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Virginia _____ (Witness) ________________________________________ Page 3 of 3 _ (Signature of Declarant) The declarant signed the foregoing advance directive in my presence. I am not the spouse or a blood relative of the declarant. (Witness) ___________________________________w, I indicate that I am emotionally and mentally competent to make this advance directive and that I understand the purpose and effect of this document. __________ (Date) _____________________________irect that (declarant's directions concerning anatomical gift or organ, tissue or eye donation): Page 2 of 3 This advance directive shall not terminate in the event of my disability. By signing beloas my agent, of _____________________________________________, ________________________________ (address and telephone number of agent) to make any such anatomical gift following my death. I further dof my body may be made pursuant to Article 2 (§ 32.1-289 et seq.) of Chapter 8 of Title 32.1 and in accordance with my directions, if any. I hereby appoint ___________________________ (name of agent) T OF AN AGENT TO MAKE AN ANATOMICAL GIFT (CROSS THROUGH IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE AN ANATOMICAL GIFT FOR YOU.) Upon my death, I direct that an anatomical gift of all or any part ders. F. To make decisions regarding visitation. Further, my agent shall not be liable for the costs of treatment pursuant to his authorization, based solely on that authorization. OPTION: APPOINTMEN1 (§ 37.1-63 et seq.) of Chapter 2 of Title 37.1; and E. To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical proviy) from any hospital, hospice, nursing home, adult home or other medical care facility for services other than those for treatment of mental illness requiring admission procedures provided in Article records, and to consent to the disclosure of this information; C. To employ and discharge my health care providers; D. To authorize my admission to or discharge (including transfer to another facilition or inadvertently hastens my death; B. To request, receive, and review any information, verbal or written, regarding my physical or mental health, including but not limited to, medical and hospitaler to consent to the administration of dosages of pain-relieving medication in excess of recommended dosages in an amount sufficient to relieve pain, even if such medication carries the risk of addict function, including, but not limited to, artificial respiration, artificially administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the pownsent to or refuse or withdraw consent to any type of medical care, treatment, surgical procedure, diagnostic procedure, medication and the use of mechanical or other procedures that affect any bodily my best interests. OPTION: POWERS OF MY AGENT (CROSS THROUGH ANY LANGUAGE YOU DO NOT WANT AND ADD ANY LANGUAGE YOU DO WANT) Page 1 of 3 The powers of my agent shall include the following: A. To coher expressed orally or in writing. If my agent cannot determine what treatment choice I would have made on my own behalf, then my agent shall make a choice for me based upon what he believes to be inth treatment or non-treatment. My agent shall not authorize a course of treatment which he knows, or upon reasonable inquiry ought to know, is contrary to my religious beliefs or my basic values, whetise known to my agent. My agent shall be guided by my medical diagnosis and prognosis and any information provided by my physicians as to the intrusiveness, pain, risks, and side effects associated wis thereafter while the treatment continues. In exercising the power to make health care decisions on my behalf, my agent shall follow my desires and preferences as stated in this document or as otherwe certified in writing. Such certification shall be required before treatment is withheld or withdrawn, and before, or as soon as reasonably practicable after, treatment is provided, and every 180 dayation that I am incapable of making an informed decision shall be made by my attending physician and a second physician or licensed clinical psychologist after a personal examination of me and shall blternatives to that decision, or unable to communicate such understanding in any way. My agent's authority hereunder is effective as long as I am incapable of making an informed decision. The determint and probable consequences of a proposed medical decision or unable to make a rational evaluation of the risks and benefits of a proposed medical decision as compared with the risks and benefits of acapable of making an informed decision about providing, withholding or withdrawing medical treatment. The phrase "incapable of making an informed decision" means unable to understand the nature, extenber) to serve in that capacity. I hereby grant to my agent, named above, full power and authority to make health care decisions on my behalf as described below whenever I have been determined to be inct as my agent, then I appoint ___________________________________________________, (alternate agent) of ____________________________________________________________________ (address and telephone nume health care decisions on my behalf as authorized in this document. If _____________________________________________________ (primary agent) is not reasonably available or is unable or unwilling to a_________________________, (primary agent) of _____________________________________________________________________ __________________________________ (address and telephone number) as my agent to makVIRGINIA POWER OF ATTORNEY FOR HEALTH CARE I, _________________________________________________, willfully and voluntarily make known my desire and do hereby declare: I hereby appoint ________________ Virginia