Pennsylvania Living Will and Medical Power of Attorney Form (Combined)

The Pennsylvania Living Will And Medical Power Of Attorney (Combined) provides the principal with the option of controlling the type of health care they receive if they somehow become incapacitated through serious illness such as a coma. The Pennsylvania combined form provides the principal with authority over their health care with the option to select another person known as an`Agent` to have this same authority over their health care treatment, choosing certain things which the agent may not have authority over as well as being able to include specific other choices and preferences they may wish to apply. The document may be void at any time the principal chooses. The combined power of attorney and living will complies with the  US statutes §§ 5421 – 5488 and requires 2 witnesses for it to be classed as an official legal document.

How to Write

Combine Living Will Health Care Power Of Attorney

Durable Health Care Power Of Attorney (Part 2)

The principal must enter their details.

  • Name.
  • County.


Appointment Of Health Care Agent

The Details of the health care agent and any alternative health care agents must be entered.

  • Name.
  • Relationship.
  • Address.
  • Home/Work telephone numbers.
  • Email address.


Guidance For Health Care Agent (Optional)

The principal must enter details regarding their goals for their medical health care if they are suffering and end stage or irreversible medical condition.


Severe Brain Damage Or Dissease

The principal must state their wishes regarding receipt of life preserving treatment in the event of brain damage or any other end of stage condition.

  • Initial to agree to refuse treatment.
  • Initial to disagree to refuse treatment.


Health Care Treatment Instructions For End Stage Conditions Or Permanent Unconsciousness (Part 3)

3) The principal must enter `I Do Want` or cross out the following treatments.

  • Heart-lung resuscitation (CPR).
  • Mechanical ventilator.
  • Dialysis.
  • Surgery.
  • Chemotherapy.
  • Radiation treatment.
  • Antibiotics.


Feeding Tubes

The principal must initial the relevant blank field to denote their wishes regarding receipt of feeding tubes.


Health Care Agent`s Use Of Instructions

The principal must express their wishes regarding the health care agent`s authority with respects to the health care instructions.

  • Initial if the agent must follow the the health care instructions.
  • Initial and enter details regarding instructions for the health care agent.


Organ Donation

The principal must initial the relevant blank field and enter any specific limitations regarding organ donation.

  • Initial to make an organ donation and enter specific limitations.
  • Initial NOT to make an organ donation.



The principal, witnesses and notary must enter their details.

  • Date.
  • Principal`s signature.
  • Witnesses signatures.
  • Date.
  • County.
  • State.
  • Notary`s signature.
  • Date of expiration of commission.