Category Archives: Resources and Reflections

MISSOURI DURABLE POWER OF ATTTORNEY FOR HEALTH CARE — WILL TO LIVE FORM

Missouri Durable Power of Attorney for Health Care

Will to Live Form

I, __________________________________________________________, of

(name of principal)

Address:_____________________________________________________,

Home Telephone:_______________Work Telephone: _______________

hereby designate ____________________________________________

(name of attorney in fact)

Address ______________________________________________________

Home Telephone: _______________ Work Telephone: ______________

as my attorney in fact to make any health care decisions for me
as authorized in this declaration consistent with the
instructions below.

In the event the person I designate above is unable, unwilling or unavailable to act as my attorney in fact,
I hereby appoint the following persons (each to act alone and successively, in the order named):

A. ____________________________________________________________

(name of successor attorney in fact)

Address _______________________________________________________

Home Telephone:_______________ Work Telephone: ________________

B._____________________________________________________________

(name of second successor attorney in fact)

Address _______________________________________________________

Home Telephone:_______________ Work Telephone: ________________

as my successor attorney(s) in fact to make any health care decisions for me
as authorized in this document consistent with the instructions below.

GENERAL PRESUMPTION FOR LIFE

I direct my health care provider(s) and attorney in fact to make health care decisions consistent with my
general desire for the use of medical treatment that would preserve my life, as well as for the use of medical
treatment that can cure, improve, or reduce or prevent deterioration in, any physical or mental condition.
Food and water are not medical treatment, but basic necessities. I direct my health care provider(s) and
attorney in fact to provide me with food and fluids orally, intravenously, by tube, or by other means to the full extent necessary both to preserve my life and to assure me the optimal health possible.

I direct that medication to alleviate my pain be provided, as long as the medication is not used in order to
cause my death.

  • I direct that the following be provided:

 

  • the administration of medication;

 

  • cardiopulmonary resuscitation (CPR);

and

  • the performance of all other medical procedures, techniques, and technologies, including surgery,
    — all to the full extent necessary to correct, reverse, or alleviate life-threatening or health-impairing conditions, or complications arising from those conditions.

 

  • I also direct that I be provided basic nursing care and procedures to provide comfort care.
  • I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of an unborn or newborn child, who has been subject to an induced abortion. This rejection does not apply to the use of tissues or organs obtained in the course of the removal of an ectopic pregnancy.
  • I also reject any treatments that use an organ or tissue of another person obtained in a manner that causes, contributes to, or hastens that person’s death.
  • The instructions in this document are intended to be followed even if suicide is alleged to be attempted at some point after it is signed.
  • I request and direct that medical treatment and care be provided to me to preserve my life without
    discrimination based on my age or physical or mental disability or the “quality” of my life. I reject any action or omission that is intended to cause or hasten my death.
  • I direct my health care provider(s) and attorney in fact to follow the above policy, even if I am judged to be incompetent.
  • During the time I am incompetent, my attorney in fact, as named above, is authorized to make medical
    decisions on my behalf, consistent with the above policy, after consultation with my health care provider(s),
    utilizing the most current diagnoses and/or prognosis of my medical condition, in the following situations with the written special conditions.

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.)

IF I AM PREGNANT

D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and health care
representative(s) to use all lifesaving procedures for myself with none of the above special conditions applying
if there is a chance that prolonging my life might allow my child to be born alive. I also direct that lifesaving
procedures be used even if I am legally determined to be brain dead if there is a chance that doing so might
allow my child to be born alive. Except as I specify by writing my signature in the box below, no one is
authorized to consent to any procedure for me that would result in the death of my unborn child.

___________________________________________________________

If I am pregnant, and I am not in the final stage of a terminal condition as defined above, medical
procedures required to prevent my death are authorized even if they may result in the death of my unborn
child provided every possible effort is made to preserve both my life and the life of my unborn child.

___________________________________________________________

Signature

___________________________________________________________

THIS IS A DURABLE POWER OF ATTORNEY AND THE AUTHORITY OF MY ATTORNEY IN
FACT SHALL NOT TERMINATE IF I BECOME DISABLED OR INCAPACITATED OR IN THE EVENT
OF LATER UNCERTAINTY AS TO WHETHER I AM DEAD OR ALIVE.

This power of attorney becomes effective upon certification by two licensed physicians that I am
incapacitated and can no longer make my own medical decisions. The powers and duties of my attorney in fact
shall cease upon certification that I am no longer incapacitated. This determination of incapacity shall be
periodically reviewed by my attending physician and my attorney in fact.

I, ________________________________________________________, the principal,

(print name)

sign my name to this instrument this day of _______________ ________,

and being first duly sworn, do hereby declare to the undersigned authority
that I sign it willingly, that I execute it as my free and voluntary act
for the purposes therein expressed, and that I am eighteen years of age
or older, of sound mind, and under no constraint or undue influence.

Date: ________________ __________________________________

(Signature)

State of Missouri )

) SS.

County of )

On this __________ day of ________________, 2________, before me personally
appeared , to me known to be the person described in and who executed
the foregoing instrument, and acknowledged that he or she executed the
same as his/her free act and deed.

Notary Public ______________________________________________

My commission expires: ___________________________

(Notary Seal)

Form Prepared 2001 – See Attorney General’s website to update this.