Suggestions for the Georgia Will to Live Form
Originally printed from http://www.grtl.org
Copyright © 2004 Georgia Right to Life 

SUGGESTIONS FOR PREPARING WILL TO LIVE
DURABLE POWER OF ATTORNEY

(PLEASE READ THE DOCUMENT ITSELF BEFORE READING THIS. IT WILL HELP YOU
BETTER UNDERSTAND THE SUGGESTIONS.)

YOU ARE NOT REQUIRED TO FILL OUT ANY PART OF THIS "WILL TO LIVE" OR ANY
OTHER DOCUMENT SUCH AS A LIVING WILL OR DURABLE POWER OF ATTORNEY FOR
HEALTH CARE. NO ONE MAY FORCE YOU TO SIGN THIS DOCUMENT OR ANY OTHER OF
ITS KIND.

The Will to Live form starts from the principle that the presumption
should be for life. If you sign it without writing any "SPECIAL
CONDITIONS," you are giving directions to your health care provider(s)
and health care agent to do their best to preserve your life.

Some people may wish to continue certain types of medical treatment
when they are terminally ill and in the final stages of life. Others
may not.

If you wish to refuse some specific medical treatment, the Will to Live
form provides space to do so ("SPECIAL CONDITIONS"). You may make
special conditions for your treatment when your death is imminent,
meaning you will live no more than a week even if given all available
medical treatment; or when you are incurably terminally ill, meaning
you will live no more than three months even if given all available
medical treatment. There is also space for you to write down special
conditions for circumstances you describe yourself.

The important thing for you to remember if you choose to fill out any
part of the "SPECIAL CONDITIONS" sections of the Will to Live is that
you must be very specific in listing what treatments you do not want.
Some examples of how to be specific will be given shortly, or you may
ask your physician what types of treatment might be expected in your
specific case.

Why is it important to be specific? Because, given the pro-euthanasia
views widespread in society and particularly among many (not all)
health care providers, there is great danger that a vague description
of what you do not want will be misunderstood or distorted so as to
deny you treatment that you do want.

Many in the medical profession as well as in the courts are now so
committed to the quality of life ethic that they take as a given that
patients with severe disabilities are better off dead and would prefer
not to receive either life-saving measures or nutrition and hydration.
So pervasive is this "consensus" that it is accurate to say that in
practice it is no longer true that the "presumption is for life" but
rather for death. In other words, instead of assuming that a now
incompetent patient would want to receive treatment and care in the
absence of clear evidence to the contrary, the assumption has virtually
become that since any "reasonable" person would want to exercise a
"right to die," treatment and care should be withheld or withdrawn
unless there is evidence to the contrary. The Will to Live is intended
to maximize the chance of providing that evidence.

It is important to remember that you are writing a legal document, not
holding a conversation, and not writing a moral textbook. The language
you or a religious or moral leader might use in discussing what is and
is not moral to refuse is, from a legal standpoint, often much too
vague. Therefore, it is subject to misunderstanding or deliberate abuse.

The person you appoint as your health care agent may understand general
terms in the same way you do. But remember that the person you appoint
may die, or become incapacitated, or simply be unavailable when
decisions must be made about your health care. If any of these happens,
a court might appoint someone else you don't know in that person's
place. Also remember that since the agent has to follow the
instructions you write in this form, a health care provider could try
to persuade a court that the agent isn't really following your wishes.
A court could overrule your agent's insistence on treatment in cases in
which the court interprets any vague language you put in your "Will to
Live" less protectively than you meant it.

So, for example, do not simply say you don't want "extraordinary
treatment." Whatever the value of that language in moral discussions,
there is so much debate over what it means legally that it could be
interpreted very broadly by a doctor or a court. For instance, it might
be interpreted to require starving you to death when you have a
disability, even if you are in no danger of death if you are fed.

For the same reason, do not use language rejecting treatment which has
a phrase like "excessive pain, expense or other excessive burden."
Doctors and courts may have a very different definition of what is
"excessive" or a "burden" than you do. Do not use language that rejects
treatment that "does not offer a reasonable hope of benefit." "Benefit"
is a legally vague term. If you had a significant disability, a health
care provider or court might think you would want no medical treatment
at all, since many doctors and judges unfortunately believe there is no
"benefit" to life with a severe disability.

What sort of language is specific enough if you wish to write
exclusions? Here are some examples of things you might--or might
not--want to list under one or more of the "Special Conditions"
described on the form. Remember that any of these will prevent
treatment ONLY under the circumstances--such as when death is
imminent--described in the "Special Condition" you list it under. (The
examples are not meant to be all inclusive--just samples of the type of
thing you might want to write.)

"Cardiopulmonary resuscitation (CPR)." (If you would like CPR in some
but not all circumstances when you are terminally ill, you should try
to be still more specific: for example, you might write "CPR if
cardiopulmonary arrest has been caused by my terminal illness or a
complication of it." This would mean that you would still get CPR if,
for example, you were the victim of smoke inhalation in a fire.) "Organ
transplants." (Again, you could be still more specific, rejecting, for
example, just a "heart transplant.")

"Surgery that would not cure me, would not improve either my mental or
my physical condition, would not make me more comfortable, and would
not help me to have less pain, but would only keep me alive longer."

"A treatment that will itself cause me severe, intractable, and
long-lasting pain but will not cure me."

Pain Relief

Under the "General Presumption for Life," of your Will to Live, you
will be given medication necessary to control any pain you may have "as
long as the medication is not used in order to cause my death." This
means that you may be given pain medication that has the secondary, but
unintended, effect of shortening your life. If this is not your wish,
you may want to write something like one of the following under the
third set of "Special Conditions" (the section for conditions you
describe yourself):

"I would like medication to relieve my pain but only to the extent the
medication would not seriously threaten to shorten my life." OR

"I would like medication to relieve my pain but only to the extent it
is known, to a reasonable medical certainty, that it will not shorten
my life."

Think carefully about any special conditions you decide to write in
your "Will to Live." You may want to show them to your intended agent
and a couple of other people to see if they find them clear and if they
mean the same thing to them as they mean to you. Remember that how
carefully you write may literally be a matter of life or death--your
own.

After writing down your special conditions, if any, you should mark out
the rest of the blank lines left on the form for them (just as you do
after writing out the amount on a check) to prevent any danger that
somebody other than you could write in something else.

It is wise to review your Will to Live periodically to ensure that it
still gives the directions you want followed.

Click here to download your "Will to Live"
 
1 Some states use the terms “attorney in fact,” “surrogate,”
“designee,” and “representative” instead of “agent.” They are
synonymous in for
purposes of these suggestions.
i
SUGGESTIONS FOR PREPARING WILL TO LIVE DURABLE POWER OF ATTORNEY
(Please read the document itself before reading this. It will help you
better understand the suggestions.) You are not required to fill out
any part of this “Will to Live” or any other document such as a living
will or durable power of attorney for health care. No one may force you
to sign this document or any other of its kind. The Will to Live form
starts from the principle that the presumption should be for life. If
you sign it without writing any "SPECIAL CONDITIONS," you are giving
directions to your health care provider(s) and health care agent1 to do
their best to preserve your life.
Some people may wish to continue certain types of medical treatment
when they are terminally ill and in the final stages of life. Others
may not. If you wish to refuse some specific medical treatment, the
Will to Live form provides space to do so ("SPECIAL CONDITIONS"). You
may make special conditions for your treatment when your death is
imminent, meaning you will live no more than a week even if given all
available medical treatment; or when you are incurably terminally ill,
meaning you will live no more than three months even if given all
available medical treatment. There is also space for you to write down
special conditions for circumstances you describe yourself. The
important thing for you to remember if you choose to fill out any part
of the "SPECIAL CONDITIONS" sections of the Will to Live is that you
must be very specific in listing what treatments you do not want. Some
examples of how to be specific will be given shortly, or you may ask
your physician what types of treatment might be expected in your
specific case.
Why is it important to be specific? Because, given the pro-euthanasia
views widespread in society and particularly among many (not all)
health care providers, there is great danger that a vague description
of what you do not want will be misunderstood or distorted so as to
deny you treatment that you do want.
Many in the medical profession as well as in the courts are now so
committed to the quality of life ethic that they take as a given that
patients with severe disabilities are better off dead and would prefer
not to receive either life-saving measures or nutrition and hydration.
So pervasive is this "consensus" that it is accurate to say that in
practice it is no longer true that the "presumption is for life" but
rather for death. In other words, instead of ii assuming that a now
incompetent patient would want to receive treatment and care in the
absence of clear evidence to the contrary, the assumption has virtually
become that since any "reasonable" person would want to exercise a
"right to die," treatment and care should be withheld or withdrawn
unless there is evidence to the contrary. The Will to Live is intended
to maximize the chance of providing that evidence. It is important to
remember that you are writing a legal document, not holding a
conversation, and not writing a moral textbook. The language you or a
religious or moral leader might use in discussing what is and is not
moral to refuse is, from a legal standpoint, often much too vague.
Therefore, it is subject to misunderstanding or deliberate abuse. The
person you appoint as your health care agent may understand general
terms in the same way you do. But remember that the person you appoint
may die, or become incapacitated, or simply be unavailable when
decisions must be made about your health care. If any of these happens,
a court might appoint someone else you don't know in that person's
place. Also remember that since the agent has to follow the
instructions you write in this form, a health care provider could try
to persuade a court that the agent isn't really following your wishes.
A court could overrule your agent's insistence on treatment in cases in
which the court interprets any vague language you put in your "Will to
Live" less protectively than you meant it.
So, for example, do not simply say you don't want "extraordinary
treatment." Whatever the value of that language in moral discussions,
there is so much debate over what it means legally that it could be
interpreted very broadly by a doctor or a court. For instance, it might
be interpreted to require starving you to death when you have a
disability, even if you are in no danger of death if you are fed. For
the same reason, do not use language rejecting treatment which has a
phrase like "excessive pain, expense or other excessive burden."
Doctors and courts may have a very different definition of what is
"excessive" or a "burden" than you do.
Do not use language that rejects treatment that "does not offer a
reasonable hope of benefit." "Benefit" is a legally vague term. If you
had a significant disability, a health care provider or court might
think you would want no medical treatment at all, since many doctors
and judges unfortunately believe there is no "benefit" to life with a
severe disability.
What sort of language is specific enough if you wish to write
exclusions? Here are some examples of things you might--or might
not--want to list under one or more of the "Special Conditions"
described on the form.
Remember that any of these will prevent treatment ONLY under the
circumstances--such as when death is imminent--described in the
"Special Condition" you list it under. (The examples are not meant to
be all inclusive-- just samples of the type of thing you might want to
write.) "Cardiopulmonary resuscitation (CPR)." (If you would like CPR
in some but not all circumstances when you are terminally ill, you
should try to be still more specific: for example, you might write "CPR
if cardiopulmonary arrest has been caused by my terminal illness or a
complication of it." This would mean that you would still get CPR if,
for example, you were the victim of smoke inhalation in a fire.) "Organ
transplants." (Again, you could be still more specific, rejecting, for
example, just a "heart transplant.") "Surgery that would not cure me,
would not improve either my mental or my physical condition, would not
make me more comfortable, and would not help me to have less pain, but
would only keep me alive longer." iii "A treatment that will itself
cause me severe, intractable, and long-lasting pain but will not cure
me." Pain Relief Under the "General Presumption for Life," of your Will
to Live, you will be given medication necessary to control any pain you
may have "as long as the medication is not used in order to cause my
death." This means that you may be given pain medication that has the
secondary, but unintended, effect of shortening your life. If this is
not your wish, you may want to write something like one of the
following under the third set of "Special Conditions" (the section for
conditions you describe yourself):
"I would like medication to relieve my pain but only to the extent the
medication would not seriously threaten to shorten my life." OR "I
would like medication to relieve my pain but only to the extent it is
known, to a reasonable medical certainty, that it will not shorten my
life." Think carefully about any special conditions you decide to write
in your "Will to Live." You may want to show them to your intended
agent and a couple of other people to see if they find them clear and
if they mean the same thing to them as they mean to you. Remember that
how carefully you write may literally be a matter of life or
death--your own. After writing down your special conditions, if any,
you should mark out the rest of the blank lines left on the form for
them (just as you do after writing out the amount on a check) to
prevent any danger that som ebody other than you could write in
something else. It is wise to review your Will to Live periodically to
ensure that it still gives the directions you want followed. 
National Right to Life Committee
www.nrlc.org
(202)626-8800
i
How to Use the Georgia Will to Live Form
--Suggestions and Requirements:
1. This document allows you to name a health care agent who will make
health care decisions for you whenever you are unable to make them for
yourself. It also allows you to give instructions concerning medical
treatment decisions that the agent must follow.
2. Your doctor, nurse, or any other health care provider may not serve
as your agent.
3. It is helpful to appoint successor agents to take over if your first
agent is unable to serve. There is a space on the form for you to name
two successors to the agent.
NOTE: You may wish to name a guardian for yourself on page 1 in case a
court decides that one should be appointed for you at some time. You
may, but are not required to, nominate as your guardian the same person
you named as your health care agent. Under Georgia law, even if a
guardian is appointed for you, if you have named a health care agent,
the health care agent rather than the guardian will have authority to
make decisions concerning your health care.
4. Your agent's authority takes effect only when you no longer have the
capacity to make health care decisions. It does not include the
authority to authorize psychosurgery, sterilization, or involuntary
mental health hospitalization or treatment.
5. You must sign and date this document in the presence of at least two
witnesses who are at least 18 years of age. (If you are unable to sign
and date the document yourself, you may direct someone to do it for you
in your presence.) The two witnesses should provide their signatures
and addresses below your signature in the space provided in the
document.
NOTE: If you are a patient in a hospital or skilled nursing facility at
the time you sign this document, you must also have your attending
physician put his or her signature and address below your signature in
the space provided in the document, and this must be done in your
presence.
ii
6. A properly signed and witnessed declaration will remain in effect
until you revoke (cancel) it. The revocation may be made in writing
(signed and dated by you); orally (in the presence of a witness at
least 18 years of age who then, within 30 days, puts it in writing and
signs and dates it); or in any other way in which you indicate your
intention to revoke.
7. Unless your document specifies otherwise, if, after having made this
Durable Power of Attorney for Health Care, you get married, your
marriage will revoke the designation of the person it names as your
agent unless he or she is your spouse. And if, after having made this
declaration, your marriage is dissolved or annulled, your former spouse
will automatically be removed as your agent to make health care
decisions.
8. You should tell your doctor about this document. You should also ask
your doctor to keep a copy of this document as a part of your medical
health record. Give copies of the signed original to your health care
agent, family members, and anyone else you think appropriate. Keep the
original document in a safe place that will be easily accessible to
others in case of an emergency and tell someone where it is.
9. This type of document has been authorized by the Georgia Durable
Power of Attorney for Health Care Act, Ga. Code §§ 31-36-1 to -13.
10. You should periodically review your document to be sure it complies
with your wishes. Before making any changes, be aware that it is
possible that the statutes controlling this document have changed since
this form was prepared.
Contact the Will to Live Project by visiting www.nrlc.org (click on
“Will to Live”) or an attorney to determine if this form can still be
used.
11. If you have any questions regarding the information in this
document or want assistance filling it out, please consult an attorney.
_______________________________________________________________
For additional copies of the Will to Live, please visit:
www.nrlc.org and click on “Will to Live”
Form prepared 2001
1
GEORGIA DURABLE POWER OF ATTORNEY
WILL TO LIVE FORM
DURABLE POWER OF ATTORNEY made this day of , .
I, (your name, address, and telephone number) hereby appoint (agent's
name, address, and telephone number) as my attorney-in-fact (my agent)
to act for me and in my name in any way I could act in person to make
any and all decisions for me concerning my health care and to consent
to health care in accordance with the following instructions. My agent
shall have the same access to my medical records that I have, including
the right to disclose the contents to others.
If any agent named by me shall die, become legally disabled,
incapacitated, or incompetent, or resign, refuse to act, or be
unavailable, I name the following (each to act successively in the
order named) as successors to such agent:
1. (first successor's name, address, and telephone number)
2. (second successor's name, address, and telephone number) (The
following
paragraph is OPTIONAL. If you do not want to nominate a guardian, CROSS
OFF the blank lines and initial your cross-off.) If a guardian of my
person is to be appointed, I nominate the following to serve as my
guardian:
(nominated guardian's name, address, and telephone number)
GENERAL PRESUMPTION FOR LIFE
I direct my health care provider(s) and health care agent to make
health care decisions consistent with my general desire for the use of
medical treatment that would preserve my life, as well as for the use
of medical treatment that can cure, improve, or reduce or prevent
deterioration in, any physical or mental condition.
Food and water are not medical treatment, but basic necessities. I
direct my health care provider(s) and health care agent to provide me
with food and fluids orally, intravenously, by tube, or by other means
to the full extent necessary both to preserve my life and to assure me
the optimal health possible.
I direct that medication to alleviate my pain be provided, as long as
the medication is not used in order to cause my death.
2
I direct that the following be provided:
* the administration of medication; * cardiopulmonary resuscitation
(CPR); and * the performance of all other medical procedures,
techniques, and technologies, including surgery, -- all to the full
extent necessary to correct, reverse, or alleviate life-threatening or
health-impairing conditions, or complications arising from those
conditions.
I also direct that I be provided basic nursing care and procedures to
provide comfort care.
I reject, however, any treatments that use an unborn or newborn child,
or any tissue or organ of an unborn or newborn child, who has been
subject to an induced abortion.
This rejection does not apply to the use of tissues or organs obtained
in the course of the removal of an ectopic pregnancy.
I also reject any treatments that use an organ or tissue of another
person obtained in a manner that causes, contributes to, or hastens
that person's death.
The instructions in this document are intended to be followed even if
suicide is alleged to be attempted at some point after it is signed.
I request and direct that medical treatment and care be provided to me
to preserve my life without discrimination based on my age or physical
or mental disability or the "quality" of my life. I reject any action
or omission that is intended to cause or hasten my death.
I direct my health care provider(s) and health care agent to follow the
above policy, even if I am judged to be incompetent.
During the time I am incompetent, my agent, as named above, is
authorized to make medical decisions on my behalf, consistent with the
above policy, after consultation with my health care provider(s),
utilizing the most current diagnoses and/or prognosis of my medical
condition, in the following situations with the written special
conditions.
WHEN MY DEATH IS IMMINENT
A. If I have an incurable terminal illness or injury, and I will die
imminently--meaning that a reasonably prudent physician, knowledgeable
about the case and the treatment possibilities with respect to the
medical conditions involved, would judge that I will live only a week
or less even if lifesaving treatment or care is provided to me--the
following may be withheld or withdrawn:
(Be as specific as possible; SEE SUGGESTIONS.):
(Cross off any remaining blank lines.)
WHEN I AM TERMINALLY ILL
B. Final Stage of Terminal Condition. If I have an incurable terminal
illness or injury and even though death is not imminent I am in the
final stage of that terminal condition--meaning that a reasonably
prudent physician, knowledgeable about the case and the treatment
possibilities with respect to the medical conditions involved, would
judge that I will live only three months or less, even if lifesaving
treatment or care is provided to me--the following may be withheld or
withdrawn:
3
If I am pregnant, and I am not in the final stage of a terminal
condition as defined above, medical procedures required to prevent my
death are authorized even if they may result in the death of my unborn
child provided every possible effort is made to preserve both my life
and the life of my unborn child.
Signature (Be as specific as possible; SEE SUGGESTIONS.):
(Cross off any remaining blank lines.)
C. OTHER SPECIAL CONDITIONS:
(Be as specific as possible; SEE SUGGESTIONS.):
(Cross off any remaining blank lines.)
IF I AM PREGNANT
D. Special Instructions for Pregnancy. If I am pregnant, I direct my
health care provider(s) and health care representative(s) to use all
lifesaving procedures for myself with none of the above special
conditions applying if there is a chance that prolonging my life might
allow my child to be born alive. I also direct that lifesaving
procedures be used even if I am legally determined to be brain dead if
there is a chance that doing so might allow my child to be born alive.
Except as I specify by writing my signature in the box below, no one is
authorized to consent to any procedure for me that would result in the
death of my unborn child.
This power of attorney shall become effective in the event I become
disabled, incapacitated or incompetent.
I am fully informed about all the contents of this form and understand
the full import of this grant of powers to my agent.
4
Signed
(Principal)
The principal has had an opportunity to read the above form and has
signed the above form in our presence. We, the undersigned, each being
over 18 years of age, witness the principal's signature at the request
and in the presence of the principal, and in the presence of each
other, on the day and year above set out.
Witnesses: Addresses:
Additional witness required when health care agency is signed in a
hospital or skilled nursing facility:
I hereby witness this health care agency and attest that I believe the
principal to be of sound mind and to have made this health care agency
willingly and voluntarily.
Witness:
(Attending Physician)
Address:
YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND SUCCESSOR
AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU INCLUDE SPECIMEN
SIGNATURES IN THIS POWER OF ATTORNEY, YOU MUST COMPLETE THE
CERTIFICATION OPPOSITE THE SIGNATURES OF THE AGENTS.
Specimen signatures of agent I certify that the signature of my agent
and and successor(s) successor(s) is correct.
(agent) (your name)
(first successor agent) (your name)
(second successor agent) (your name)
Form Prepared 2001