I, ____________________________________________________________________,

I, ____________________________________________________________________,

appoint _______________________________________________________________

(Name) (Work Phone)

_______________________________________________________________

(Address) (Home Phone)

as my attorney-in-fact or agent to make health and personal care decisions for me if I become incapable of making my own decisions.

If the person named above is unable to serve as my agent for any reason, I appoint an alternate to serve as my agent:

_______________________________________________________________

(Name) (Work Phone)

_______________________________________________________________

(Address) (Home Phone)

This Durable Power of Attorney for Health Care shall become effective upon my incapacity. I grant the following powers to my agent:

To authorize my admission to or discharge from any medical, nursing, residential, or similar facility and to enter into agreements for my care.

To authorize, refuse, or withdraw consent to any and all types of medical and surgical procedures, care, or treatment, including, but not limited to, nutrition and hydration administered by artificial or invasive means.

I have discussed my wishes concerning my health care with my agent, who shall follow my directions to the extent known. If my agent is unable to determine what I would want, then my agent shall make a decision based upon what he or she believes to be in my best interests.

I revoke any prior power of attorney for health care.

My signature below means that I understand this document and intend this grant of powers to my agent to be legally binding.

__________________________________

(Signature) (Date)

__________________________________

(Witness) (Date)

__________________________________

(Witness) (Date)

I, ___________________________, have read the above durable power of attorney for health care and am the person identified as the agent for _________________ (the Principal). My signature below means that I understand and acknowledge that when I act as agent:

I shall exercise the powers for the benefit of the Principal; and

I shall exercise reasonable caution and prudence and act in the best interests of the Principal.

Signature Date

PENNSYLVANIA ADVANCE DIRECTIVE FOR HEALTH CARE

Section 5404 Declaration(20 Pa.C.S.-5404) DECLARATIONI, _____________________, being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below.I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness.I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment.In addition, if I am in the condition described above, I feel especially strong about the following forms of treatment:I ( ) do ( ) do not want cardiac resuscitation. I ( ) do ( ) do not want mechanical respiration.I ( ) do ( ) do not want tube feeding or any other artificial or invasive form of ( ) nutrition (food) ( ), or hydration (water)I ( ) do ( ) do not want blood or blood products.I ( ) do ( ) do not want any form of surgery or invasive diagnostic tests.I ( ) do ( ) do not want kidney dialysis.I ( ) do ( ) do not want antibiotics.I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment.Other InstructionsI ( ) do ( ) do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness.Name and address of surrogate (if applicable):_______________________________________________ _________________________________________________ Name and address of substitute surrogate (if surrogate designated above is unable to serve):_________________________________________ _______________________ ________________________________I ( ) do ( ) do not want to make an anatomical gift of all or part of my body, subject to the following limitations, if any:_____________________ _______________________ _____________________________________ ________________________

____________________________________ ________________________________________________

I made this declaration on the ____ day of __________________ (month, year)

Declarant: ________________________________

Signature: ________________________________

Address: ________________________________ ________________________________

The declarant, or the person on behalf of and at the direction of the declarant, knowingly and voluntarily signed this writing by signature or mark in my presence.

Witness: ________________________________

Signature: ________________________________

Address: ________________________________

________________________________

Witness: ________________________________

Signature: ________________________________

Address: ________________________________

________________________________