Health Care Power of Attorney and Living Will

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© Copyright 2009 Allegheny County Bar Association
This brochure and accompanying form are subject to a legal copyright. They may be printed or reproduced
as a combined document for use or distribution, but they may not be sold by any party other than the
copyright holder. Alteration and distribution of the form in any way, including use of the form without
the accompanying brochure, will violate the copyright. The use or distribution of an altered version of any
portion of the form and brochure which retains the logos or suggests the approval of the Allegheny County
Medical Society and the Allegheny County Bar Association is strictly prohibited. The completed form may
be reproduced and distributed as a single document to carry out the individual’s health care instructions.
This form and pamphlet have been provided as a public service by the
Allegheny County Bar Association and the Allegheny County Medical Society.
They are not intended to take the place of specific legal or medical advice for
which you should rely upon your own attorney and physician.

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Health Care Decision Making
Modern health care can help you live a long and full life. In certain situations, modern health
care can also prolong the process of your dying or may maintain you in a state of permanent
unconsciousness. You may see this as undesirable and such medical care unduly burdensome.
In Pennsylvania, you have the legal and ethical right to make your own decisions about the type
of health care you want. As long as you are well enough, your physicians will involve you directly
in making decisions about your medical treatment. However, if you are unable to make decisions
about your care, others will have to make these decisions for you. You have the right to decide
• who will make these decisions for you
• when someone can speak for you
• how those decisions would be made, and
• what instructions you may wish to give your doctor and your agent about
these health care decisions
Your wishes 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 and guidance to your health care
agent and your doctor
You should consider planning ahead for a time when you cannot make decisions about your
medical treatment. You can give directions in advance in case you become unable to understand,
make or communicate decisions about your medical care, and:
• you are in an end-stage medical condition (for example, you are dying from
an incurable cancer or you are in an advanced state of a chronic obstructive
lung disease or congestive heart failure); or
• you have no possibility of recovery from an unconscious state (for example,
due to a severe stroke or a traumatic brain injury); or
• you have an irreversible medical condition such as advanced Alzheimer’s
disease that leaves you unable to care for yourself or even unable to recognize
loved ones
You can tell others who you want to make those decisions for you and how you want to be treated
by preparing an advance health care directive, commonly called a Living Will.
APPROVED BY: Allegheny County Bar Association

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Questions and Answers About Advance Health Care Directives
Q. What is an Advance Health Care Directive?
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. It may contain health care treatment instructions, or a “Living
Will”, where you tell your health care agent and health care providers your choices about starting,
continuing, refusing or stopping life-preserving treatment and other specific directions. Often, as with
the form attached, it contains both a Living Will and a Health Care Power of Attorney.
Q. What is a Health Care Agent?
A Health Care Agent is a person you choose to make health care decisions for you. You can name a
family member or a friend who is familiar with your beliefs and values to interpret your instructions and
to make these decisions. This Health Care Agent can authorize, withhold or withdraw treatment.
Q. When does my Health Care Agent speak for me?
This form gives your Health Care Agent the power to speak for you whenever you cannot speak for yourself.
If you get better and are again able to make your own decisions, you can again speak for yourself. The law
allows you to have your Health Care Agent to speak for you immediately, if you wish. If you want your Health
Care Agent to speak for you right away, or at any time, all you need to do is personally inform your attending
physician, who should record your decision in your medical records. If you have any questions about this,
you may wish to consult with your attorney and physician to be sure that your wishes are clearly expressed.
Q. Should I talk to my Health Care Agent about this?
Absolutely. It is very important that you discuss your wishes with your Health Care Agent, so that you
know that the person you appoint is willing to act as your Health Care Agent, and that your Health Care
Agent understands your wishes and priorities as well as possible.
Q. Will my agent be responsible for my medical bills?
No. Your agent makes decisions about your care. The cost of your medical care is your responsibility or the
responsibility of your insurance company.
Q. If I am unable to make decisions, what happens if I don’t have an Advance Health
Care Directive?
If you don’t have an Advance Health Care Directive, a Health Care Representative may be selected in the
order prescribed by the Pennsylvania statute from your relatives or another adult person who may know
your preferences and values for purposes of health care decision making. However, the person selected
by the statute may not be the one you wish to make decisions for you. Without any written guidance,
your family members may be confused or disagree about what care to give you. Your wishes may not
be followed.
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Q. What if my physician or health care provider does not want to follow my advance directive?
Your physician or health care provider must tell you if they cannot in good conscience follow your wishes or if
the policies of the institution prevent them from honoring your wishes. By law the physician or health care
provider must help transfer you to another physician or health care provider willing to carry out your directives.
Q. What should I do with my completed Advance Health Care Directive?
You should give a copy of your Advance Health Care Directive to your Health Care Agent, to your
alternative Health Care Agents and to your physician and discuss it with them. Tell your family that you
have written this document and discuss it with them and with others, such as your attorney or clergy,
if you desire. Keep a copy in an accessible but secure place. Note that a copy kept in a safe deposit box may
not be accessible when needed.
Q. Can I change my Advance Health Care Directive?
Yes! You can change your mind by telling your physician at any time. You can write a new Advance Health
Care Directive and replace all old copies with the new one. You should discuss any changes with your
Health Care Agent and physician as well as family members and loved ones.
Q. What if I fill out an Advance Health Care Directive in one state and am hospitalized in
a different state?
Legal requirements vary from state to state. Your Advance Health Care Directive helps your doctors
understand your wishes no matter where you are. If you spend a lot of time in another state you might
consider consulting an attorney in that state to make sure that your wishes will be honored in that state.
Q. Whom can I contact for additional information:
You can contact: Allegheny County Bar Association, (412) 261-6161 Allegheny County Medical Society,
(412) 321-5030
Conclusion
A discussion of Advance Health Care Directives touches on sensitive matters. Most of us would rather
not think about being sick or dying. But, by considering these issues now, you can save your family and
those close to you the burden of having to make choices for you without adequate guidance. Talking with
your family, your physician, clergy, or with others whose views you respect may help you decide on the path
best suited for you.
APPROVED BY: Allegheny County Bar Association

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INSTRUCTIONS FOR PAGE 1
A Durable Health Care Power of Attorney and Living Will form is attached for your use. This
form allows you to do two things. The Durable Health Care Power of Attorney appoints a specific
person (a Health Care Agent) who will have the power to make health care decisions for you. The
Guidance for Agent and the Health Care Treatment Instructions (Living Will) tell your Health
Care Agent and your health care providers what specific health care treatments you do want and do
not want to receive to prolong life in certain situations. Because you cannot anticipate every
circumstance, the appointment of a Health Care Agent is critical. If you appoint an agent who
knows you and your values, and who is willing to be involved in your care, it is more likely that your
wishes will be honored.
If you disagree with any of the statements in this form, you may cross out that portion. If you do so,
you should consult with your physician or attorney to make sure that your wishes are clearly understood.
Specific Instructions: Part I – Durable Health Care Power of Attorney/Appointing an Agent
Name and County. Fill in your full name and the county where you live.
Health Care Agent Speaks for You Only When Needed Or Whenever You Want Them to Speak for You.
This form allows your Health Care Agent to speak for you when you are unable to understand,
make or communicate a choice regarding a health care decision. This is based upon the point of view
that you should keep control of your health care decisions as long as you can. If you wish your
Health Care Agent to make health care decisions for you right away, or at any time, you may do so
by personally informing your doctor, who will record your decision in your medical records. If you
have any questions about this, you may wish to discuss it with your physician or your attorney.
Appointment of Health Care Agent and Alternates. Fill in the full name, address, telephone
numbers and email address of your Health Care Agent and any alternative agents. Note that you
may not appoint your doctor or other health care provider as your health care agent unless they are
family members. If, for any reason, your agent is not reasonably available under the circumstances,
your alternative agents will be contacted in the order you list them.
Only One Health Care Agent at a Time. This form gives only one Health Care Agent the power
to act at any time, provided that he or she is reasonably available, so that the line of authority is
very clear. The Health Care Agent is strongly urged to discuss decisions with the Alternate Health
Care Agents, other family members, clergy and other trusted advisors, where possible, to insure that
your wishes are followed. If you wish for two or more of your Health Care Agents to act together,
you should consult with your attorney and physician to prepare a form that deals with unavailability
or disagreement among the Health Care Agents.
Separate HIPAA Authorization. Your Health Care Agent has full access to your medical records
when they are acting on your behalf, but before that time, those records are private. However, it is
desirable that your doctor may be able to discuss your care with your Health Care Agent while you
are still able to make your own decisions for yourself, or in communications between your doctor,
your Health Care Agent and you. This language is intended to encourage that communication.
APPROVED BY: Allegheny County Bar Association

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ADVANCE HEALTH CARE DIRECTIVE PAGE 1
I. HEALTH CARE POWER OF ATTORNEY
AND
II. HEALTH CARE TREATMENT INSTRUCTIONS IN THE EVENT OF END-STAGE
MEDICAL CONDITION OR PERMANENT UNCONSCIOUSNESS
(“LIVING WILL”)
PART I - 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 whenever
I cannot understand, make or communicate a choice regarding a health care decision as determined by my
doctor or whenever I personally inform my doctor. My agent may not delegate the authority to make decisions.
APPOINTMENT OF HEALTH CARE AGENT:
I appoint the following health care agent: 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.
Health Care Agent: __________________________________________________________________________
(Name and Relationship)
Address:
Telephone Numbers
____________________________________________________________________________________ Home
____________________________________________________________________________________ Work
E-Mail: ______________________________________________________________________________ Cell
If my health care agent is not reasonably available, or is unable or unwilling to act in a timely manner, 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).
_______________________________________
_______________________________________
Name and Relationship
Name and Relationship
TE
TE
_______________________________________
_______________________________________
Address
Address
TERNA _______________________________________
TERNA _______________________________________
City
State
Zip
City
State
Zip
AL
AL
ST
ND
1 _______________________________________
_______________________________________
2
Home Phone
Cell Phone
Home Phone
Cell Phone
_______________________________________
_______________________________________
Work Phone
E-Mail
Work Phone
E-Mail
SEPARATE HIPAA AUTHORIZATION EFFECTIVE IMMEDIATELY
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 (“HIPAA”), the regulations issued under
HIPAA 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 these privacy rules.
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ADVANCE HEALTH CARE DIRECTIVE PAGE 2
HEALTH CARE AGENT POWERS
My health care agent has all of the following powers subject to the health care treatment instructions that follow
in PART II (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 obtain 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 request that a physician responsible for my care issue a do-not-resuscitate (DNR) order,
including an out-of-hospital DNR order, a Physician Order for Life-Sustaining Treatment
(POLST) or other order effectuating my wishes and to sign any required documents and consents.
6. To carry out my wishes regarding funeral, burial, and the disposition of my body.
7. To take any legal action necessary to do what I have directed.
The foregoing powers shall apply with respect to both physical and mental health care as defined under Section
5422 of the Probate, Estates and Fiduciaries Code. I do not have a mental health care power of attorney or
declaration under Chapter 58 of the Probate, Estates and Fiduciaries Code. (Modify or use a different form as
needed if you have a mental health care power of attorney or declaration)
I nominate my health care agent as the guardian of my person, should such a guardian be necessary.
GUIDANCE FOR HEALTH CARE AGENT (OPTIONAL) Goals (Leave Blank if Goals Adequately
Expressed in the Rest of this Document):
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 life for as
long as possible, preservation of mental function, care at home, etc.):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Severe Brain Damage or Brain Disease:
If I should suffer from severe and irreversible brain damage or brain disease which has made me unable to
recognize or interact with other people and from which my doctors believe there is no realistic hope of significant
recovery, I would consider such a condition unacceptable and the application of aggressive medical care to extend
my life in this condition to be burdensome. I therefore request that my health care agent respond to any 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. Keep me comfortable and allow natural death to occur.
Initials ________ I disagree. Use all medical treatment that is needed to keep me alive.
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INSTRUCTIONS FOR PAGE 2
List of Health Care Agent’s Powers. The form lists seven broad powers for your agent. Pay
particular attention to number 2, which gives your agent the power to withhold or withdraw food
or water supplied by tube. You may cross out any power you do not wish to give to your agent,
but if you do, be sure to discuss it with your doctor and your lawyer to make sure that your wishes
are clearly expressed.
Mental Health Care. This form grants powers to your Health Care Agent which generally include
both physical and mental health care. It does not, however, express your specific wishes concerning
mental health conditions apart from severe brain damage or brain disease which might
make you unable to recognize or interact with other people. It assumes that you do not have a
separate mental health care power of attorney or mental health care declaration which deals directly with
specific mental health issues and is governed by Chapter 58 of the Probate, Estates and Fiduciaries Code.
If you do have such a separate document, or you wish to express specific wishes concerning
mental health care, you should consult with your lawyer and your doctor and use a different form
or forms to do so.
Appointment of Health Care Agent as Guardian of the Person. By signing a Health Care Power
of Attorney appointing a Health Care Agent to make decisions for you when you are unable
to do so yourself, you minimize the chance that a court proceeding will be necessary under
Pennsylvania’s Guardianship laws to appoint a guardian of your person to make decisions about
your care. However, should such a guardian of your person be required for any reason, you
nominate your Health Care Agent as such Guardian.
Guidance for Health Care Agent. This section gives you the opportunity to separately state
your health care goals should you suffer from an end-stage medical condition or other extreme and
irreversible medical condition. If your wishes and priorities are adequately expressed in the
remainder of the document, you may leave this section blank. But this is an opportunity to express
the values that are most important to you, whether it is the preservation of your life for as long as
possible, or to be cared for at home as long as possible, even if this might result in a shortened life,
then this is the place provided to you to say it.
Severe Brain Damage or Brain Disease. This section refers to conditions currently believed to be
irreversible, such as advanced Alzheimer’s disease or other severe brain damage. In such situations,
you might not be in an end-stage medical condition or permanently unconscious, but you might
be unable to care for yourself, or even unable to recognize loved ones. You should tell your Health
Care Agent and your doctor whether you wish medical care to be applied aggressively or not in
that situation.
For example, if you were to develop a life-threatening condition (pneumonia for example) and
life-preserving measures must be considered, you may wish for your doctor and your Health Care
Agent to follow your instructions just as if you were in an end-stage medical condition or are
permanently unconscious. Alternatively, you may wish for your doctor and your Health Care Agent
to use all medical treatment that is needed to keep you alive.
APPROVED BY: Allegheny County Bar Association

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INSTRUCTIONS FOR PAGE 3
Specific Instructions: Part II – Health Care Treatment Instructions (Living Will)
How to Complete Your Living Will
End-Stage Medical Condition or Permanent Unconsciousness
A Living Will in Pennsylvania states what medical care you do and do not want to keep you alive
if you are in an end-stage medical condition or in a state of permanent unconsciousness. It does
not apply to any other situations. This is different from your Health Care Power of Attorney, which
applies whenever you are unable to understand, make or communicate a health care decision.
By initialing your choice that you do or do not want aggressive medical care in those situations,
you agree to the instructions set out below those statements. Read these instructions carefully to
make sure they state your wishes accurately. If they do not, you may modify them, but you should
review any modifications to these instructions with your physician and your attorney to make sure
that your wishes are expressed clearly.
Special Rules For Pregnancy.
If you are a woman and are diagnosed as being pregnant at the time a health care decision would
otherwise be made pursuant to this form, special rules apply. Pennsylvania law directs that life-
sustaining treatment, including nutrition and hydration, be given unless your attending physician
and an obstetrician who have examined you certify in your medical record that such treatment will
not permit the continuing development and birth of the unborn child, will be harmful to you, or will
cause pain that cannot be alleviated by medication. If you wish to express your wishes in this regard,
and it is different from the Pennsylvania law, you may wish to discuss this matter with your attorney.
Tube Feedings. Initial one of the two choices.
Agent’s Use of Instructions. Initial the first choice if you want your Health Care Agent to be bound
by your instructions. Initial the second choice if you want your Health Care Agent to be able to
override your instructions and do what he or she thinks is best for you.
Follow your Instructions. If you direct that your Health Care Agent is to follow your instructions,
you are taking full responsibility for the choices that you have directed. Your doctor and your
Health Care Agent will still have considerable authority to make judgments about your health
care choices since they must determine under the circumstances whether there is realistic hope of
a significant recovery. But otherwise, your instructions must be followed.
Full Power to Health Care Agent. If you give your Health Care Agent full power and final
authority, even to override your instructions, you will have given your Health Care Agent all of the
power which you yourself possess over your health care. If you choose to give your Health Care
Agent this full power and authority, you may list any limitations on that authority in the lines
below. If you list such limitations, it is extremely important that you express your wishes clearly,
so it is advisable to review the wording with your doctor and your lawyer.
APPROVED BY: Allegheny County Bar Association

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