I, _______, residing at [address]; make, constitute and appoint _______, _______, residing at [address] (hereinafter referred to as my "Health Care Representative"), my true and lawful attorney-in-fact to be my Health Care Representative with respect to all health care matters, upon the terms and conditions hereinafter set forth.

1. Although I wish to live and enjoy life as long as possible, I do not wish to receive futile medical treatment, which I define as treatment that will provide little or no benefit to me and will only prolong my inevitable death or irreversible coma.

2. I desire that my wishes with respect to all health care matters be carried out through the authority given to my Health Care Representative under this Health Care Power of Attorney despite any contrary feelings, beliefs or opinions of other members of my family, relatives or friends. I have thoroughly discussed my personal preferences and desires with my Health Care Representative, and his or her successor. I am fully satisfied that each will know best what I would wish and I have the utmost faith and confidence in their respective good judgments.

3. In exercising the authority herein given to my Health Care Representative, my Health Care Representative should try to discuss with me the specifics of any proposed health care decision if I am able to communicate in any manner whatsoever, even by blinking my eyes. I hereby further direct and instruct my Health Care Representative that if I am unable to give an informed consent to my medical treatment or if the physician(s) providing me with medical care determine that I lack capacity to make a particular health care decision, my Health Care Representative shall make such health care decision for me based upon any treatment choices or other desires that I have previously expressed while competent, whether under this Health Care Power of Attorney or otherwise.

4. In order to aid my Health Care Representative in making decisions under this Health Care Power of Attorney, but in no way to limit the absolute authority and discretion granted herein to my Health Care Representative, if:

(A) Two licensed physicians who are familiar with my condition have diagnosed and noted in my medical records that I am in the terminal stage of an irreversible fatal illness, disease or condition and/or my condition is expected to result in my death within six (6) months or less regardless of what medical treatment I may receive;

(B) Two licensed physicians who are familiar with my condition have diagnosed and noted in my medical records that I am permanently unconscious. "Permanently unconscious" shall mean a medical condition that has been diagnosed in accordance with currently accepted medical standards and with reasonable medical certainty as total and irreversible loss of consciousness and capacity for interaction with the environment. The term "permanently unconscious" shall include without limitation a persistent vegetative state or irreversible coma;

(C) There have been two electroencephalograms (EEGs) which have been taken more than twenty-four (24) hours apart, and each scan indicates a flat brain wave pattern; or

(D) Two licensed physicians who are familiar with my condition have determined that my life may only be maintained by artificial means, including, but not limited to, respirators and feeding tubes, and that there is no reasonable possibility that I will ever be able to sustain my life without such artificial means; then, and in any of such events, my Health Care Representative is authorized to do any one or more of the following:

(i) To sign on my behalf any documents necessary to carry out the authorizations described below, including waivers or releases of liabilities required by any health care provider;

(ii) To give or withhold consent to any medical care or treatment, to revoke or change any consent previously given or implied by law for any medical care or treatment, and to arrange for my placement in or removal from any hospital, convalescent home or other health care institution;

(iii) To require that medical treatment that would only prolong my inevitable death or permanent unconsciousness (including by way of example, but not limited to, such treatment as cardiopulmonary resuscitation, surgery, dialysis, the use of a respirator, blood transfusion, antibiotics, antiarrhythmic and pressure drugs, or transplants) not be instituted, or if previously instituted, to require that it or they be discontinued;

(iv) To require, if I have been permanently unconscious, as defined above, for _______ (___) days or more, that procedures used to provide me with fluids and nutrition (including, by way of example only, parenteral feeding, intravenous feedings, misting, endotracheal or nasogastric tube use) not be instituted or if previously instituted, to require that they be discontinued; and

(v) To authorize the administration of pain relieving drugs, even if they may shorten my remaining life.

5. The rights and authority conferred on my Health Care Representative herein appointed shall include, but is by no means limited to, the right to receive information and reports from all treating physicians, other health care professionals, health care institutions, etc., regarding proposed health care, surgery, or any other aspect of my medical treatment; the right to receive and review my medical records and information to the same extent that I am entitled to and to disclose or consent to the disclosure of my medical records to others; to contract on my behalf for any health care related service or facility (without my Health Care Representative incurring personal financial liability for such contracts); and to hire and fire medical, social service and other support personnel responsible for my care.

6. This instrument is to be construed and interpreted as an "advance directive for health care" as such term is defined in [state statute ] (hereinafter the "Act"). In determining the rights of my Health Care Representative herein appointed, the enumeration of the specific items, rights, acts or powers set forth herein is not intended to nor does it limit, and it is not to be construed or interpreted as limiting, the specific power of my Health Care Representative to do and perform any and all acts with respect to my health care which I would be able to perform if I were competent and able to do so and as are within the bounds of authority granted by the Act.

7. In the event _______, _______, shall become unable to act as my Health Care Representative hereunder for any reason whatsoever, including, but not limited to, death, incapacity, or resignation, then I do hereby make, constitute and appoint _______ as successor Health Care Representative to serve in the place of the Health Care Representative first above named.

8. No person who relies in good faith upon any representations by my Health Care Representative or any successor Health Care Representative shall be liable to me, my estate, my heirs or my assigns, for recognizing the Health Care Representative's authority. The directions of my Health Care Representative shall be binding in all respects upon all those involved in my care. My Health Care Representative and all those acting upon his or her directions shall be entitled to indemnification from my estate in connection with all claims asserted against them, unless the directions given and relied on are wholly inconsistent with my intentions as expressed above.

9. If a guardian of my person should for any reason be appointed, I hereby nominate my Health Care Representative (or his or her successor), named above.

10. ADMINISTRATIVE PROVISIONS.

(A) I hereby revoke any prior Health Care Power of Attorney.

(B) This Health Care Power of Attorney is intended to be valid in any jurisdiction in which it is presented.

(C) My Health Care Representative shall not be entitled to compensation for services performed under this Health Care Power of Attorney, but he or she shall be entitled to reimbursement for all reasonable expenses incurred as a result of carrying out any provisions of this Health Care Power of Attorney.

(D) In the event of any disagreement between my Health Care Representative and my attending physician concerning my decision-making capacity or the appropriate interpretation and application of the terms of this Health Care Power of Attorney to my course of treatment, it is my wish and desire that such disagreement be resolved in accordance with the written direction of my Health Care Representative.

(E) The powers delegated under this Health Care Power of Attorney are separate, so that the invalidity of any one (1) or more powers shall not affect any others.

11. By this instrument, I intend to create a durable power of attorney effective upon and only during any period of incapacity in which, in the opinion of (i) my Health Care Representative and (ii) one or more other confirming physicians, I lack capacity to make a particular health care decision (i.e. "Period of Incapacity"). The rights, powers and authority of my Health Care Representative herein appointed shall commence and shall be in full force and effect upon any such determination as to the commencement of a Period of Incapacity, and such rights, powers and authority shall remain in full force and effect from the above-mentioned date until such time as I have regained my capacity to make such health care decision(s) or until my death, as the case may be; PROVIDED, HOWEVER, that this Health Care Power of Attorney may be revoked by me by a written instrument duly acknowledged before a notary public or by such other manner as shall be allowed under the Act; and PROVIDED, FURTHER, that my regaining capacity following any Period of Incapacity shall not be treated as an event causing the revocation of this Health Care Power of Attorney and this Health Care Power of Attorney shall be construed as if such Period of Incapacity never occurred.

I UNDERSTAND THE PURPOSE AND EFFECT OF THIS HEALTH CARE POWER OF ATTORNEY AND SIGN IT AFTER CAREFUL DELIBERATION THIS _______ DAY OF _______, 20___.

__________________________ (L.S.)

Each of the undersigned declares that the person who signed this Health Care Power of Attorney did so in the presence of the undersigned; that said person is personally known to the undersigned and appears to be of sound mind and acting willingly and free from duress or undue influence; and that each of the undersigned and the person executing this Health Care Power of Attorney is 18 years of age or older; and the undersigned is not designated as the person's Health Care Representative under this Health Care Power of Attorney.

______________________________ residing at

______________________________

______________________________

______________________________ residing at

______________________________

______________________________

STATE OF )

) SS:

COUNTY OF )

I hereby certify that on [date ] _______ personally came before me and acknowledged under oath, to my satisfaction, that [he/she ] is the person named in and personally signed this Health Care Power of Attorney, and that [he/she ] signed, sealed and delivered this Health Care Power of Attorney as [his/her ] act and deed for the uses and purposes therein expressed.