Under Pennsylvania law (20 Pa.C.S. §5404), "an individual of sound mind who is 18 years of age or older or who has graduated from high school or has married may execute at any time a declaration governing the initiation, continuation, withholding or withdrawal of life-sustaining treatment. The declaration must be signed by the declarant, or by another on behalf of and at the direction of the declarant, and must be witnessed by two individuals each of whom is 18 years of age or older. A witness shall not be the person who signed the declaration on behalf of and at the direction of the declarant."

The form for a Living Will. Under Pennsylvania law, a declaration may, but need not be in the following form, and may include other specific directions, including, but not limited to, designation of another person to make the treatment decision for the declarant if the declarant is incompetent and is determined to be in a terminal condition or to be permanently unconscious.

DECLARATION

I, [insert name], being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below.

I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness.

I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment.

In addition, if I am in the condition described above, I feel especially strong about the following forms of treatment:

I ( ) do ( ) do not want cardiac resuscitation.
I ( ) do ( ) do not want mechanical respiration.
I ( ) do ( ) do not want tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water).
I ( ) do ( ) do not want blood or blood products.
I ( ) do ( ) do not want any form of surgery or invasive diagnostic tests.
I ( ) do ( ) do not want kidney dialysis.
I ( ) do ( ) do not want antibiotics.

I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment.

Other instructions:
I ( ) do ( ) do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness. Name and address of surrogate (if applicable):

Name and address of substitute surrogate (if surrogate designated above is unable to serve):

I ( ) do ( ) do not want to make an anatomical gift of all or part of my body, subject to the following limitations, if any:

I made this declaration on the day of (month, year).

Declarant's signature:
Declarant's address:

The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence.

Witness's signature:
Witness's address:
Witness's signature:
Witness's address:

 

FORM OF FINANCIAL POWER OF ATTORNEY

Under Pennsylvania law (20 Pa.C.S. § 5404): "A principal may, by inclusion of the language quoted in any of the following paragraphs or by inclusion of other language showing a similar intent on the part of the principal, empower an agent to do any or all of the following, each of which is defined in section 5603 (relating to implementation of power of attorney):

1) "To make limited gifts."
2) "To create a trust for my benefit."
3) "To make additions to an existing trust for my benefit."
4) "To claim an elective share of the estate of my deceased spouse."
5) "To disclaim any interest in property."
6) "To renounce fiduciary positions."
7) "To withdraw and receive the income or corpus of a trust."
8) "To authorize my admission to a medical, nursing, residential or similar facility and to enter into agreements for my care."
9) "To authorize medical and surgical procedures."
10) "To engage in real property transactions."
11) "To engage in tangible personal property transactions."
12) "To engage in stock, bond and other securities transactions."
13) "To engage in commodity and option transactions."
14) "To engage in banking and financial transactions."
15) "To borrow money."
16) "To enter safe deposit boxes."
17) "To engage in insurance transactions."
18) "To engage in retirement plan transactions."

19) "To handle interests in estates and trusts."
20) "To pursue claims and litigation."
21) "To receive government benefits."
22) "To pursue tax matters."
23) "To make an anatomical gift of all or part of my body."

A principal may also provide for:

1) The appointment of more than one agent, who shall act jointly, severally or in any other combination that the principal may designate, but if there is no such designation, such agents shall only act jointly.
1.1) The delegation of one or more powers by the agent to such person or persons as the agent may designate and on terms as the power of attorney may specify.
2) The appointment of one or more successor agents who shall serve in the order named in the power of attorney, unless the principal expressly directs to the contrary.
3) The delegation to an original or successor agent of the power to appoint his successor or successors.