Subd. 1. Content.

A durable power of attorney for health care executed pursuant to this chapter may, but need not, be in the following form:

"I appoint .......... as my agent (my attorney in fact) to make any health care decision for me when, in the judgment of my attending physician, I am unable to make or communicate the decision myself and my agent consents to make or communicate the decision on my behalf.

My agent has the power to make any health care decision for me. This power includes the power to give consent, to refuse consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat my physical or mental condition, including giving me food or water by artificial means. My agent has the power, where consistent with the laws of this state, to make a health care decision to withhold or stop health care necessary to keep me alive. It is my intention that my agent or any alternative agent has a personal obligation to me to make health care decisions for me consistent with my expressed wishes. I understand, however, that my agent or any alternative agent has no legal duty to act.

My agent and any alternative agents have consented to act as my agent. My agent and any alternative agents have been notified that they will be nominated as a guardian or conservator for me.

My agent must act consistently with my desires as stated in this document or as otherwise made known by me to my agent.

My agent has the same right as I would have to receive, review, and obtain copies of my medical records and to consent to disclosure of those records."

Subd. 2. Additional provisions.

The durable power of attorney for health care may include additional provisions consistent with this chapter, including:

1. (1) the designation of one or more alternative agents to act if the named agent is unable, unavailable, or unwilling to serve;
2. (2) specific instructions to the agent or any alternative agents;
3. (3) limitations, if any, on the right of the agent or any alternative agents to receive, review, obtain copies of, and consent to the disclosure of the principal's medical records;
4. (4) limitations, if any, on the nomination of the agent as guardian or conservator for purposes of section 525.544; and
5. (5) a document of gift for the purpose of making an anatomical gift, as set forth in sections 525.921 to 525.9224, or an amendment to, revocation of, or refusal to make an anatomical gift.