HEALTHCARE POWER OF ATTORNEY

Unlike a living will which only addresses life sustaining procedures, a durable health care power of attorney can authorize your agent to have access to medical records, allow autopsies or transfer you to a nursing home or other health care facility.

The Durable Power of Attorney is state specific. Below is a sample form from the state of Ohio.

NOTICE TO ADULTS EXECUTING THIS DOCUMENT. THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:

This document gives the person you name as your agent (the attorney-in- fact) the power to make most health care decisions for you if you lose the capacity to make informed health care decisions for yourself, and notwithstanding this document, as long as you have the capacity to make informed health care decisions for yourself, you retain the right to make all medical and other health care decisions for yourself.

You may include specific limitations in this document on the authority of the attorney in fact to make health care decisions for you.

Subject to any specific limitations you include in this document, if your attending physician determines that you have lost the capacity to make an informed decision on a health care matter, the attorney in fact generally will be authorized by this document to make health care decisions for you to the same extent as you could make those decision yourself, if you had the capacity to do so. The authority of the attorney in fact to make health care decisions for you GENERALLY will include the authority to give informed consent, to refuse to give informed consent or to withdraw informed consent to any care, treatment, service, or procedure to maintain, diagnose or treat a physical or mental condition.

HOWEVER, even if the attorney in fact has general authority to make health care decisions for you under this document, the attorney in fact NEVER will be authorized to do any of the following:

(1) Refuse or withdraw informed consent to life sustaining treatment (unless your attending physician and one other physician who examines you determine to a reasonable degree of medical certainty and accordance with reasonable medical standards, that either of the following applies:

(a) You are suffering from an irreversible, incurable and untreatable condition caused by disease, illness or injury from which (i) there can be no recovery and {ii) your death is likely to occur within a relatively short time if life sustaining treatment is not administered, and your attending physician additionally determines, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that there is no reasonable possibility that you will regain the capacity to make informed health care decisions for yourself

(b) You are in a state of permanent unconsciousness that is characterized by you being irreversibly unaware of yourself and your environment and by a total loss of cerebral cortical functioning, resulting in you having no capacity to experience pain or suffering and your attending physician additionally determines, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that there is no reasonable possibility that you will regain the capacity to make informed health care decisions for yourself);

(2) Refuse or withdraw informed consent to health care necessary to provide you with comfort (except that, if he is not prohibited from doing so under (3) below, the attorney in fact could refuse or withdraw informed consent to the provision of nutrition or hydration to you as described under (3) below. (YOU SHOULD UNDERSTAND THAT COMFORT CARE IS DEFINED IN OHIO LAW TO MEAN ARTIFICIALLY OR TECHNOLOGICALLY ADMINISTERED SUSTENANCE (NUTRITION) OR FLUIDS (HYDRATION) WHEN ADMINISTERED TO DIMINISH YOUR PAIN OR DISCOMFORT, NOT TO POSTPONE YOUR DEATH AND ANY OTHER MEDICAL OR NURSING PROCEDURE , TREATMENT, INTERVENTION, OR OTHER MEASURE THAT SHOULD BE TAKEN TO DIMINISH YOUR PAIN OR DISCOMFORT, NOT TO POSTPONE YOUR DEATH. CONSEQUENTLY, IF YOUR ATTENDING PHYSICIAN, WERE TO DETERMINE THAT A PREVIOUSLY DESCRIBED MEDICAL OR NURSING PROCEDURE, TREATMENT, INTERVENTION OR OTHER MEASURE WILL NOT OR NO LONGER WILL SERVICE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN, THEN SUBJECT TO (4) BELOW, YOU ATTORNEY IN FACT WOULD BE AUTHORIZED TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE);

(3) Refuse or withdraw informed consent to the provision of artificially or technologically administered sustenance (nutrition) or fluids (hydration) to you, unless

(a) You are in a terminal condition or permanent unconscious state

(b) Your attending physician and at least one other physician who has examined you determine, to a reasonable degree of medical certainty and in accordance to you or alleviate your pain.

(c) If, but only if, your are in a permanently unconscious state, you authorize the attorney in fact to refuse or withdraw informed consent to the provision of nutrition or hydration to you by doing both of the following within the document

(i) Including a statement in capital letters that the attorney in fact may refuse or withdraw informed consent to the provision of nutrition or hydration to you if you are in a permanently unconscious state and if the determination that nutrition or hydration will not or no longer will serve to provide comfort to you or alleviate your pain is made, or checking or otherwise marking a box or line (if any) that is adjacent to a similar statement on this document;

(ii) Placing your initials or signature underneath or adjacent to the statement, check or other mark previously described.

(d) your attending physician determines, in good faith, that you authorized the attorney in fact to refuse or withdraw informed consent to the provision of nutrition or hydration to you if you are in a permanently unconscious state by complying with the requirements of (3)(c)(i) and (ii) above.

(4) Withdraw informed consent to any health care to which you previously consented, unless a change in your physical condition has significantly decreased the benefit of that health care to you, or unless the health care is not or is no longer significantly effective in achieving the purposes for which you consented to is use.

Additionally, when exercising his authority to make health care decisions for you the attorney in fact will have to act consistently with your desires or, if your desires are unknown, to act in your best interest. You may express your desires to the attorney in fact by including them in this document or by making them known to him in another manner.

When acting pursuant to the document, the attorney in fact GENERALLY will have the same rights that you have to receive information about proposed health care or to review health care records and to consent to the disclosure of health care records. You can limit that right in this document if you so chose.

Generally you may designate any competent adult as the attorney in fact under this document. However, you CANNOT designate your attending physician or the administrator of any nursing home in which you are receiving care as the attorney in fact under this document. Additionally, you CANNOT designate an employee or agent of your attending physician, or an employee or agent of a health care facility at which you are being treated, as the attorney in fact under this document, unless either type of employee or agent is a competent adult and related to you by blood, marriage or adoption or unless either type of employee or agent is a competent adult and your and the employee or agent are members of the same religious order

This document has no expiration date under Ohio law, but you may choose to specify a date upon which your durable power of attorney for health care generally will expire. However, if you specify an expiration date and then lack the capacity to make informed health care decisions for yourself on that date the document and the power it grants to your attorney in fact will continue in effect until you regain the capacity to make informed health care decisions for yourself.

You have the right to revoke the designation of the attorney in fact and the right to revoke the entire document at any time and in any manner. Any such revocation generally will be effective when you express your intention to make the revocation. However, if you make your attending physician aware of this document, any such revocation will be effective only when you communicate it to your attending physician or when a wittiness to the revocation or other health care personnel to whom the revocation is communicated by such a witnesses communicates it to your attending physician.

If you execute this document and create a valid, durable power of attorney for health care with it, it will revoke any prior, valid durable power of attorney for health care that you created, unless you indicate otherwise in this document.. This document is not valid as a durable power of attorney for health. Unless it is acknowledged before a notary public or is signed by a least two adult witnesses who are present when your sign or acknowledge your signature. No person who is related to you by blood, marriage or adoption may be a witness. The attorney in fact, your attending physician, and the administrator of any nursing home in which you are receiving care also are ineligible to be witnesses.

If there is anything in this document that you do not understand, you should ask you lawyer to explain it to you.

I, [YOUR NAME] am an adult of sound mind, and not under or subject to any duress, fraud, or undue influence. With full understanding of its import and effect, I hereby create this power of attorney for health care pursuant to Ohio Revised Code sections 1337.11 to 1337.17, and appoint {agent name] do hereby appoint [AGENT NAME] of [AGENT ADDRESS] , [AGENT CSZ] , [AGENT TELEPHONE #] as my agent to make health care decisions for me if I have lost the capacity to make informed health care decisions for myself.

(A) I authorize my attorney in fact to make informed health care decisions for me, which decisions shall include giving or refusing to give informed consent, or withdrawing informed consent previously given, to any health care, treatment, service, or procedure to maintain, diagnose or treat a physical or medical decision.

(B) My attorney in fact may withdraw consent previously given by me personally, when a change in my physical condition significantly decreases the benefit of such care to me, or when such care is no longer significantly effective in achieving the purposes for which I consented to it.

(C) If my condition is not terminal or I am not in a permanently unconscious state, my attorney in fact is not authorized to refuse or withdraw informed consent to health care necessary to keep me alive.

(D) Except as provided in division (E) below, my attorney in fact is not authorized to refuse or withdraw health care necessary for my comfort. or to alleviate pain.

______ (1) IF I AM IN A PERMANENTLY UNCONSCIOUS STATE AND IF THE DETERMINATION THAT NUTRITION OR HYDRATION WILL NOT OR NO LONGER SERVE TO PROVIDE COMFORT FOR ME OR ALLEVIATE MY PAIN ,MY ATTORNEY IN FACT IS AUTHORIZED TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION

_______________ Signature or initials of principal

______ (2) IF I AM SUFFERING FROM AN IRREVERSIBLE, INCURABLE AND UNTREATABLE CONDITION CAUSED BY DISEASE, ILLNESS OR INJURY FROM WHICH THERE CAN BE NO RECOVERY AND MY DEATH IS LIKELY TO OCCUR WITHIN A RELATIVE SHORT TIME IS LIFE SUSTAINING TREATMENT IS NOT ADMINISTERED AND MY ATTENDING PHYSICIAN DETERMINES TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS THAT THERE IS NO REASONABLE POSSIBILITY THAT I WILL REGAIN THE CAPACITY TO MAKE INFORMED HEALTH CARE DECISIONS FOR MYSELF, MY ATTORNEY IN FACT IS AUTHORIZED TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION

_______________ Signature or initials of principal

______ (3) IF I AM IN A PERMANENTLY UNCONSCIOUS STATES THAT IS CHARACTERIZED BY MY BEING IRREVERSIBLE UNAWARE OF MYSELF AND MY ENVIRONMENT AND BY A TOTAL LOSS OF CEREBRAL CORTICAL FUNCTION, RESULTING IN MY HAVING NO CAPACITY TO EXPERIENCE PAIN OR SUFFERING AND MY ATTENDING PHYSICIAN DETERMINES TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS THAT THERE IS NO REASONABLE POSSIBILITY THAT I WILL REGAIN THE CAPACITY TO MAKE INFORMED HEALTH CARE DECISIONS FOR MYSELF, MY ATTORNEY IN FACT IS AUTHORIZED TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION

_______________ Signature or initials of principal

(E) My attorney in fact has the same rights as myself to receive information about proposed health care for me, to obtain and review my medical and health care records, and to consent to the disclosure of such records.

(F) [INSTRUCTION STATEMENT]

(G) My attorney in fact must be act consistently with my wishes and desires, or if my desires are unknown in my best interest.

(H) I give my attorney in fact full power to do any act necessary or proper to carry out the

(I) This power of attorney shall expire on [EXPIRATION DATE] , unless at that time I lack the capacity to make informed health care decisions for myself, in which case it shall continue in effect until such time as I regain such capacity. My attending physician shall determine if I lack or have regained the capacity to make informed health care decisions.

(J) If any provision of this instrument is found to be invalid or unenforceable, it shall not be construed to limit or otherwise affect any other provision.

(K) As used in this instrument, when determined to a reasonable degree of medical certainty in accordance with reasonable medical standards by my attending physician and one other physician who has examined me:

(1) "Terminal condition" means an irreversible, incurable, and untreatable condition caused by disease, illness, or injury from which I cannot recover, and in which my death is likely to occur within a relatively short time if life sustaining treatment is not administered;

(2) "Permanently unconscious state" means a state of permanent unconsciousness in which I am irreversibly unaware of myself and my environment, and there is a total loss of cerebral cortical functioning resulting in my having no capacity to experience pain or suffering. For purposes of section (D) of this instrument, the consulting physician who, with my attending physician, makes the determination that I am in a permanently unconscious state shall be specially qualified as provided in Ohio Revised Code section 1337.13(B)(2).

WITNESS my signature, on this date of [EXECUTION DATE] .

__________________________
Signature of principal

ATTESTATION

The principal signed the foregoing power of attorney for health care or acknowledged his signature in our presence, and in his presence and the presence of each other we signed our names as witnesses, all on the date stated. Each of us says that the principal appeared at the time to be of sound mind and not under or subject to duress, fraud, or undue influence. Further, each of us says that he is an adult, and that neither is the attorney in fact named in the instrument, or related to the principal by blood, marriage, or adoption, or the principal's attending physician, or the administrator of a nursing home in which the principal is receiving care.

______________________          ______________________
Signature of witness            Signature of witness

______________________          ______________________
Typed or printed name           Typed or printed name

______________________          ______________________
Address                         Address

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