Life Support - Advance Directive
TERMS OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE
l. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE
By this document I intend to create a durable power of attorney by appointing the person designated below to make health care decisions for me as allowed by Sections 2410 to 2443, inclusive, of the California Civil Code. This power of attorney shall not be affected by my subsequent incapacity. I hereby revoke any prior durable power of attorney for health care. I am a California resident who is at least 18 years old, of sound mind and acting of my own free will.
2. APPOINTMENT OF HEALTH CARE AGENT (Fill in below the name, address and telephone number of the person you wish to make health care decisions for you if you become incapacitated. You should make sure that this person agrees to accept this responsibility. The following may not serve as your agent: (1) your treating health care provider; (2) an operator of a community care facility or residential care facility for the elderly; or (3) an employee of your treating health care provider, a community care facility, or a residential care facility for the elderly, unless that employee is related to you by blood, marriage or adoption. If you are a conservatee under the Lanterman-Petris-Short Act (the law governing involuntary commitment to a mental health facility) and you wish to appoint your conservator as your agent, you must consult a lawyer, who must sign and attach a special declaration for this document to be valid.)
I, (insert your name)
hereby appoint: Name:
Address:
Work Telephone:
Home Telephone:
as my agent (attorney-in-fact) to make health care decisions for me as authorized in this document. I understand that this power of attorney will be effective for an indefinite period of time unless I revoke it or limit its duration below.
(OPTIONAL) This power of attorney shall expire on the following
date:
3. AUTHORITY OF AGENT
If I become incapable of giving informed consent to health care decisions, I grant my agent full power and authority to make those decisions for me, subject to any statements of desires or limitations set forth below. Unless I have limited my agent's authority in this document, that authority shall include the right to consent, refuse consent, or withdraw consent to any medical care, treatment, service, or procedure; to receive and to consent to the release of medical information; to authorize an autopsy to determine the cause of my death; to make a gift of all or part of my body; and to direct the disposition of my remains, subject to any instructions I have given in a written contract for funeral services, my will or by some other method. I understand that, by law, my agent may not consent to any of the following: commitment to a mental health treatment facility, convulsive treatment, psychosurgery, sterilization or abortion.
4. MEDICAL TREATMENT DESIRES AND LIMITATIONS (OPTIONAL)
(Your agent must make health care decisions that are consistent with your known desires. You may, but are not required to, state your desires about the kinds of medical care you do or do not want to receive, including your desires concerning life support if you are seriously ill. If you do not want your agent to have the authority to make certain decisions, you must write a statement to that effect in the space provided below; otherwise, your agent will have the broad powers to make health care decisions for you that are outlined in paragraph 3 above. In either case, it is important that you discuss your health care desires with the person you appoint as your agent and with your doctor(s).
(Following is a general statement about withholding and removal of life-sustaining treatment. If the statement accurately reflects your desires, you may initial it. If you wish to add to it or to write your own statement instead, you may do so in the space provided.)
I do not want efforts made to prolong my life and I do not want life-sustaining treatment to be provided or continued: (1) if I am in an irreversible coma or persistent vegetative state; or (2) if I am terminally ill and the use of life-sustaining procedures would serve only to artificially delay the moment of my death; or (3) under any other circumstances where the burdens of the treatment outweigh the expected benefits. In making decisions about life-sustaining treatment under provision (3) above, I want my agent to consider the relief of suffering and the quality of my life, as well as the extent of the possible extension of my life.
If this statement reflects your desires, initial here: _______
Other or additional statements of medical treatment desires and limitations:
(You may attach additional pages if you need more space to complete your statement. Each additional page must be dated and signed at the same time you date and sign this document.)
5. APPOINTMENT OF ALTERNATE AGENTS (OPTIONAL)
(You may appoint alternate agents to make health care decisions for you in case the person you appointed in Paragraph 2 is unable or unwilling to do so.)
If the person named as my agent in Paragraph 2 is not available or willing to make health care decisions for me as authorized in this document, I appoint the following persons to do so, listed in the order they should be asked:
A. First Alternative Agent
Name:
B. Second Alternative Agent
6. USE OF COPIES
I hereby authorize that photocopies of this document can be relied upon by my agent and others as though they were originals.
DATE AND SIGNATURE OF PRINCIPAL
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY) I sign my name to this Durable Power of Attorney for Health Care
________________________________________ (Signature of Principal)
STATEMENT OF WITNESSES
(This power of attorney will not be valid for making health care decisions unless it is either (1) signed by two qualified adult witnesses who personally know you (or to whom you present evidence of your identity) and who are present when you sign or acknowledge your signature or (2) acknowledged before a notary public in California. If you elect to use witnesses rather than a notary public, the law provides that none of the following may be used as witnesses: (1) the persons you have appointed as your agent and alternate agents, (2) your health care provider or an employee of your health care provider, or (3) an operator or employee of an operator of a community care facility or residential care facility for the elderly. Additionally, at least one of the witnesses cannot be related to you by blood, marriage or adoption, or be named in your will.
IF YOU ARE A PATIENT IN A SKILLED NURSING FACILITY, YOU MUST HAVE A PATIENT ADVOCATE OR OMBUDSMAN SIGN BOTH THE STATEMENT OF WITNESSES BELOW AND THE DECLARATION ON THE FOLLOWING PAGE.)
I declare under penalty of perjury under the laws of California that the person who signed or acknowledged this document is personally known to me to be the principal, or that the identity of the principal was proved to me by convincing evidence,* that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as attorney in fact by this document, and that I am not a health care provider, an employee of a health care provider, the operator of a community care facility or a residential care facility for the elderly, nor an employee of an operator of a community care facility or residential care facility for the elderly.
(AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.)
I further declare under penalty of perjury under the laws of California that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.
_________________________________________
SPECIAL REQUIREMENT: STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN
(If you are a patient in a skilled nursing facility, a patient advocate or ombudsman must sign the Statement of Witnesses above and must also sign the following declaration.)
I further declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and am serving as a witness as required by subdivision (f) of Civil Code Section 2432.
You may print out this form by selecting Print from the File menu or clicking the Print button on your browser's toolbar.
(c) 1996 Kaiser Permanente KP Direct is a sample of work created by Garth Catterall-Heart Click for more information about SpiritWorks Software Development Activity & Expense Tracker Plus or Small Business Tracker Deluxe