STATE OF OHIO
DURABLE POWER OF ATTORNEY
FOR HEALTH CARE
1. DESIGNATION OF ATTORNEY-IN-FACT.
I, ________________________________________________, presently residing at ___________________________________________________, Ohio (the "Principal") being of sound mind and not under or subject to duress, fraud or undue influence, intending to create a Durable Power of Attorney for Health Care under Chapter 1337 of the Ohio Revised Code, as amended from time to time, do hereby designate and appoint: ________________________, presently residing at ___________________________________________________________, Phone: _______________________ as my attorney-in-fact who shall act as my agent to make health care decisions for me as authorized in this document.
2. GENERAL STATEMENT OF AUTHORITY GRANTED.
I hereby grant my agent full power and authority to make all health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, at any time during which I do not have the capacity to make informed health care decisions for myself. Such agent shall have the authority to give, to withdraw or to refuse to give informed consent to any medical or nursing procedure, treatment, intervention or other measure used to maintain, diagnose or treat my physical or mental condition. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent by me or, if I have not made my desires known, that are, in the judgement of my agent, in my best interests.
3. ADDITIONAL AUTHORITIES OF AGENT.
Where necessary or desirable to implement the health care decisions that my agent is authorized to make pursuant to this document my agent has the power and authority to do any and all of the following:
(a) If I am in a terminal condition, to give, to withdraw or to refuse to give informed consent to life-sustaining treatment, including the provision of artificially or technologically supplied nutrition or hydration;
(b) If I am in a permanently unconscious state, to give, to withdraw or to refuse to give informed consent to life-sustaining treatment; provided, however, my agent is not authorized to refuse or direct the withdrawal of artificially or technologically supplied nutrition or hydration unless I have specifically authorized such refusal or withdrawal in Paragraph 4;
(c) To request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, all of my medical and health care facility records;
(d) To execute on my behalf any releases or other documents that may be required in order to obtain this information;
(e) To consent to the further disclosure of this information if necessary;
(f) To select, employ, and discharge health care personnel, such as physicians, nurses, therapists and other medical professionals, including individuals and services providing home health care, as my agent shall determine to be appropriate;
(g) To select and contract with any medical of health care facility on my behalf, including, but not limited to, hospitals, nursing homes, assisted residence facilities, and the like; and
(h) To execute on my behalf any or all of the following:
(1) Documents that are written consents to medical treatment. Do Not Resuscitate orders, or other similar orders;
(2) Documents that are written requests that I be transferred to another facility, written requests to be discharged against medical advice, or other similar requests; and
(3) Any other document necessary or desirable to implement health care decisions that my agent is authorized to make pursuant to this document.
4. WITHDRAWAL OF NUTRITION AND HYDRATION WHEN IN A PERMANENTLY UNCONSCIOUS STATE.
[ ] ____IF I HAVE MARKED THE FOREGOING BOX AND HAVE PLACED MY INITIALS ON THE LINE ADJACENT TO IT, MY AGENT MAY REFUSE, OR IN THE EVENT THAT TREATMENT HAS ALREADY COMMENCED, WITHDRAW INFORMED CONSENT TO THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIED NUTRITION AND HYDRATION, IF I AM IN A PERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED ME DETERMINE, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT SUCH NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO ME OR ALLEVIATE MY PAIN.
5. DESIGNATION OF ALTERNATE AGENT.
Because I wish that an agent shall be available to exercise the authorities granted hereunder
at all times, I further designate each of the following individuals to succeed to such authorities and
to serve under this instrument, in the order named, if at any time the agent first named (or any
alternate designee) is not readily available or is unwilling or unable to serve or to continue to serve:
First Alternate Agent: ___________________________________
Relationship ________________________
Presently residing at ____________________________________________________________
Phone: ____________________________
Second Alternate Agent: ___________________________________
Relationship ________________________
Presently residing at ____________________________________________________________
Phone: ____________________________
Each alternate shall have and exercise all of the authority conferred above.
6. NO EXPIRATION DATE.
This Durable Power of Attorney for Health Care shall not be affected by my disability or by lapse of time. This Durable Power of Attorney for Health Care shall have no expiration date.
7. SEVERABILITY.
Any invalid or unenforceable power, authority or provision of this instrument shall not affect any other power, authority or provision or the appointment of my agent to make health care decisions.
8. PRIOR DESIGNATIONS REVOKED.
I hereby revoke any prior Durable Power of Attorney for Health Care executed by me under Chapter 1337 of the Ohio Revised Code.
I understand the purpose and effect of this document and sign my name to this Durable Power of Attorney for Health Care after careful deliberation 3rd day of May, 2000 in the City of Worthington, Ohio.
______________________________
______________________________, Principal
I attest that the Principal signed or acknowledged this Durable Power of Attorney for Health Care in my presence, and that the Principal appears to be of sound mind and not under or subject to duress, fraud or undue influence. I further attest that I am not the agent designated in this document, I am not the attending physician of the principal, I am not the administrator of a nursing home in which the principal is receiving care, and that I am an adult not related to the principal by blood, marriage or adoption.
Dated: ______________________
________________________ ________________________
Witness- Witness-
Address- Address-
ACKNOWLEDGMENT
STATE OF OHIO )
COUNTY OF _________________ )
Before me, a Notary Public in and for said County, personally appeared the above-named ______________________________, known to me or satisfactorily proven to be the person whose name is subscribed to the above Durable Health Care Power of Attorney, and acknowledged that ______ executed the same for the purposes expressed therein. I attest that the Declarant appears to be of sound mind and not under or subject to duress, fraud or undue influence.
_________________________
Notary Public:
NOTE: YOU MAY WISH TO GIVE EXECUTED COPIES OF THIS DURABLE POWER OF ATTORNEY FOR HEALTH CARE TO THE AGENT NAMED IN THIS DOCUMENT, EACH ALTERNATIVE AGENT, AND TO YOUR LAWYER, YOUR PERSONAL PHYSICIAN AND MEMBERS OF YOUR FAMILY.
The following notice is included in this printed form as required by
Ohio Revised Code Section 1337.17.
NOTICE TO ADULT EXECUTING THIS DOCUMENT
This is an important legal document. Before executing this document, you should know these facts:
This document gives the person you designate (the attorney-in-fact) the power to make MOST health care decisions for you is you lose the capacity to make informed health care decisions for yourself. This power is effective only when your attending physician determines that you have lost 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 heath 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 decisions yourself, if you had 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 an 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 in 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 care (except that, if he is not prohibited from doing so under (4) below, the attorney-in-fact could refuse or withdraw informed consent to the provision of nutrition or hydration to you as described under (4) 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. 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 SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN, THEN, SUBJECT TO (4) BELOW, YOUR 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 health care for you if you are pregnant and if the refused or withdrawal would terminate the pregnancy (unless the pregnancy or health care would pose a substantial risk to your life, or unless your attending physician and at least one other physician who examines you determine, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that the fetus would not be born alive);
(4) 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 IN A PERMANENTLY 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 WITH REASONABLE MEDICAL STANDARDS, THAT NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN.
(c) IF, BUT ONLY IF, YOU 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 IN THIS 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 (4)(c)(i) AND (ii) ABOVE.
(5) 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 its 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.
As a public service, a special committee of the Ohio State Bar Association prepared this form, which has been approved by the Ohio State Medical Association.
©August 1991. Ohio State Bar Association and Ohio State Medical Association. May be reprinted and copied for use by attorneys, medical and osteopathic physicians, hospitals, bar associations, medical societies and associations, the public, and non-profit organizations. May not be reproduced or sold for profit.