Durable Power of Attorney for Health Care and Living Will

VA FORM
10-0137
Page 3 of 7
JUL 2015
This section of the advance directive form is called a Living Will. This section of it lets you write down how
you want to be treated in case you aren't able to decide for yourself anymore. Its purpose is to help others
decide about your care.
VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle) LAST FOUR DIGITS OF SSN:
PART III: LIVING WILL
A - SPECIFIC PREFERENCES ABOUT LIFE-SUSTAINING TREATMENTS
If I have permanent, severe brain damage that
makes me unable to recognize my family or friends
(for example, severe dementia).
If I am unconscious, in a coma, or in a vegetative
state and there is little or no chance of recovery.
In this section, you can indicate your preferences for life-sustaining treatments in certain situations. Some
examples of life-sustaining treatments are:
l
CPR (cardiopulmonary resuscitation)
l
a breathing machine (mechanical ventilation)
l
kidney dialysis
l
a feeding tube (artificial nutrition and hydration)
Think about each situation described on the left and ask yourself, “In that situation, would I want to have
life-sustaining treatments?” Place your initials in the box that best describes your treatment preference. You
may complete some, all, or none of this section. Choose only one box for each statement.
Initials InitialsInitials
Yes.
I would want
life-sustaining
treatments.
I'm not sure. It
would depend
on the
circumstances.
No.
I would not want
life-sustaining
treatments.
Initials InitialsInitials
Fill out this section if you want to appoint a second person to make health care decisions for you,
in case the first person isn’t available.
City, State, Zip:
Street Address:
Work Phone with Area Code:Home Phone with Area Code: Mobile Phone with Area Code:
Name (Last, First, Middle): Relationship to Me:
If the person named above can't or doesn't want to make decisions for me, I appoint the person
named below to act as my Health Care Agent.
Initials
B - ALTERNATE HEALTH CARE AGENT
Page 3/7
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