APPOINTMENT OF HEALTH CARE REPRESENTATIVE
I understand that, as a competent adult, I have the right to make decisions about my health
care. There may come a time when I am unable, due to incapacity, to make my own health
care decisions. In these circumstances, those caring for me will need direction and will turn
to someone who knows my values and health care wishes. By signing this appointment of
health care representative, I appoint a health care representative with legal authority to
make health care decisions on my behalf in such case or at such time.
I appoint ___________________________________ to be my health care representative.
If my attending physician determines that I am unable to understand and appreciate the
nature and consequences of health care decisions and to reach and communicate an
informed decision regarding treatment my health care representative is authorized
make any and all health care decisions for me, including the decision to accept or
refuse any treatment, service or procedure used to diagnose or treat my physical or
mental condition and the decision to provide, withhold or withdraw life support
systems, except as otherwise provided by law which excludes for example psychosurgery
or shock therapy.
I direct my health care representative to make decisions on my behalf in accordance with
my wishes as stated in a living will, or as otherwise known to my health care representative.
In the event my wishes are not clear or a situation arises that I did not anticipate, my health
care representative may make a decision in my best interests, based upon what is known
of my wishes.
If ________________________________ is unwilling or unable to serve as my health care
representative, I appoint ____________________________________ to be my alternative
health care representative.
This request is made, after careful reflection, while I am of sound mind.
______ / ______ / ______ (Date) X______________________________