Medical Durable POA Examples of “Instructions to Agent” Optional Language

Examples are optional and not legal advice.

• I would / would not want life sustaining treatment: 
  • If I am unconscious, in a coma, or in a vegetative state and there is little or no chance of recovery.
  • If I have permanent, severe brain damage that makes me unable to recognize my family or friends (for example, severe dementia).
  • If I have a permanent condition where other people must help me with my daily needs (for example, eating, bathing, toileting).
  • 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. 
• Preference for pets being allowed in room or at bedside. 
• Preference of where one would like to pass away ( hospital/hospice/care facility/home or other). 
• Preference for Organ Donation. 
• Consider palliative care consult regarding goals of care. 
• Please keep me company and as comfortable as possible. 
• Please allow my family and friends to be by my side as much as they need. 
• Preference for when an agent’s powers begin (if not on form): 
  • Immediately upon my signature (standing power as needed)
  • When my physician or other qualified medical professional has determined that I am unable to make or express my own decisions, and for as long as I am unable to make or express my own decisions. (Springing power determined by medical professionals)  

Do Not Use the Instructions to Agent Optional Section on the MDPOA form to State the Following: 

Your preference for CPR - a MOST Form or CPR Directive must be completed with your provider. Only seek a CPR Directive or MOST Form if you DO NOT want anyone to attempt CPR from the moment you sign one of these documents.