Updated June 02, 2022
A Pennsylvania medical power of attorney form allows a patient to select an agent to make health care decisions on their behalf. It is recommended for the principal to write their goals on how to best decide treatment options. The principal can also multiple agents to serve in case the primary agent is not available.
Definition
“Health care power of attorney.” A writing made by a principal designating an individual to make health care decisions for the principal.
Laws
- Signing Requirements – Two (2) witnesses. In addition to the witnesses, notarization is optional but not required (§ 5452 and § 5471).
- Statutes – Chapter 54 Subchapter C (§ 5441 to § 5447)
How to Write
Download: Adobe PDF
1 – Access And Fill Out This Template To Name An Individual As A Health Care Agent In Pennsylvania
The form on this page will definitively appoint a person with the Power to make Health Care Decisions and Take Actions with a Principal’s Medical Care should the Principal be unable to communicate.
2 – The Principal Must Be Introduced In The First Paragraph
The person who wishes to grant Health Care Powers to an Agent must have his or her Name recorded on the first available empty line in the introduction.
The second available empty line will require a basic verification of the Principal’s Identity through the presentation of his or her Address.
3 – Review The Powers Being Granted To The Agent And Identify Him Or Her
The basic Decisions and Actions a Health Care Agent will have the Power to conduct on the Principal’s behalf will need to be reviewed before proceeding. Locate the numbered list of Principal Authority on the first page. Any of these Principal Powers can be removed or deleted before the Principal signs this Directive, but not after he or she does. Thus, the Principal should go through this list. By default it will give the Health Care Agent the Authority to withhold/withdraw medical care and surgical procedures, withhold/withdraw artificial nutrition and hydration, Admit or Discharge the Principal from Health Care Facilities (i.e. Medical, nursing, residential, hospice, etc.), hire/fire individuals responsible for the Principal’s Health (i.e. Social Service, Support Personel), engage in Legal Action to enforce the Principal’s wishes, and request the Principal’s Physician to issue a DNR (Do Not Resuscitate).If any list item contains a definition of actions the Health Care Agent should not be allowed to engage in, cross it out with a horizontal line or delete it using the appropriate software.
Next, it will be time to present the Identity of the Health Care Agent. This task will be handled in the section labeled “Appointment Of Health Care.” Here several lines will be provided to effectively disclose the identity of the person the Principal wishes to name as his or her Health Care Agent. Find the line following the words “I Appoint The Following Health Care Agent,” then enter the Full Name of the Health Care Agent. This statement will act as a formal declaration of the principal.
Re-enter the Health Care Agent’s Name on the blank space following the words “Health Care Agent (Name And Relationships)” along with the role the Health Care Agent plays in the Principal’s life (i.e. “Cousin,” “Close Friend,” “Daughter”).
The next several blank lines will be devoted purely for the purpose of defining the Health Care Agent’s Location and Contact Information. Enter his or her Address on the “Address” line.
Next using the two spaces (labeled “Home” and “Work”) following the label “Telephone Number,” enter Health Care Agent’s Home Telephone Number and Work Number
The blank line labeled “E-Mail” requires the E-Mail Address of the Health Care Agent entered on it. This should be an up-to-date account that is regularly monitored by the Health Care Agent.
If the Health Care Agent is not available, cannot wield Principal Power, or will not live up to his or her assigned role then it may be considered wise to have an Alternate Health Care Agent set-up to assume Principal Power. To do this, locate the two paragraph beginning with the term “If You Do Not Name A Health Care Agent…” then use the next portions of this area to declare a “First Alternative Health Care Agent (Name And Relationship)” on the first blank line. (i.e. Johnathan Doe, Son). Below this, enter the First Alternative Health Care Agent’s Address, Telephone Numbers (Home and Work), and E-Mail Address.
In the portion of this document beginning with the line labeled “Second Alternative Health Care Agent (Name And Relationship),” record the Full Name of the Second Alternative Health Care Agent along with how this individual is related to the Principal (i.e. Janet Doe, Daughter). Then, on the next few blank lines, document this entity’s Address, Home Telephone Number, Work Telephone Number, and Email Address. Keep in mind that neither Alternative First or Second Health Care Agents will access Principal Power only through succession. That is, the Health Care Agent must be unavailable so the First Alternative Health Care Agent may use Principal Power.
4 – Prepare And Report The Principal Directives the Health Care Agent Must Obey
Locate the area titled “Guidance For Health Care Agent (Optional).” In this area, using the blank lines under the word “Goals,” the Principal may address the Health Care Agent and anyone privy to this document his or her exact preferences when medical events occur and he or she cannot communicate or is in a long-term vegetative state. Generally, it is recommended the Principal speak freely. For instance, he or she may have religious concerns when it comes to Medical Care or he or she may wish the Health Care Agent to withhold/withdraw artificial nutrition and hydration(food and water through a tube) only under certain conditions. The Principal may address any issue in this area and provide any Directive that he or she expects the Health Care Agent and Medical Professionals to follow so long as such Directives are legal.
The next area requiring that may be attended to (at the Principal’s discretion) is titled “Severe Brain Damage Or Brain Disease.” There will be two blank lines labeled “I Agree” and “I Disagree” one of which the Principal must initial. If the Principal is in a state described in this statement (suffering from Brain Damage or Disease that is overly burdensome, painful, and terminal) and wishes the Health Care Agent to respond to this condition as if it were an “End-State Medical Condition” or “Permanent Unconsciousness,” then he or she should initial the first blank line. If the Principal does not wish the Health Care Agent to treat such a condition as an End-Stage Event, then he or she should initial the second blank line.
5 – Present The Principal’s Decisions On A Couple Of Additional Issues
In the section labeled “Health Care Agent’s Use Of Instructions,” the Principal can indicate how he or she wishes the Health Care Agent to treat these instructions. If the Health Care Agent should follow this Directive in a strict and unyielding manner regardless of any complication, the Principal must initial the first blank line in this section.
If the Principal wishes these instructions to act as only as a sort of guidance and prefers the Agent to have the Power to override these instructions, then he or she should initial the second blank line. If there are any exceptions to this preference they should be documented using the area provided.
One final Directive that may be addressed, if desired by the Principal, is titled “Organ Donation (Initial One Option Only).” If the Principal intends to consent to an Organ Donation or any other Anatomical Gifts, then he or she should initial the first blank line here. Any limitations, restrictions, or conditions may be listed in the area provided.
If the Principal does not wish to make any Anatomical Gifts or Donate Any Organs, then he or she should intitial the blank line corresponding to the statement “I Do Not Consent To Donate…”
6 – To Deliver The Principal Power To The Health Care Agent, The Principal Must Sign His Or Her Name
This document will conclude with the Dated and Witnessed Signature of the Principal. The first task before the Principal here will be to enter the Calendar Day, Month, and Year that he or she is signing this document.
Below this will be a long blank line the Principal must sign. The Principal must sign his or her Full Name here.
Each Witness must also provide his or her Signature at the time of the Principal Signing. This task should be performed on the blank lines labeled “Witness.” Each Witness must sign a unique line in this area.
Finally, the “Notarization (Optional)” area has been provided so the Notary Public subjecting this Directive to the Notarization process. While this area is optional, it is generally recommended the execution of such delegations is notarized. 