Durable Power of Attorney for Healthcare

NOTE: The following text is a sample of a durable power of attorney for healthcare (DPOA-HC). The DPOA-HC is the way that you appoint someone to speak for you if you are sick and unable to direct your own healthcare. You are appointing an agent and giving them strong legal rights to carry out your wishes when you cannot speak or take care of yourself. Your immediate family--your legal spouse, your adult children, or your parents--can speak for you without needing a DPOA document. Even so, many people create a DPOA and formally appoint a trusted family member as their agent. It reduces the chance of error or disagreements among family, friends, or medical people treating you.

The legal strength of the durable power of attorney for health care has been tested in court. The US Supreme Court ruled in support of DPOA-HC documents and legal rights. This national recognition means that your DPOA-HC does not have to strictly match rules and regulations in your state. However, using a DPOA-HC that matches your state's specific rules is a smart thing to do because it removes sources of confusion or conflict when you are sick. All 50 states have passed laws authorizing DPOA-HC papers and functions. You can get state-specific DPOA-HC documents from http://www.caringinfo.org.

If you do not agree with one of the statements in paragraphs 1 through 6, you should draw a line through it and put your initials in the right-hand margin by the crossed-out text.

Durable Power of Attorney for Healthcare - Sample

This is a durable power of attorney for healthcare, and the authority of my agent shall not terminate if I become incapacitated. I grant to my agent full authority to make decisions for me regarding my healthcare. In exercising this authority, my agent shall follow my desires as stated in my Healthcare Treatment Directive or as otherwise known to my agent. My agent's authority to interpret my desires is intended to be as broad as possible and any expenses incurred should be paid by my resources. My agent may not delegate the authority to make decisions. My agent is authorized as follows to:

1. Consent or refuse or withdraw consent to any care, treatment, service, or procedure (including artificially supplied nutrition and/or hydration/tube feeding) used to maintain, diagnose, or treat a physical or mental condition.
2. Make decisions regarding organ donation, autopsy, and the disposition of my body.
3. Make all necessary arrangements for any hospital, psychiatric hospital, or psychiatric treatment facility, hospice, nursing facility, or similar institution or to employ or discharge healthcare personnel (any person who is licensed, certified, or otherwise authorized or permitted by the laws of the state to administer healthcare) as the agent shall deem necessary for my physical, mental, and emotional well being.
4. Request, receive, and review any information, verbal or written, regarding my personal affairs or physical or mental health including medical and hospital records and to execute any releases of other documents that may be required in order to obtain such information.
5. Move me into or out of any state or facility for the purpose of complying with my Healthcare Treatment Directive or the decisions of my agent.
6. Take any legal action reasonably necessary to do what I have directed.

I appoint the following person to be my agent to make healthcare decisions for me when and only when I lack the capacity to make or communicate a choice regarding a particular healthcare decision and my Healthcare Treatment Directive does not adequately cover the circumstances. I request that the person serving as my agent be my guardian if a guardian is needed.

Agent's Name ______________________________Telephone________________________

Address:_____________________________________________________________

____________________________________________________________________

If my agent is not available or not willing to make healthcare decisions for me or if my agent is my spouse and is legally separated or divorced from me, I appoint the person or persons named below (in the order named if more than one is listed) as my agent: (It is not necessary to name an alternate agent.)

 
First Alternate Agent              Second Alternate Agent
Name:__________________________  Name:_______________________________
Address:_______________________  Address:____________________________
_______________________________  ____________________________________
Telephone:_____________________  Telephone:__________________________

Protection of Persons Who Act as My Agent: I and my estate hold my agent and my caregivers harmless and protect them against any claim for following this durable power of attorney.

Severability: If any part of this document is held to be unenforceable under law, I direct that all of the other provisions of the document shall remain in force and in effect.

Date: _____________ Signature:______________________________________

Witness: ____________________________________ Date: _______________

Witness:_____________________________________ Date: _______________

Notarization

[Notarization of the Durable Power of Attorney is required in some states (for example, Missouri but not Kansas). If this document is both witnessed and notarized, it is more likely to be honored in other states]

On this _______day of __________________, 200__, before me personally appeared the aforesaid declarant, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County of _________________, State of ________________________, the day and year first above written.

________________________________________________________________

Notary Public

My Commission Expires________________________________________________

Acceptance [Optional]: I have discussed this document with the person making this durable power of attorney and I accept the responsibility designated to me as stated above.

Date: ________________ Agent: ___________________________________