Item (1)Write the name, home address and telephone number of the person you are selecting as your agent.
Item (2)
If you want to appoint an alternate agent, write the name, home address, and telephone number of the person you are selecting as your alternate agent
Item (3)
Your health care proxy will remain valid indefinitely unless you set and expiration date or condition for its expiration. This section is optional and should be filled in only if you want your Health Care Proxy to expire.
Item (4)
If you have special instructions for your agent write them here. Also, If you wish to limit your agents authority in any way, you may say so here or discuss them with your heath care agent. If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decision to consent or refuse life-sustaining treatment.
If you want to give your agent broad authority, you may do so right on the form. Simply write: I have discussed my wishes with my health care agent and alternate and they know my wishes including those about artificial nutrition and hydration.
If you wish to make more specific instructions, you could say:
If I become terminally ill, I do/don't want to receive the following types of treatments....
If I am in a coma or have little conscious understanding, with no hope of recovery, then I do/don't want the following types of treatments....
If I have brain damage or brain disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, I do/don't want the following types of treatments.....