Durable Power of Attorney for Health Care and Living Will

VA FORM
10-0137
Page 4 of 7
JUL 2015
VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle) LAST FOUR DIGITS OF SSN:
B - MENTAL HEALTH PREFERENCES
This section is optional. You may skip this section if you do not have a serious mental health problem or if you
do not want to write down your preferences for mental health care. If you have a serious mental health
condition, you might want to write down medications that have worked for you in the past and that you would
want again, or you might want to write down the mental health facilities or hospitals that you like and those
that you don’t like. If you need more space, you may attach extra pages and use this space to refer to
attached pages. Be sure to initial and date every page that you attach.
If I need to use a breathing machine and be in bed
for the rest of my life.
If I have pain or other severe symptoms that cause
suffering and can't be relieved.
If I have a condition that will make me die very soon,
even with life-sustaining treatments.
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Other:
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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.
If I have a permanent condition where other people
must help me with my daily needs (for example,
eating, bathing, toileting).
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Page 4/7
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