----------------------------------------------------------------------
Durable Power of Attorney for Health Care
I, _____Full_Legal_Name______ , execute this legal document as a formal
declaration of my informed and resolute treatment instructions.
1. On the basis of my individual conscience as well as my faith in
(and my personal understanding of) both the Hebrew and Christian
Scriptures, I direct that NO TRANSFUSIONS, INFUSIONS, OR INJECTIONS
OF WHOLE BLOOD OR ITS FRACTIONS AND DERIVATIVES be administered to
me under any circumstances, even if health-care providers believe
that such are necessary to preserve my life. I likewise refuse to
pre-donate and store my own blood for later infusion.
--- Please see Leviticus 17:10-13 and Acts 15:28,29 ---
2. I have ADDITIONALLY chosen, in harmony with the right of informed
choice implied in the laws of informed consent, and on the basis of
deeply held PERSONAL values & convictions which give life meaning,
to ENTIRELY AVOID medical (i.e. chemical, surgical & other allopathic)
therapies & proceedures (lNCLUDlNG HOSPITALIZATION) in favor of
certain non-medical, NON-SPIRITISTIC, entirely physical and
biological therapies (most Chiropractic and Naturopathic disciplines
as prime examples) which, in my personal circumstances and experience
have proven reasonable, understandable and effective both in illness
AND INJURY (but which are not entirely compatible with traditional
western medicine). THIS IS NOT A DEATH WISH. I will earnestly pursue
such so-called "alternative" therapies to the best of my ability.
I firmly beg and INSIST that Emergency Medical Technicians (and others
who feel "responsible") respect this choice EVEN IF I AM UNCONSCIOUS.
I WOULD appreciate basic NON-BLOOD, non-chemical, non-invasive,
physical first aid if needed -- to arrest or retard profuse bleeding
or set and splint broken bones, for example. If, in spite of
reasonable efforts, I appear to be dying, please take me home,
if at all possible, and let me die ( or revive ) IN PEACE.
In case it is not self-evident from the above instructions, I do NOT
want to be administered mechanical or chemical "ARTIFICIAL LIFE
SUPPORT" of any kind (including artifical nutrition and hydration) or
even "natural" therapies that function only as drugs and do not supply
the body with "resources" (such as energy or "building materials") to
carry out it's own repair, maintenance, and internal "housekeeping".
3. I realize there are risks to these choices, JUST AS THERE ARE
RISKS to ALL MEDICAL therapies, and hereby release those who have done
their best to follow these instructions from any charge of neglect.
I give no one ( including any appointed decision-making agents ) any
authority to disregard or override my instructions set forth herein.
Relatives, friends OR PROFESSIONALS may disagree with me, but any
such disagreement does not diminish the strength or substance of my
ABSOLUTE REFUSAL OF BLOOD or my other decisions and instructions.
_(Page 1 of 2)_
4. Health-Care Agents or Advocates:
While the above should leave very little to be decided by anyone
except accredited non-medical, non-spiritistic health-care
professionals, I appoint the person(s) named below as my advocate(s)
to take any necessary steps, including legal action, to ensure that my
decisions and instructions are honored. I give my advocate(s) full
power and authority to consent to or to refuse treatment on my behalf,
(WITHIN BOUNDS OF THE ABOVE INSTRUCTIONS) to consult with appropriate
available health-care professionals, to obtain copies of any medical
records regarding my condition, and to make any other health-care
decisions not already set out above. If my first appointed advocate
becomes unavailable, unable, or unwilling to serve, I appoint an
alternate advocate below to serve with the same power and authority.
______________________________ ______________________________
(ADVOCATE) (ALTERNATE ADVOCATE)
______________________________ ______________________________
(address) (address)
______________________________ ______________________________
______________________________ ______________________________
(telephone/s) (telephone/s)
. . . . . . . . . . . . . . . . . . . . . . .
.
Durable Power of Attorney .
for Health Care . ______________________________
. (MY SIGNATURE)
.
! NO BLOOD ! .
. ______________________________
. (address)
NO ARTIFICIAL .
.
LIFE SUPPORT . ______________________________
.
(Signed Legal Document) .
. ______________________
. . . . . . . . . . . . . (date) . . . . . . .
5. STATEMENT OF WITNESSES: I attest that the person who signed
above, voluntarily signed or voluntarily directed another to sign
this document in my presence. He or she appears to be of sound mind
and free from duress, fraud, or undue influence, and is 18 years of
age or older, as I also am.
______________________________ ______________________________
(signature) (signature)
______________________________ ______________________________
(address) (address)
_ _(Page 2 of 2)_
----------------------------------------------------------------------
Here's a plain text version of
the above form
if you find enough of it useful you'd like to copy it to your
word processor for editing and printing.
(The link opens in a new window
so you won't lose the navagation system of the HTML pages.)
Of course, you'll want to keep the original in a secure and fire-proof
location, and give copies to your advocates, primary health care
provider, and appropriate family members. And, of course, if your
Advance Medical Directives are REALLY important to you, be sure to
carry a copy on your person with your jurisdiction's official
personal I.D.
|