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    Puerto Rico POA JW Template

    Uploaded by

    Sarah Fonseca
    This document outlines an individual's advance health care directive and refusal of blood transfusions in accordance with their religious beliefs as a Jehovah's Witness. It appoints a health care agent and alternate agent to make medical decisions on their behalf if they become incapacitated. It also refuses prolonging life if the situation is deemed hopeless by doctors or keeping them alive on machines indefinitely. The individual swears and signs the document before a notary.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Puerto Rico POA JW Template

    Uploaded by

    Sarah Fonseca
    89 views2 pages
    This document outlines an individual's advance health care directive and refusal of blood transfusions in accordance with their religious beliefs as a Jehovah's Witness. It appoints a health care agent and alternate agent to make medical decisions on their behalf if they become incapacitated. It also refuses prolonging life if the situation is deemed hopeless by doctors or keeping them alive on machines indefinitely. The individual swears and signs the document before a notary.

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    © © All Rights Reserved

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    This document outlines an individual's advance health care directive and refusal of blood transfusions in accordance with their religious beliefs as a Jehovah's Witness. It appoints a health care agent and alternate agent to make medical decisions on their behalf if they become incapacitated. It also refuses prolonging life if the situation is deemed hopeless by doctors or keeping them alive on machines indefinitely. The individual swears and signs the document before a notary.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    89 views2 pages

    Puerto Rico POA JW Template

    Uploaded by

    Sarah Fonseca
    This document outlines an individual's advance health care directive and refusal of blood transfusions in accordance with their religious beliefs as a Jehovah's Witness. It appoints a health care agent and alternate agent to make medical decisions on their behalf if they become incapacitated. It also refuses prolonging life if the situation is deemed hopeless by doctors or keeping them alive on machines indefinitely. The individual swears and signs the document before a notary.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Advance Health Care Directive

    (Law No. 160 of November 17, 2001; Law No. 194 of August 25, 2000)

    1. I, (print or type full name), fill out this document to


    set forth my treatment instructions and to appoint a health-care agent in case of my incapacity.
    2. I am one of Jehovah's Witnesses, and I direct that NO TRANSFUSIONS of whole blood,
    red cells, white cells, platelets, or plasma be given me under any circumstances, even if health-
    care providers believe that such are necessary to preserve my life (Acts 15:28, 29). I refuse to
    pre-donate and store my blood for later infusion.
    3. Regarding end-of-life matters: [initial one of the two choices]
    (a) I do not want my life to be prolonged if, to a reasonable degree of medical
    certainty, my situation is hopeless.
    (b) I want my life to be prolonged as long as possible within the limits of
    generally accepted medical standards, even if this means that I might be kept alive on machines
    for years.
    4. Regarding other health-care instructions (such as current medications, allergies, and
    medical problems):

    5. Health care instructions in case of pregnancy: I direct that my health care provider and
    health care agent fully defend my refusal of blood transfusions, even if I am pregnant. In case I
    were incapacitated, my health care agent has my authorization to make health care decisions
    even if I am pregnant.
    6. I give no one (including my agent) any authority to disregard or override my instructions set
    forth herein. Family members, relatives, or friends may disagree with me, but any such
    disagreement does not diminish the strength or substance of my refusal of blood or other
    instructions.
    7. Apart from the matters covered above, I appoint the person named herein as my agent to
    make health-care decisions for me. I give my agent full power and authority to consent to or to
    refuse treatment on my behalf, to consult with my doctors and receive copies of my medical
    records, and to take legal action to ensure that my wishes are honored. If my first appointed
    agent is unavailable, unable, or unwilling to serve, I appoint an alternate agent herein to serve
    with the same power and authority.

    Page 1 of 2
    8. I hereby swear and subscribe this document in ____________________, Puerto Rico, today,
    the _______ day of _____________________, _______________.

    (Declarant’s signature)
    AFFIDAVIT NUMBER: __________

    Sworn and subscribed me by _____________________________________, of legal age,


    ___________________ (marital status), _______________________ (profession), and resident
    of ___________________________________, Puerto Rico, whom I personally know or have
    verified his/her identity by ____________________________________________. I, the
    authorizing notary, declare that I verified with the declarant the voluntary character of this
    Declaration, and I am satisfied that the decision that he/she made, aforementioned, has been free
    and voluntary and after having reflected upon its content.

    ___________, Puerto Rico, today, the _____ day of ________________, ______.

    (Notary Public’s signature)

    HEALTH-CARE AGENT* Note: Before signing this document, fill it out


    completely (including the names, addresses, and
    telephone numbers of your health-care agents). You
    Name:
    should sign this document before a notary. You may
    Address: choose any adult older than 21 years to be your agent,
    but it is recommended that you not choose your
    physician, any of your physician’s employees, or any
    employee of a hospital or nursing home where you
    Phone(s): might be a patient unless the individual is related to you
    by blood, marriage, or adoption.

    ALTERNATE HEALTH-CARE AGENT*


    Advance Health-Care Directive
    (Signed document inside. Unfold.)
    Name:
    Address: NO BLOOD
    Phone(s):

    dpa-E 1/16 Page 2 of 2

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