Durable Power of Attorney for Health Care Will to Live Form - Iowa

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health care provider(s), utilizing the most current diagnoses and/or prognosis of my medical
condition, in the following situations with the written special instructions.
WHEN MY DEATH IS IMMINENT
A. If I have an incurable terminal illness or injury, and I will die imminently – meaning that a
reasonably prudent physician, knowledgeable about the case and the treatment possibilities with
respect to the medical conditions involved, would judge that I will live only a week or less even
if lifesaving treatment or care is provided to me – the following may be withheld or withdrawn:
(Be as specific as possible; SEE SUGGESTIONS.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Cross off any remaining blank lines.)
WHEN I AM TERMINALLY ILL
B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even
though death is not imminent I am in the final stage of that terminal condition – meaning that a
reasonably prudent physician, knowledgeable about the case and the treatment possibilities with
respect to the medical conditions involved, would judge that I will live only three months or less,
even if lifesaving treatment or care is provided to me – the following may be withheld or
withdrawn:
(Be as specific as possible; SEE SUGGESTIONS.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Cross off any remaining blank lines.)
C. OTHER SPECIAL CONDITIONS:
(Be as specific as possible; SEE SUGGESTIONS.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Cross off any remaining blank lines.)
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Durable Power of Attorney for Health Care Will to Live Form - Iowa PDF

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