(2) AGENT'S AUTHORITY: My agent is authorized to make all health-care decisions for me,
including decisions to provide, withhold, or withdraw artificial nutrition and hydration, and all other
forms of health care to keep me alive, except as I state here:
(Add additional sheets if needed.)
(3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority
becomes effective when my primary physician determines that I am unable to make my
own health-care decisions unless I mark the following box. If I mark this box [ ], my
agent's authority to make health-care decisions for me takes effect immediately.
(4) AGENT'S OBLIGATION: My agent shall make health-care decisions for me in
accordance with this power of attorney for health care, any instructions I give in Part 2 of
this form, and my other wishes to the extent known to my agent. To the extent my
wishes are unknown, my agent shall make health-care decisions for me in accordance
with what my agent determines to be in my best interest. In determining my best interest,
my agent shall consider my personal values to the extent known to my agent.
(5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed
for me by a court, I nominate the agent designated in this form. If that agent is not
willing, able, or reasonably available to act as guardian, I nominate the alternate agents
whom I have named, in the order designated.