and sign any required documents and
        consents.
        APPOINTMENT OF HEALTH CARE AGENT
        I appoint the following health care agent:
            Health Care Agent:.............................
                                         (Name and relationship)
            Address:.............................................
            .....................................................
            Telephone Number:  Home............. Work............
            E-mail:..................................................
        IF YOU DO NOT NAME A HEALTH CARE AGENT, HEALTH CARE PROVIDERS
        WILL ASK YOUR FAMILY OR AN ADULT WHO KNOWS YOUR PREFERENCES
        AND VALUES FOR HELP IN DETERMINING YOUR WISHES FOR TREATMENT.
        NOTE THAT YOU MAY NOT APPOINT YOUR DOCTOR OR OTHER HEALTH
        CARE PROVIDER AS YOUR HEALTH CARE AGENT UNLESS RELATED TO YOU
        BY BLOOD, MARRIAGE OR ADOPTION.
            If my health care agent is not readily available or if my
            health care agent is my spouse and an action for divorce
            is filed by either of us after the date of this document,
            I appoint the person or persons named below in the order
            named. (It is helpful, but not required, to name
            alternative health care agents.)
            First Alternative Health Care Agent:.................
                                         (Name and relationship)
            Address:.............................................
            .....................................................
            Telephone Number:  Home............. Work............
            E-mail:..................................................
            Second Alternative Health Care Agent:................
                                         (Name and relationship)
            Address:.............................................
            .....................................................
            Telephone Number:  Home............. Work............
            E-mail:..................................................
        GUIDANCE FOR HEALTH CARE AGENT (OPTIONAL)
            GOALS
            If I have an end-stage medical condition or other extreme
        irreversible medical condition, my goals in making medical
        decisions are as follows (insert your personal priorities
        such as comfort, care, preservation of mental function,
        etc.):................ ......................................
        .............................................................
        .............................................................
        .............................................................
        SEVERE BRAIN DAMAGE OR BRAIN DISEASE
            If I should suffer from severe and irreversible brain
        damage or brain disease with no realistic hope of significant
        recovery, I would consider such a condition intolerable and
        the application of aggressive medical care to be burdensome.
        I therefore request that my health care agent respond to any
        intervening (other and separate) life-threatening conditions
        in the same manner as directed for an end-stage medical
        condition or state of permanent unconsciousness as I have
        indicated below.
            Initials..............I agree
            Initials..............I disagree
                                  PART III
               HEALTH CARE TREATMENT INSTRUCTIONS IN THE EVENT
                       OF END-STAGE MEDICAL CONDITION
                       OR PERMANENT UNCONSCIOUSNESS
                                (LIVING WILL)
            The following health care treatment instructions exercise
        my right to make my own health care decisions. These
        instructions are intended to provide clear and convincing
        evidence of my wishes to be followed when I lack the capacity
        to understand, make or communicate my treatment decisions:
            IF I HAVE AN END-STAGE MEDICAL CONDITION (WHICH WILL
        RESULT IN MY DEATH, DESPITE THE INTRODUCTION OR CONTINUATION
        OF MEDICAL TREATMENT) OR AM PERMANENTLY UNCONSCIOUS SUCH AS
        AN IRREVERSIBLE COMA OR AN IRREVERSIBLE VEGETATIVE STATE AND
        THERE IS NO REALISTIC HOPE OF SIGNIFICANT RECOVERY, ALL OF
        THE FOLLOWING APPLY (CROSS OUT ANY TREATMENT INSTRUCTIONS
        WITH WHICH YOU DO NOT AGREE):
            1.  I direct that I be given health care treatment to
        relieve pain or provide comfort even if such treatment might
        shorten my life, suppress my appetite or my breathing, or be
        habit forming.
            2.  I direct that all life prolonging procedures be
        withheld or withdrawn.
            3.  I specifically do not want any of the following as
        life prolonging procedures: (If you wish to receive any of
        these treatments, write "I do want" after the treatment)
                heart-lung resuscitation (CPR).......................
                mechanical ventilator (breathing machine)............
                dialysis (kidney machine)............................
                surgery..............................................
                chemotherapy.........................................
                radiation treatment .................................
                antibiotics..........................................
            Please indicate whether you want nutrition (food) or
        hydration (water) medically supplied by a tube into your
        nose, stomach, intestine, arteries, or veins if you have an
        end-stage medical condition or are permanently unconscious
        and there is no realistic hope of significant recovery.
        (Initial only one statement.)
        TUBE FEEDINGS
            ........I want tube feedings to be given
        OR
        NO TUBE FEEDINGS
            ........I do not want tube feedings to be given.
        HEALTH CARE AGENT'S USE OF INSTRUCTIONS
        (INITIAL ONE OPTION ONLY).
            ........My health care agent must follow these
                    instructions.
        OR
            ........These instructions are only guidance.
                    My health care agent shall have final say and may
                    override any of my instructions. (Indicate any
                    exceptions)......................................
                    .................................................
            If I did not appoint a health care agent, these
        instructions shall be followed.
        LEGAL PROTECTION
            Pennsylvania law protects my health care agent and health
        care providers from any legal liability for their good faith
        actions in following my wishes as expressed in this form or
        in complying with my health care agent's direction. On behalf
        of myself, my executors and heirs, I further hold my health
        care agent and my health care providers harmless and
        indemnify them against any claim for their good faith actions
        in recognizing my health care agent's authority or in
        following my treatment instructions.
        ORGAN DONATION (INITIAL ONE OPTION ONLY.)
            ........I consent to donate my organs and tissues at the
                    time of my death for the purpose of transplant,
                    medical study or education. (Insert any
                    limitations you desire on donation of specific
                    organs or tissues or uses for donation of organs
                    and tissues.)....................................
                    .................................................
            OR
            ........I do not consent to donate my organs or tissues
                    at the time of my death.
        SIGNATURE
            Having carefully read this document, I have signed it
        this.......day of............., 20..., revoking all previous
        health care powers of attorney and health care treatment
        instructions.
        .............................................................
        (SIGN FULL NAME HERE FOR HEALTH CARE POWER OF ATTORNEY AND
        HEALTH CARE TREATMENT INSTRUCTIONS)
            WITNESS:.......................
            WITNESS:.......................
            Two witnesses at least 18 years of age are required by
        Pennsylvania law and should witness your signature in each
        other's presence. A person who signs this document on behalf
        of and at the direction of a principal may not be a witness.
        (It is preferable if the witnesses are not your heirs, nor
        your creditors, nor employed by any of your health care
        providers.)
                           NOTARIZATION (OPTIONAL)
            (Notarization of document is not required by Pennsylvania
        law, but if the document is both witnessed and notarized, it
        is more likely to be honored by the laws of some other
        states.)
            On this..........day of .............., 20...., before me
        personally appeared the aforesaid declarant and principal, to
        me known to be the person described in and who executed the
        foregoing instrument and acknowledged that he/she executed
        the same as his/her free act and deed.
            IN WITNESS WHEREOF, I have hereunto set my hand and
        affixed my official seal in the County of............., State
        of.............. the day and year first above written.
        ...............................      ........................
                 Notary Public                  My commission expires