Copyright 2010, Marc S. Weissman|
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This Article is designed to be of general interest. The specific techniques and information discussed may not apply to you. Before acting on any matter contained herein, you should consult with your personal legal adviser.
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
1. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE:
By this document I intend to create an Advance Health Care Directive/Power of Attorney as authorized by the California Probate Code. This power of attorney shall not be affected by my subsequent incapacity.
2. DESIGNATION OF HEALTH CARE AGENT:
I, _______________________, of __________________ County, California, age _____, hereby designate and appoint _____________________________, of ____________________ County, California, as my agent (attorney in fact) to make health care decisions authorized in this document.
3. GENERAL STATEMENT OF AUTHORITY GRANTED:
A. In the event I become incapable of giving an informed consent to any health care decision, I hereby grant to my agent full power and authority to consent, refuse consent, or withdraw consent to any type of health care procedure (including any procedure to maintain, diagnose, or treat any physical or mental condition), or to make any other health care decision, to the same extent that I could if I were competent to do so, subject to the terms of this instrument. My agent shall exercise this power and authority in accordance with my expressed desires, known to my agent, whether contained in this document or not. My agent is further authorized:
To authorize, or refuse to authorize, any health care decision, or medical treatment, if I shall be physically or mentally incapacitated, or otherwise unable to make such authorization for myself, including, but not limited to authorization for emergency care, hospitalization, surgery, therapy, and/or any other kind of treatment or procedure that, in my agent's sole discretion, my agent thinks necessary for my benefit and well being.
To consult with and advise any physicians, nurses, therapists, dentists, or any other medical and/or health care institutions on my behalf, as such consultations relate to my health and welfare. All such personnel and institutions are specifically requested to abide by any and all decisions and instructions of my agent and to release to my agent any and all information which they may request concerning my health and well-being.
To receive into my agent's sole possession any and all items of personal property and effects that may be recovered from or about my person by any hospital, police agency, or any other person at the time of my illness, disability, or death, this to specifically include my remains, if applicable.
B. "Health care decisions" means consent, refusal of consent, or withdrawal of consent for any care, treatment, service, or procedure to affect my physical or mental condition, as well as consent to release of medical information.
C. I trust my agent, who knows and understands my desires, and in whose judgment I have absolute faith, to exercise his discretion, in a manner that would be satisfactory to me, if I had the capacity to give or refuse to give consent.
acting, my agent shall attempt to communicate with me regarding my desires
unless such attempt would be futile. If
I am unreachable by such communication, and my desires regarding a p
E. I direct that while I am a patient in any hospital or health care facility including, but not limited to, any intensive care or coronary care unit of any medical facility, my agent and those selected by my agent be given preference when it becomes necessary to restrict my visitors. If, in addition, my agent ever determines that a visitor is distressing me or interfering with my treatment, my agent shall have sole discretion to limit or prevent such visitation.
4. STATEMENT OF DESIRES CONCERNING LIFE SUSTAINING TREATMENT AND SPECIAL PROVISIONS:
A. If the extension of my life would result in a mere biological existence, devoid of cognitive function, with no reasonable hope for normal functioning, then I do not desire any form of life sustaining procedures, including nutrition and hydration unless necessary for my comfort or alleviation of pain or, if life sustaining treatment has been instituted, I desire that it be withdrawn. It is my desire that my agent consider relief from suffering, preservation or restoration of functioning, and the quality as well as extent of the life being preserved when decisions are made concerning life sustaining care, treatment, services, and procedures. In making the decision to withhold or remove treatment, my agent should ask the question: "Is the proposed treatment an aid to recovery or merely a postponement of inevitable death?" What is "reasonable," what is "an aid to recovery," and what is "merely a postponement of inevitable death" shall be determined by my agent after consulting with my attending physicians.
B. It is my desire that my agent consent to and arrange for the administration of any type of pain relief, even though its use may lead to permanent damage, addiction, or even hasten the moment of my death.
C. Regarding the decision to withhold or withdraw life sustaining treatment, I desire that my agent act after allowing a reasonable period of time for observation and diagnosis.
5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH:
My agent has the power and authority to do all of the following:
(a) Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records.
on my behalf, any releases or other
(c) Consent to disclosure of this information.
(d) Execute all necessary instruments and to perform all necessary acts required in the sole and absolute discretion of my agent for the execution and implementation of all authorization contained in this document.
6. SIGNING DOCUMENTS, WAIVERS, AND RELEASES:
My agent has the power and
authority to execute any and all
7. DESIGNATION OF ALTERNATE AGENTS:
If the person I designated as my agent in paragraph 2 is unable or unwilling to act as my agent, or if I revoke that person's appointment as my agent, then I designate the following persons to serve as my agent, to serve in the order listed below, to make health care decisions for me, as authorized in this document:
FIRST ALTERNATE AGENT: ___________________________
SECOND ALTERNATE AGENT: ___________________________
THIRD ALTERNATE AGENT: ___________________________
8. ANATOMICAL GIFTS:
to the Uniform Anatomical Gifts Act, I hereby give, effective on my death, any
[__] Any legally authorized use;
[__] Transplant/therapeutic use only;
9. DISPOSITION OF REMAINS:
I prefer that my agent direct the disposition of my remains by the following method:
[_] cremation, ashes to be:
[_] given to _________
[_] ashes spread at sea
[_] as my agent deems appropriate.
I prefer the following service/ceremony after my death:
This power of attorney is effective immediately and shall remain in force with no limit on its duration.
Furthermore, I desire that the authority granted by this document be liberally interpreted to allow the named attorney in fact to act on my behalf in any jurisdiction.
Furthermore, I desire that the authority granted by this document be liberally interpreted to allow the named attorney in fact the fullest powers to act on my behalf, under present law, or expansions of such laws in the future. For example, I understand that at present, certain actions such as euthanasia are impermissible, but I desire that my attorney in fact be allowed the fullest authority to make such decisions in the event that such actions become permissible at any time in the future.
I revoke any durable power of attorney for health care previously executed by me.
12. DECLARATION OF PRINCIPAL:
Pursuant to Probate Code Section 4753, I hereby eliminate the authority of any person listed in Probate Code Section 4765 other than myself to petition the court under Probate Code Section 4750-4771 to the maximum extent possible.
A photocopy or facsimile of this document has the same effect as the original.
WARNING TO PERSON EXECUTING THIS DOCUMENT
THIS IS AN IMPORTANT LEGAL DOCUMENT WHICH
IS AUTHORIZED BY THE
THIS DOCUMENT GIVES THE PERSON YOU
DESIGNATE AS YOUR AGENT (THE ATTORNEY IN FACT) THE POWER TO MAKE HEALTH CARE
DECISIONS FOR YOU. YOUR AGEN
EXCEPT AS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THIS DOCUMENT GIVES YOUR AGENT THE POWER TO CONSENT TO YOUR DOCTOR NOT GIVING TREATMENT OR STOPPING TREATMENT NECESSARY TO KEEP YOU ALIVE.
NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE
RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF SO LONG AS
YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION. IN ADDITION, NO TREATMEN
THIS DOCUMENT GIVES YOUR AGENT AUTHORITY TO
CONSENT, TO REFUSE TO CONSENT, OR TO WITHDRAW CONSENT TO ANY CARE, TREATMENT, SERVICE,
OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL
CONDITION. THIS POWER IS SUBJECT TO ANY
STATEMENT OF YOUR DESIRES AND ANY LIMITATIONS THAT YOU INCLUDE IN THIS
YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY OF YOUR AGENT BY NOTIFYING YOUR AGENT OR YOUR TREATING DOCTOR, HOSPITAL, OR OTHER HEALTH CARE PROVIDER ORALLY OR IN WRITING OF THE REVOCATION.
YOUR AGENT HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT.
IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.
DO NOT USE THIS FORM IF YOU ARE A CONSERVATEE UNDER THE LANTERMAN-PETRIS-SHORT ACT AND YOU WANT TO APPOINT YOUR CONSERVATOR AS YOUR AGENT. YOU CAN DO THAT ONLY IF THE APPOINTMENT DOCUMENT INCLUDES A CERTIFICATE OF YOUR ATTORNEY.
_____________________, at ______________________,
COUNTY OF }
On ______________, 2009, before me, _________________________, Notary Public, personally appeared ______________________, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under penalty of perjury under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
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