A PERSONAL DECISION
Practical information about
determining your future medical care
including living wills and
powers of attorney for health care
Provided by: the
Illinois State Medical Society
Determining Your Medical Care Is Your
Right
While advances in medicine and
medical technology can save many lives that only fifty years ago might have
been lost, the issue of quality at the end of life has come under intensive
judicial and public scrutiny. In the state of
Decisions about the quality of the end of life about life support systems,
aggressive resuscitation efforts, about hydration and nutrition of comatose patients are all serious,
personal decisions each of us must arrive at privately. Neither the law nor any
person can require you to make such a decision against your will. If you wish
to exercise your right to determine the care you receive should you be injured
or ill, this brochure will help you make an informed decision.
In
Durable
power of attorney for health care.
Using this document you can designate
someone else, called an agent or surrogate, to make decisions about your health
care in the event you are unable to do so yourself. This person can, by law, be
anyone you choose over the age of 18 (not 21) except the doctor providing your care. This person
will have the legal right and responsibility to make decisions about your
health care, including the initiation and termination of medical procedures and
life support systems, organ donation and autopsy. For example, a person with
irreversible brain injuries remains in a coma from which doctors have
determined the patient will never recover.
The agent designated in the durable power of attorney for health care can
refuse the antibiotic treatment that the hospital would administer should the
patient develop pneumonia. Without antibiotics, the pneumonia would most likely
be fatal. Because the patient has determined in advance, through discussion
with surrogates and by signing the durable power of attorney that death
should not be delayed in this circumstance, the agent is authorized to decline
lifesaving efforts. Most people select a member of their family or a close
friend to act as their surrogate in these situations. You may designate several
surrogates, in case your first choice of a decisionmaker is unavailable or unwilling to serve.
Whoever you choose, you should discuss your wishes with them.
While your caregivers must respect your surrogate's decisions and the court
will uphold them, the surrogate or agent can be removed by the court if doing
so is determined to be in your best interest. Your physician and the hospital
will also play a part in that decision.
This booklet includes a short form Durable Power of attorney for Health Care,
legal in the state of
The Living Will
The living will does not appoint another
person to make your health care decisions but declares your intent that if your
medical condition is incurable and irreversible the people taking care of you
not delay your death, if it is imminent, through lifesaving measures. It allows
you to control your health care even if you cannot communicate with the people
caring for you.
For example, a cancer patient whom the doctors estimate has only weeks to live
can, through the use of a living will, instruct the hospital that no
extraordinary measures are to be taken to prolong her life; if she suffers
cardiac arrest, for example, the hospital is not to attempt to revive her. She
may also choose to decline the future use of a respirator, or techniques such
as blood transfusions or kidney dialysis.
Any adult (over the age of 18) of sound mind can make a living will. It must be
created as a voluntary act, must be signed by a patient (or another person at
the direction of the patient) and must be witnessed by two adults. The living
will has no effect legally unless the physician responsible for the patient's
care certifies, in writing, that the patient's condition is terminal, that
death is imminent, and that deathdelaying
procedures will only prolong the process of dying. Nutrition and hydration may
not be withheld or withdrawn if such act and not the existing medical condition
will cause death. The living will form in this brochure has been developed by
the
Living Will
The Living Will Act includes the
following suggested form:
Declaration (As included in the Illinois Living Will Act, Ill. Rev. Stat. 1989,
Ch. 110 1/2 par. 703) This declaration is made this day of
________________________________________________________ (month, year).
I,________________________________________
being of sound mind, willfully and voluntarily make known my desires that
my moment of death shall not be artificially postponed.
If at any time I should have an incurable and irreversible injury, disease or
illness judged to be a terminal condition by my attending physician who has
personally examined me and has determined that my death is imminent except for deathdelaying procedures, I
direct that such procedures which would only prolong the dying process be
withheld or withdrawn, and that I be permitted to die naturally with only the
administration of medication, sustenance, or the performance of any medical
procedure deemed necessary by my attending physician to provide me with comfort
care.
In the absence of my ability to give directions regarding the use of such deathdelaying procedures, it is
my intention that this declaration shall be honored by my family and physician
as the final expression of my legal right to refuse medical or surgical
treatment and accept the consequences from such refusal.
Signed________________________________________________________
City, County and State of
The declarant is personally known to me and I believe
him or her to be of sound mind. I saw the declarant sign the declaration in my presence, or
the declarant acknowledged
in my presence that he or she had signed the declaration, and I signed the
declaration as a witness in the presence of the declarant. I did not sign the declarant's signature above for or at the direction
of the declarant. At the
date of this instrument, I am not entitled to any portion of the estate of the declarant according to the laws
of intestate succession or
to the best of my knowledge and belief, under any will of declarant or other instrument taking effect at declarant's death or directly
financially responsible for declarant's
medical care.
Witness ______________________________________________________________
Witness ______________________________________________________________
(Comment: Even though the Act states that another form, which may include
specific prohibitions or types of procedures that may be acceptable, it is
advisable that any variation from the form above should be subject to review by
an attorney to assure its validity.)
Changing Your Decision
You can at any time amend, alter or void
your living will or durable power of attorney by destroying the document or
preparing a written statement declaring your intent to set them aside.
The forms in this brochure allow you to direct your family, your health care
providers and the others involved in your medical care to follow your wishes,
should the time come when these difficult decisions must be made. You need not
consult an attorney to put any of these into effect; it is very important,
however, that you discuss your decisions and these documents with your family,
your physician and your legal advisor, to assure that your wishes are followed.
Consequences of not executing an
Advance Directive
If you do not execute an advance
directive and your medical condition is terminal, incurable or irreversible,
you lack decisional capacity, or you are permanently unconscious, a surrogate
may be appointed for you. This surrogate will have the authority to make lifesustaining treatment
decisions for you. In other circumstances, your hospital, another health care
institution or doctors may be required to do everything in their power to keep
you alive, no matter what your condition or chances of recovery.
Illinois Power of Attorney Act Official Statutory Form
11 Rev. Stat., (a), Effective Jan. 1, 1990
Illinois Statutory Short Form Power of
Attorney For Health Care
Notice: the purpose of this Power of
attorney is to give the Person you designate (your "agent") broad
powers to make health care decisions for you, including power to require,
consent to or withdraw any type of personal care or medical treatment for any
physical or mental condition and to admit you to or discharge you from any
hospital, home or other institution. This form does not impose a duty on your
agent to exercise granted powers; but when powers are exercised, your agent
will have to use due care to act for your benefit and in accordance with this
form and keep a record of receipts, disbursements and significant actions taken
as agent. A court can take away the powers of your agent if it finds the agent
is not acting properly. You may name successor agents under this form but not coagents, and no health care
provider may be named. Unless you expressly limit the duration of this power in
the manner provided below, until you revoke this power or a court acting on
your behalf terminates it, your agent may exercise the powers given here
throughout your lifetime, even after you become disabled The powers you give
your agent, your right to revoke those powers and the penalties for violating
the law are explained more fully in sections 45, 46, 49 and 410(b) of the
Illinois "Powers of attorney for Health Care Law" of which this form
is a part. That law expressly permits the use of any different form of power of
attorney you may desire. If there is anything about this form that you do not
understand, you should ask a lawyer to explain it to you.
Power of Attorney made this ________day _________(month)_______
(year)
1.____________________________________________________________________________________
(insert name and address of principal)
hereby appoint
___________________________________________________________________________
(insert name and address of agent for
removal of lifesustaining
treatment are set forth below. If you agree with one of these statements, you
may initial that statement but do not initial more than one):
(Initial_______ ) I do not want my
life to be prolonged nor do I want lifesustaining
treatment to be provided or continued if my agent believes the burdens of the
treatment outweigh the expected benefits. I want my agent to consider the
relief of suffering, the expense involved and the quality as well as the
possible extension of my life in making decisions concerning life sustaining
treatment, hospitalization and health care and to require, withhold or withdraw
any type of medical treatment or procedure, even though my death may ensue. My
agent shall have the same access to my medical records that I have, including
the fight to disclose the contents to others. My agent
shall also have full power to make a disposition of any part or all of my body
for medical purposes, authorize an autopsy and direct the disposition of my
remains.
(The above grant of power is intended to be as broad as possible so that your
agent will have authority to make any decision you could make to obtain or
terminate any type of health care, including withdrawal of food and water and
other lifesustaining
measures, if your agent believes such action would be consistent with your
intent and desires. If you wish to limit the scope of your agent's powers or
prescribe special rules or limit the power to make an anatomical gift, authorize
autopsy or dispose of remains, you may do so in the following paragraphs.)
2. The powers granted above shall not include the following powers or shall be
subject to the following rules or limitations (here you may include any
specific limitations) as my attorneyinfact
(my "agent") to act for me and in my name (in any way I could act in
person) to make any and all decisions for me concerning my personal care,
medical limitations you deem appropriate, such as: your own definition of when lifesustaining measures should
be withheld; a direction to continue food and fluids or lifesustaining treatment in all events; or
instructions to refuse any specific types of treatment that are inconsistent
with your religious beliefs or unacceptable to you for any other reason, such
as blood transfusion, electroconvulsive
therapy, amputation, psychosurgery, voluntary admission to a mental
institution, etc.:
The subject of lifesustaining
treatment is of particular importance. For
your convenience in dealing with that subject, some general statements
concerning the withholding
treatment.
(Initial_______ ) I want my life
to be prolonged and I want lifesustaining
treatment to be provided or continued unless I am in a coma which my attending
physician believes to be irreversible, in accordance with reasonable medical
standards at the time of reference. If and when I have suffered irreversible
coma, I want lifesustaining
treatment to be withheld or discontinued.
(Initial_______ ) I want my life to be prolonged to the greatest extent
possible without regard to my condition, the chances I have for recovery or the
cost of the procedures.
(This power of attorney may be amended or revoked by you in the manner provided
in section 46 of the
( ) This power of attorney shall become effective
on________________________________________________________________________ (insert
a future date or event during your lifetime, such as a court determination of
your disability, when you want this power to first take effect)
( )
This power of attorney shall terminate on __________________________________________________________________________
(insert a future date or event, such
as a court determination of your disability, when you want this power to
terminate prior to your death)
(If you wish to name successor agents, insert the names and addresses of
such successors in the following paragraph.)
5. If any agent named by me shall die, become incompetent, resign, refuse
to accept the office of agent or be unavailable, I name the following (each to
act alone and successively, in the order named) as successors to such agent:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
For purposes of this paragraph 5, a person shall be considered to be
incompetent if and while the person is a minor or an adjudicated incompetent or
disabled person or the person is unable to give prompt and intelligent
consideration to health care matters, as certified by a licensed physician.
(If you wish to name your agent as guardian of your person, in the event a
court decides that one should be appointed, you may, but are not
required to, do so by retaining the following paragraph. The court will appoint
your agent if the court finds that such appointment will serve your best
interests and welfare. Strike out paragraph 6 if you do not want your agent to
act as guardian.)
6. If a guardian of my person is to be appointed, I nominate the agent
acting under this power of attorney as such guardian, to serve without bond or
security.
7. I am fully informed as to all the contents of this form and understand the
full import of this grant of powers to my agent.
Signed______________________________________________________________________________
(principal)
The principal has had an
opportunity to read the above form and has signed the form or acknowledged his
or her signature or mark on the form in my presence. Residing at:_______________________________________________________________________________________________________________________________________________________________________________________ (witness)________________________________________________________________
(You may, but
are not required to, request your agent and successor agents to provide
specimen signatures below. If you include specimen signatures in this power of attorney, you must complete
the certification opposite the signatures of the agents.)
Specimen signatures of agent (and
successors).
I certify that the signatures of my agent (and successors) are correct.
_______________________________________________________
(agent) (principal)
______________________________ _________________________
(successor agent) (principal)
______________________________ _________________________
(successor agent) (principal)