Medical Power of Attorney Form

    Person you want to appoint as first attorney

    Same for alternate attorneys
    Do you have any specific wishes?

    Tell us your wishes:

    If there is no reasonable prospect of my recovery from physical or mental illness or impairment expected to cause me severe distress or to render me incapable of rational existence, I request that I be allowed to die and not be kept alive by artificial means and that I receive whatever quantity of drugs may be required to keep me free from pain or distress even if the moment of death is hastened.I express the wish that such of my bodily organs and tissue which can be of benefit to others be removed after my death and used for therapeutic purposes by any hospital of the Commonwealth.I value life, but not under all conditions. I consider dignity and quality of life to be more important than mere existence.I request that I be given sufficient medication to control my pain, even if this hastens my death.