CLINICAL ETHICS CENTER at Memorial Medical Center

home page
Home Page

Completing a Power of Attorney for Health Care form allows you to specify a person (an 'agent') whom you would like your health care providers to speak to about your medical care if you are unable to make decisions for yourself. The agent has the authority to act on your behalf anytime you are unable to speak for yourself, your condition does not have to be terminal or irreversible. The agent has the authority to speak for you and decide on your behalf regarding any healthcare decisions that might need to be made, not just decisions about life-support equipment but including things like consent to invasive procedures, suregery and dialysis. You may give the agent specifc instructions regarding certain issues or you may chose to limit his or her authority.

Conditions of Application:
Any time patient is unable to make health care decisions on their own behalf
Types of Decisions Covered:
Any health care treatment decision
How Preferences Are Expressed:
An agent appointed by the patient in the document to make decisions with or without instructions
How Document Is Revoked:
By tearing the document; Oral revocation (should be documented); Or in writing

All of the advance directive forms are Adobe Acrobat files and require Adobe Acrobat Reader to open them. If you do not have Adobe Acrobat Reader installed on your computer, click here for a free downloadable Adobe Acrobat Reader copy.

Illinois Power of Attorney for Health Care, Statutory Short Form (PDF Format)

Illinois Power of Attorney for Health Care, Statutory Short Form (Spanish)
(PDF Format)

Questions or comments - email us at Clinical Ethics Center
Last Updated May 24, 2012
Copyright © 2011-2012, Board of Trustees,
Southern Illinois University| Privacy Policy