I would STRONGLY suggest, if you are going to use the following Health Care Power Of Attorney as an example, that you print it out or download this document as well.

That way you will be able to better clarify WHAT your wishes are and what is most important to you when you see your attorney.

THE ATTACHED POWER OF ATTORNEY FOR HEALTH CARE IS PROVIDED FOR YOUR CONVENIENCE. IT MAY OR MAY NOT FIT THE REQUIREMENTS OF YOUR PARTICULAR STATE. A GROWING NUMBER OF STATES HAVE SPECIAL FORMS OR SPECIAL PROCEDURES FOR CREATING HEALTH CARE POWERS OF ATTORNEY. IF POSSIBLE, SEEK LEGAL ADVICE BEFORE SIGNING ANY POWER OF ATTORNEY. IF NOT CLEARLY RECOGNIZED BY LAW IN YOUR STATE, THE DOCUMENT MAY STILL PROVIDE THE BEST EVIDENCE OF YOUR WISHES IF YOU SHOULD BECOME UNABLE TO SPEAK FOR YOURSELF.

DESIGNATION OF HEALTH CARE AGENT:

Print your full name here as the "principal" or creator of the power of attorney. Print the full name, address and telephone number of the person (over age 18) you appoint as your health care "attorney-in-fact" or "agent". Appoint a person whom you trust to understand and carry out your values and wishes. Do not name any of your health care providers as your agent, since some states prohibit them acting as your agent.

EFFECTIVE DATE AND DURABILITY:

The sample document is effective if and when you become unable to make health care decisions. That point in time is determined by your agent and your doctor. You can, if you wish, specify other effective dates or other criteria for incapacity (such as requiring two physicians to evaluate your capacity). You can also specify that the power will end at some later date or event before death. In any case, you have the right to revoke the agent's authority at any time by notifying your agent or health care provider orally or in writing. If you revoke, it is best to notify both your agent and physician in writing and to destroy the power of attorney document itself.

AGENT'S POWERS: This grant of power is intended to be as broad as possible so that your agent will have authority to naake any decision you could make to obtain or terminate any type of health care. Even under this broad grant of authority, your agent still must follow your desires and directions, communicated by you in any manner now or in the future. You can specifically limit or direct your agent's power, if you wish in the following section

STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS:

Paragraph A. Here you may include any limitations you think are appropriate, such as instructions to refuse any specific types of treatment that are against your religious beliefs or unacceptable to you for any other reasons, such as blood transfusions, electroconvulsive therapy, sterilization, abortion, amputation, psychosurgery, admission to a mental institution, etc. State law may not allow your agent to consent to some of these procedures, regardless of your health care power of attorney. Be very careful about stating limitations, because the circumstances surrounding a future health care decision are impossible to predict if you do not want any limitations, simply write in "No limitations."

STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS

Because the subject of "life-sustaining treatment" is particularly important to many people, this paragraph provides a place for you to give general or specific directions on the subject, if you want to do so. The different paragraphs are options - choose only ~ or write your desires or instructions in your own words (in the last option). If you already have a "Living Will, you can simply refer to it by choosing the first option. Or, the instructions you provide here can do what a Living Will would do.

Because people differ widely on whether nutrition and hydration is something that ought to be refused or stopped under certain circumstances, it is important to make your wishes clear on this topic. Nutrition and hydration means food and fluids provided by a nasogastric tube or tube into the stomach, intestines, or veins. This paragraph allows you to include or not include these procedures among those that may be withheld or withdrawn under the circumstances described in the preceding paragraph. Either choice still permits non-intrusive efforts such as spoon feeding or moistening of lips and mouth.

SIGNING THE DOCUMENT: Required procedures for signing this kind of document vary from signature only to very detailed witnessing requirements, or, in some states, simply notarization. The suggested procedure here is intended to meet most of the various state requirements for signing by non-institutionalized persons. The procedure here is likely to be more detailed than is required under your own state's law, but it will help ensure that your Health Care Power is recognized in other states, too. First, sign and date the document in front of two witnesses. Your witnesses should know your identity personally and be able to declare that you appear to be of sound mind and under no duress or undue influence. Further, your witnesses should not be:

· Your treating physician, health care provider, or health facility operator, nor an employee of any of these.

· Anyone related to you by blood, marriage, or adoption.

· Anyone entided to any part of your estate under an existing will or by operation of law. Even a creditor of yours should not be used under these guidelines.

If you are in a nursing home or other institution, be sure to consult state law, because a few states require that an ombudsman or patient advocate be one of your witnesses.

Second, have your signature notarized. Some states pemit notarzation as an alternative to witnessing. Others may simply apply the rules for signing ordiary durable powers of attorney. Ordinary durable powers of attney are usually notarized. This form includes a relatively typical notary statement, but here again, it is wise tocheck state law in case a special form of notary acknowledgement is required.

NXNext

BKBack

EIBack to POA/Health Care