|
� �T _ =.= _ -,-
<br /> ����:- . . __`:��,
<br /> - � � �
<br /> . � . . � ...L:..
<br /> . '�: '_'ie"".. u'_..
<br /> . . ti --
<br /> ^ �ileidC-rttet�w --- �- '-----.._'--`—"'-. ..a.�,..��.�----....---
<br /> �• �--_ .
<br /> � ■
<br /> ' • �w ���
<br />� D. �y ittornay� in taat ascs authoxixscl as lallova: _
<br /> 1• �gf�o�ti__on- To r�Qu�ss�, rsc�iv� and rovf�w �n�► -
<br /> intcrsatian, varbal or writY.�n, ragarding wy
<br /> p�►ysical or fan�ai h.alth, incluainq awical ana
<br /> hoapital r�oords• to �x�aut� any r�l�arss or oth�r
<br /> clocuvnts tbat'a�y bt rpuir�d in ordsr to obtain
<br /> ���n intor�atiori, and to disa�ose �uch inlor�ati�on
<br /> t� �y�cp persons or antiti�� a� �y m�tornsy in lact
<br /> st�all d�� appropriat�.
<br /> Z. �1QZ � !! so�M� lsallti car� 'lb _
<br /> swploy and disc�rg� a�dical parsoien�l includinq _
<br /> phYsicians. p�Ycbfatrists, dsnti�t�, nursas, and
<br /> th�rapiatis as sy attor�ys in fact shall daaa
<br /> nacsasarY ff�c aY pbYsical, �sntal and �awtfonal
<br /> w�ll-b�inq, and to arranq� !or tha* to be paid
<br /> r�asonabl� co�pussation.
<br /> �, gf�. ■ tshol . �it�sar. or �iit Consant so
<br /> To give csr withho?a con�.:� �o
<br /> any a�dicsl proc�clurs, tsst or trsataant,
<br /> incl�ding surq�ry: to arrancJ� !or sy
<br /> hoa�ftalisation� c�r►val�scont cars. hoapicw or
<br /> hoa� car�; tu su� paraaadica or �athar as�rc3ancY
<br /> aodical p�st�l arW sssk u�r9sncy txsata�nt !or
<br /> �, s� sy ��rorn�ys in lact �hsll dass�
<br /> aPPx'opriat�; and usW�r ciranastances in vhich ay
<br /> attornay� in lact dQtarain4 that c�rtain asdical
<br /> proc�dur�s, t�ats or ttsats�nta a�a no lonq�r o!
<br /> . any b�n�lit to s� or, vhar� th� lpaaelits ar�
<br /> � �._.�.��� 1 .i `w w�wwi►�
<br /> Q�, �Z �Q � LA� f�NLifii�fi iW�iV��s/ w ��`M••� �.
<br /> trithdraw, sodily oar charxJ� conssnt to auch .
<br /> proc�d�rsa. tssts at� tr�atswnts, aa well aa ,
<br /> hospita31za41on, convaAsac�rft car�o hoapic� or
<br /> bo�e csro wbiaD T or sy attornsys in faat aay havc�
<br /> prsviously aliow�d or conssnt�d to or which aay
<br /> hav� 2�r faplikD du� to �strq�noY condi���ions. Ky
<br /> attornsys��i�a lact•s d�ciafons shoiatd bs quidtd by
<br /> talcing into account (1) ths provf�ecf� o! tLis
<br /> docuasAt; (Z) any r�liabl� �vid��wr o� prsl�r�s
<br /> that I say hav� �cpr�ssed on the subject, t�rhethsr �
<br /> b�lora or iit.�r th� �t�cution o! �bis docua�nt;
<br /> (3) whst ay attorn�ys in tact bs�#:�v� I would want
<br /> dor� in th� circumastanc�s if i wa�e able to
<br /> �xprsas ay�all; ancl (4) any inlorsatio� qivan to
<br /> � ay attor�s�'m in taat by tho pt►ysicfans tr�atinq s�
<br /> � as to =y s�dical diaqnosfs assd prognas3s and th�
<br /> : ' -fntrusivan�a.s, pain, rfaka and �ids e�facta
<br /> associat�d with th� tr�ataarzt• T� authority
<br /> " grant�i h�r�in apecilically incl�3as tha authority
<br /> - to dfr�ct th� withhaldinq cr Withclrawal o! lf�e-
<br /> sustaininq traatasnt and �artiticially adoinist�r�d
<br /> nutritfon and hydration.
<br /> _ � :2- _
<br /> ,�-�- - _-- . - _ rt�� - - h . . . _,-,�^,�
<br /> � ' � .�. • , ., � �aF. 'i.: �' .s.H, � a ! ".,���."r�"a,.c .
<br /> �`� - r. ... . . ••' . � �� s�}'. .' �,"'' � _
<br /> . .. , t. . . .i� T �•' . ' � ♦� -
<br /> ,� � � ... . - . ,i�b a�..r±���ti s� i. d,. . . ';,y.i. �.:.. -
<br />-'� � . �r �.�' r.N. ' .. .. ♦. :t t ..'f�F.��_��1[If� ..�� w:' .� _ -�wa. __-..
<br /> � ��A.i� .�..��' 6 " --
<br />- ' � .. .. - '--riv�'-i� �.« � ' :r�, '� ,. +
<br />... . . . - RYII..a� . .
<br /> , � . . _ . .. _�t •�;,,�.�.,� � '
<br /> _'; _ • , '" �:,=..
<br /> , .. ., „ao�:�
<br /> -:t • , � ` . .,"—_ .:�� �__ _ �'__
<br /> ',�r, � ' � ' � .� �, �`'.. � . .:i i 1. _
<br /> . . _ ' . �'� y!. r.�.ii.:.
<br /> �' ' �. • . r , ., � — ,. .' '�::.,,.�.. ..Y
<br /> " ' � . — ——= — -- '��_,,tts�.�''.;.._.,,�.
<br />
|