Healthcare Power of Attorney

HEALTHCARE POWER OF ATTORNEY

IMPORTANT NOTICE

THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:

1. THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR AGENT THE POWER TO MAKE HEALTHCARE DECISIONS FOR YOU IF YOU CANNOT MAKE THEM FOR YOURSELF.

2. YOUR AGENT MUST ACT CONSISTENTLY WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN.

3. UNLESS YOU STATE OTHERWISE, YOUR AGENT HAS THE SAME AUTHORITY TO MAKE DECISIONS ABOUT YOUR HEALTHCARE AS YOU WOULD HAVE HAD.

4. THIS POWER WILL EXIST FOR AN INDEFINITE PERIOD OF TIME UNLESS YOU LIMIT ITS DURATION IN THIS DOCUMENT.

5. YOU HAVE THE RIGHT TO REVOKE THIS DESIGNATION OF AGENT BY NOTIFYING YOUR AGENT OR YOUR HEALTHCARE PROVIDER ORALLY OR IN WRITING.

6. UNDERSTAND THE IMPORTANCE OF THIS DOCUMENT. IF YOU HAVE ANY QUESTIONS ABOUT THIS DOCUMENT OR THE POWERS IT GRANTS, YOU SHOULD SEEK LEGAL ADVICE BEFORE SIGNING IT.

ARTICLE I: DESIGNATION OF HEALTHCARE AGENT

I, ______________________________ [Principal's Full Legal Name], residing at _____________________________________________ [Street Address], _________________________ [City], _________________ [State] _____________ [ZIP Code], with telephone number ________________________, and date of birth ________________________, hereby designate and appoint:

Name: ______________________________ [Agent's Full Legal Name] Address: _____________________________________________ [Street Address], _________________________ [City], _________________ [State] _____________ [ZIP Code] Telephone: ________________________ [Agent's Phone Number] Relationship to Principal: ________________________

as my agent to make healthcare decisions for me as authorized in this document.

ARTICLE II: DESIGNATION OF ALTERNATE AGENTS

If my agent is unwilling, unable, or unavailable to serve or make a healthcare decision for me, then I designate the following persons, in the order listed below, to serve as my alternate agents:

First Alternate Agent:

Name: ______________________________ [First Alternate Agent's Full Legal Name] Address: _____________________________________________ [Street Address], _________________________ [City], _________________ [State] _____________ [ZIP Code] Telephone: ________________________ [First Alternate Agent's Phone Number] Relationship to Principal: ________________________

Second Alternate Agent:

Name: ______________________________ [Second Alternate Agent's Full Legal Name] Address: _____________________________________________ [Street Address], _________________________ [City], _________________ [State] _____________ [ZIP Code] Telephone: ________________________ [Second Alternate Agent's Phone Number] Relationship to Principal: ________________________

ARTICLE III: EFFECTIVE DATE AND DURABILITY

Section 3.1: Effective Date

(Choose one option by initialing)

_____ This Healthcare Power of Attorney shall become effective immediately upon execution and shall remain effective if I become disabled, incapacitated, or otherwise unable to make or communicate healthcare decisions.

_____ This Healthcare Power of Attorney shall become effective only upon a determination that I lack the capacity to make or communicate my own healthcare decisions.

Section 3.2: Determination of Incapacity

For purposes of this document, I shall be considered to lack the capacity to make healthcare decisions for myself when the following person(s) determine(s) in writing that I lack the ability to understand the nature and consequences of the proposed healthcare decisions, to make those healthcare decisions, or to communicate them to others:

(Choose one option by initialing)

_____ My attending physician.

_____ My attending physician and one additional physician.

_____ My attending physician and the following individual: ______________________________.

Section 3.3: Durability Provision

This Healthcare Power of Attorney shall not be affected by my subsequent disability, incapacity, or incompetence. This document is intended to create a durable power of attorney for healthcare decisions under applicable state law.

Section 3.4: Temporary Recovery of Capacity

If I regain capacity to make healthcare decisions, my agent's authority shall temporarily cease during the period of my recovered capacity. If I subsequently lose capacity again, my agent's authority shall be reinstated without the need for redetermination of incapacity.

ARTICLE IV: AGENT'S POWERS AND AUTHORITY

Section 4.1: General Grant of Authority

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 this document or otherwise known to my agent. My agent shall be guided by my medical diagnosis and prognosis and any information provided by my physicians regarding the intrusiveness, pain, risks, and side effects of the proposed treatment. If my wishes are unknown, my agent shall make healthcare decisions for me in accordance with what my agent determines to be in my best interests.

Section 4.2: General Medical Decision Authority

My agent is authorized to:

1. Consent to, refuse, or withdraw consent to any and all types of medical care, treatment, surgical procedures, diagnostic procedures, medication, and the use of mechanical or other procedures that affect any bodily function;
2. Have access to medical records and information to the same extent that I am entitled to, including the right to disclose the contents to others as appropriate for my healthcare;
3. Authorize my admission to or discharge from any hospital, nursing home, residential care, assisted living or similar facility or service;
4. Contract for any healthcare-related service or facility on my behalf, without my agent incurring personal financial liability for such contracts;
5. Hire and fire medical, social service, and other support personnel responsible for my care; and
6. Take any other action necessary to do what I authorize here, including signing waivers or other documents, pursuing any dispute resolution process, or taking legal action in my name.

Section 4.3: Specific Medical Treatments Authority

My agent is specifically authorized to consent to, refuse, or withdraw consent to the following specific medical treatments or procedures:

1. Surgery or other invasive procedures;
2. Administration, withholding, or withdrawal of medication;
3. Diagnostic tests and procedures;
4. Blood transfusions and blood products;
5. Chemotherapy, radiation therapy, and other cancer treatments;
6. Physical therapy, occupational therapy, and other rehabilitation services;
7. Dialysis and other renal therapies;
8. Implantation of cardiac devices, including pacemakers and defibrillators;
9. Amputation or removal of body parts;
10. Any other medical treatment or procedure that my healthcare providers recommend or deem necessary for my health and well-being.

Section 4.4: Life-Sustaining Treatment Authority

My agent is authorized to make decisions regarding life-sustaining treatment, including but not limited to:

1. Cardiopulmonary resuscitation (CPR);
2. Mechanical ventilation or breathing machines;
3. Artificial nutrition and hydration (food and water provided by feeding tube or intravenous line);
4. Dialysis;
5. Antibiotics;
6. Blood transfusions or blood products;
7. Chemotherapy, radiation therapy, and other cancer treatments;
8. Any other treatment which could potentially keep me alive but may not cure my condition.

My agent should consider the relief of suffering, the quality as well as the possible extension of my life, and my personal values and wishes as expressed in this document or otherwise made known to my agent.

Section 4.5: Facility Admission Authority

My agent is authorized to:

1. Admit me to any hospital, hospice, nursing home, assisted living facility, or other healthcare facility;
2. Transfer me from one facility to another;
3. Discharge me from any facility when my agent determines it is in my best interest;
4. Sign any documents related to admission, transfer, or discharge, including waivers of rights and financial agreements, without my agent incurring personal financial liability.

Section 4.6: Healthcare Provider Selection

My agent is authorized to:

1. Select, employ, and discharge healthcare providers, including physicians, nurses, therapists, hospice providers, and personal care assistants;
2. Change my healthcare providers when my agent determines such change is in my best interest;
3. Request a second opinion from another healthcare provider;
4. Consent to examination and treatment by healthcare providers selected by my agent.

Section 4.7: Medical Records Access

I authorize my agent to:

1. Request, review, and receive any information, verbal or written, regarding my physical or mental health, including medical and hospital records;
2. Execute any releases or other documents that may be required in order to obtain such information;
3. Disclose such information to appropriate healthcare providers or others as needed for my healthcare;
4. Consent to the disclosure of information regarding my health and medical care.

This authorization specifically includes the authority to access, authorize release of, and disclose all information and records governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 USC 1320d and 45 CFR 160-164, and all other applicable state and federal laws.

Section 4.8: Anatomical Gift Authority

(Choose one option by initialing)

_____ My agent IS authorized to make anatomical gifts of all or part of my body, authorize an autopsy, and direct the disposition of my remains.

_____ My agent IS NOT authorized to make anatomical gifts of my body, authorize an autopsy, or direct the disposition of my remains.

If I have authorized my agent to make anatomical gifts, this authority includes the ability to:

1. Donate all or any part of my body for transplantation, therapy, research, or education;
2. Determine which organs or tissues to donate;
3. Determine which individuals or institutions shall receive such donations;
4. Place reasonable conditions on such donations.

Section 4.9: Psychiatric Treatment Authority

(Choose one option by initialing)

_____ My agent IS authorized to consent to psychiatric treatment, including but not limited to administration of psychotropic medications and voluntary admission to a mental health facility.

_____ My agent IS NOT authorized to consent to psychiatric treatment, including administration of psychotropic medications or voluntary admission to a mental health facility.

If I have authorized my agent to consent to psychiatric treatment, this authority includes the ability to:

1. Consent to administration of psychotropic medications, including antipsychotics, antidepressants, mood stabilizers, and anti-anxiety medications;
2. Consent to electroconvulsive therapy if recommended by my treating psychiatrist;
3. Consent to my voluntary admission to a mental health treatment facility for up to _____ days;
4. Participate in the development of a treatment plan for psychiatric conditions;
5. Access and authorize release of my mental health records.

Section 4.10: Pain Management Authority

I authorize my agent to consent to the administration of pain relief medications and treatments, even if such medications or treatments may hasten my death or have side effects such as sedation or respiratory depression. My comfort and dignity are important to me, and I direct my agent to prioritize pain management and palliative care when appropriate.

Section 4.11: Experimental Treatment Authority

(Choose one option by initialing)

_____ My agent IS authorized to consent to my participation in experimental medical treatments, clinical trials, or research protocols that may benefit me or others, even if such treatments have not been proven effective or may involve additional risks.

_____ My agent IS NOT authorized to consent to my participation in experimental medical treatments, clinical trials, or research protocols.

If I have authorized my agent to consent to experimental treatments, my agent shall consider:

1. The potential benefits to me and to medical knowledge;
2. The risks, side effects, and discomforts involved;
3. Available alternatives and their risks and benefits;
4. My values and what I would likely choose if I were able to decide.

Section 4.12: Pregnancy Provisions

If I am pregnant at the time healthcare decisions need to be made, my agent shall: (Choose one option by initialing)

_____ Take into account the impact of any healthcare decision on my unborn child and prioritize the life and health of both me and my unborn child to the extent medically possible.

_____ Make healthcare decisions based solely on my best interests, regardless of the impact on my pregnancy.

_____ Follow these specific instructions regarding my care during pregnancy: ____________________________________________________________

ARTICLE V: LIMITATIONS ON AGENT'S AUTHORITY

Section 5.1: Specific Limitations

Notwithstanding any provision of this Healthcare Power of Attorney to the contrary, my agent shall NOT have the authority to:

Section 5.2: Religious and Moral Considerations

In making healthcare decisions for me, my agent shall consider my religious and moral beliefs and values, which are as follows:

My agent shall consult with ______________________________ [name/title of religious leader, if applicable] regarding any healthcare decisions that may conflict with my religious beliefs.

ARTICLE VI: RELATIONSHIP TO OTHER DOCUMENTS

Section 6.1: Living Will Coordination

(Choose one option by initialing)

_____ I have executed a Living Will or Advance Directive dated ________________. In case of any conflict between this Healthcare Power of Attorney and my Living Will/Advance Directive, my Living Will/Advance Directive shall take precedence.

_____ I have executed a Living Will or Advance Directive dated ________________. In case of any conflict between this Healthcare Power of Attorney and my Living Will/Advance Directive, this Healthcare Power of Attorney shall take precedence.

_____ I have NOT executed a Living Will or Advance Directive. This Healthcare Power of Attorney represents my wishes regarding healthcare decisions.

Section 6.2: Guardian Nomination

If a guardian of my person should need to be appointed, I nominate my agent designated in this document to serve as such guardian. If my agent is unable or unwilling to serve as guardian, I nominate my alternate agents in the order named.

Section 6.3: Prior HPOA Revocation

I hereby revoke any previous Healthcare Power of Attorney or similar document that I may have executed prior to the date of this document. Any such previous Healthcare Power of Attorney or similar document is null and void.

ARTICLE VII: AGENT GUIDANCE

Section 7.1: Agent Standards and Principles

In exercising the authority under this Healthcare Power of Attorney, my agent shall act:

1. In accordance with my known wishes expressed in this document, in my Living Will (if any), or otherwise communicated to my agent;
2. If my wishes are not known, in accordance with what my agent determines to be in my best interests, taking into account my personal values to the extent known to my agent;
3. With good faith and loyalty to me, avoiding conflicts of interest;
4. With diligence, competence, and care.

Section 7.2: Agent Acceptance

By accepting appointment as my healthcare agent, my agent agrees to:

1. Act in accordance with this document and my known wishes;
2. Keep me informed about decisions made under this power, to the extent I am able to understand;
3. Consult with my healthcare providers and others who can provide information relevant to my care;
4. Consult with family members and close friends who may have information about my wishes;
5. Keep records of significant actions taken as my agent.

Section 7.3: Agent Compensation and Reimbursement

My agent shall not be entitled to compensation for services performed under this Healthcare Power of Attorney, but shall be entitled to reimbursement for all reasonable expenses incurred as a result of carrying out any provision of this Healthcare Power of Attorney.

Section 7.4: Agent Liability Protection

No agent or alternate agent named in this document shall be liable to me or my estate for good faith decisions made in the exercise of the authority granted by this Healthcare Power of Attorney. I direct that my estate indemnify and hold harmless any agent for reasonable costs incurred in defending any challenge to the agent's authority or decisions made in good faith under this document.

ARTICLE VIII: HEALTHCARE PREFERENCES

Section 8.1: General Values Statement

The following represents my general values, goals, and preferences regarding healthcare:

Section 8.2: End-of-Life Preferences

If I have an incurable or irreversible condition that will result in my death within a relatively short time, or if I am in a state of permanent unconsciousness such as an irreversible coma or persistent vegetative state and there is no reasonable expectation that I will regain consciousness, or if I am in a terminal condition, then my preferences for end-of-life care are as follows:

(Choose by initialing)

_____ I direct that I be given care focused on my comfort and dignity, allowing natural death to occur. I do not want life-sustaining treatment to be provided or continued.

_____ I direct that all medically appropriate measures be provided to sustain my life, regardless of my condition or prognosis.

_____ I direct the following specific instructions regarding end-of-life care:

Regarding location of care at the end of life, my preference is: (Choose by initialing)

_____ To remain at home as long as it is medically feasible and does not impose an undue burden on my family or caregivers.

_____ To be cared for in a hospice facility.

_____ To be cared for in a hospital.

_____ Other: ____________________________________________________________

Section 8.3: Quality of Life Considerations

I consider the following conditions to represent an unacceptable quality of life: (Initial all that apply)

_____ Permanent unconsciousness or persistent vegetative state _____ Inability to communicate meaningfully with family and friends _____ Complete physical dependency for all activities of daily living _____ Advanced dementia where I no longer recognize my loved ones _____ Severe chronic pain that cannot be adequately controlled _____ Other: ____________________________________________________________

If I am in any of the conditions I have initialed above, I direct that life-sustaining treatment be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

Section 8.4: Specific Medical Conditions

I have the following specific medical conditions that my agent should be aware of when making healthcare decisions:

My preferences for managing these conditions are:

ARTICLE IX: TERMINATION

Section 9.1: Revocation Procedures

I understand that I may revoke this Healthcare Power of Attorney at any time by:

1. Physically destroying this document or directing another person to physically destroy this document in my presence;
2. Signing and dating a written revocation;
3. Orally expressing my intent to revoke this document to my agent or healthcare provider; or
4. Executing a new Healthcare Power of Attorney.

Any revocation shall be effective upon communication to my agent or healthcare provider.

Section 9.2: Automatic Termination Events

This Healthcare Power of Attorney shall automatically terminate upon:

1. My death;
2. The death, incapacity, resignation, or removal of my last named agent and alternate agent;
3. My divorce or legal separation from my spouse, if my spouse is named as my agent (unless I have named my spouse after such divorce or separation);
4. A court order specifically revoking this Healthcare Power of Attorney.

Section 9.3: Agent Resignation Process

Any agent or alternate agent may resign by giving written notice to me, to my other agents, and to my healthcare providers. If I am incapacitated, such notice shall be given to any person reasonably believed to have an interest in my welfare.

ARTICLE X: LEGAL PROVISIONS

Section 10.1: State Law Compliance

This Healthcare Power of Attorney is intended to be valid in any jurisdiction in which it is presented. The powers delegated under this document are severable, so that the invalidity of one or more powers shall not affect any others. This document shall be construed and interpreted in accordance with the laws of the state of ________________ [Principal's State of Residence].

Section 10.2: Durability Provision

This power of attorney shall not be affected by my subsequent disability or incapacity, or lapse of time.

Section 10.3: Severability Clause

If any provision of this Healthcare Power of Attorney or its application to any person or circumstance is held invalid or unenforceable, the invalidity or unenforceability shall not affect other provisions or applications of this document which can be given effect without the invalid or unenforceable provision or application, and to this end, the provisions of this Healthcare Power of Attorney are severable. If any provision of this Healthcare Power of Attorney is found to be invalid or unenforceable, such provision shall be deemed modified to the extent necessary to make it enforceable while preserving its intent, or if such modification is not possible, such provision shall be severed from this document, and the remainder of this Healthcare Power of Attorney shall continue in full force and effect.

Section 10.4: Governing Law

This Healthcare Power of Attorney shall be governed by, construed, and enforced in accordance with the laws of the state of ________________ [Principal's State of Residence].

ARTICLE XI: PRACTICAL CONSIDERATIONS

Section 11.1: Distribution of Copies

I direct that copies of this document be given to:

1. My primary healthcare agent and all alternate agents;
2. My primary care physician and any specialists currently treating me;
3. Any hospital, nursing home, or assisted living facility where I reside;
4. The following family members:

   ---

   ---

5. The following additional persons:

   ---

   ---

Section 11.2: Periodic Review Recommendation

I understand the importance of reviewing this document periodically, especially after major life events such as marriage, divorce, birth of children, death of a named agent, significant changes in health status, or relocation to another state. I intend to review this document at least every three years.

EXECUTION

IN WITNESS WHEREOF, I sign this Healthcare Power of Attorney willingly and voluntarily, and declare that I am of sound mind and under no constraint or undue influence.

Signed this _____ day of ________________, [YEAR].

[Principal's Signature]

[Principal's Printed Name]

WITNESS ATTESTATION

The declarant is personally known to me and I believe the declarant to be of sound mind and under no constraint or undue influence. I am not related to the declarant by blood, marriage, or adoption, and I am not entitled to any portion of the declarant's estate under any existing will or codicil or by operation of law. I am not the declarant's attending physician, nor an employee of the attending physician or of any healthcare facility in which the declarant is a patient.

Witness #1:

[Signature]

[Printed Name]

[Address]

[City, State, ZIP]

Witness #2:

[Signature]

[Printed Name]

[Address]

[City, State, ZIP]

NOTARY ACKNOWLEDGMENT

STATE OF ________________ ) ) ss. COUNTY OF ______________ )

On this _____ day of ________________, [YEAR], before me personally appeared ______________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained.

IN WITNESS WHEREOF, I hereunto set my hand and official seal.

Notary Public

My Commission Expires: ________________

AGENT ACCEPTANCE

I, ______________________________, hereby accept appointment as healthcare agent for ______________________________ (Principal). I understand my duties and responsibilities as healthcare agent as explained in this document, and I agree to act in accordance with the Principal's wishes and instructions as expressed in this document or otherwise made known to me. I will act in good faith and in the Principal's best interests when the Principal's wishes are unknown.

[Agent's Signature]

[Date]

FIRST ALTERNATE AGENT ACCEPTANCE

I, ______________________________, hereby accept appointment as first alternate healthcare agent for ______________________________ (Principal). I understand my duties and responsibilities as healthcare agent as explained in this document, and I agree to act in accordance with the Principal's wishes and instructions as expressed in this document or otherwise made known to me. I will act in good faith and in the Principal's best interests when the Principal's wishes are unknown.

[First Alternate Agent's Signature]

[Date]

SECOND ALTERNATE AGENT ACCEPTANCE

I, ______________________________, hereby accept appointment as second alternate healthcare agent for ______________________________ (Principal). I understand my duties and responsibilities as healthcare agent as explained in this document, and I agree to act in accordance with the Principal's wishes and instructions as expressed in this document or otherwise made known to me. I will act in good faith and in the Principal's best interests when the Principal's wishes are unknown.

[Second Alternate Agent's Signature]

[Date]