Example of a Durable Power of Attorney

 

A Guide to Choosing A Durable Power of Attorney

For Health Care

                      

Choosing Your Agent:

 

A durable power of attorney for health care allows you to choose the person who will make decisions about your medical care if you become incapable of doing so.

 

You may choose anyone you like to make these decisions for you, but it is recommended that you not choose your doctor, any of your doctor’s employees, or any employee of a hospital or nursing home where you might be a patient.

 

This document will refer to the person you have chosen as your “agent”. It will also allow you to designate alternates in case the first person you choose is later unwilling or unable to make these decisions. Of course, you should ask the person in advance if he or she is willing to serve as your agent. Remember that your agent will make choices for you only if you become unable to do so.

 

Revoking or reinstating an agent’s authority:

 

a.                A durable power of attorney may be revoked by a mentally competent person but not by a person who is mentally incompetent.

b.               If revocation or reinstatement is made, the attending physician or other health care provider shall make the declaration a part of the medical record.

 

Choosing Medical Care:

 

After choosing your agent, you can also use this document to indicate the kinds of medical care you wish to receive or not receive. You should make certain that your agent understands your wishes.

 

Completing this Document:

 

If you have any questions about this document, you should consult with your doctor or with an attorney. In addition, you must sign this document in the presence of a Notary Public. (Your bank, hospital, or Alaska Legal Services has a Notary Public who can notarize this for you.)

 

Keep this document with your other important papers. A copy of this document needs to be given to your agent, physician, and hospital.

 

Durable Power of Attorney For Health Care

Section 1

 

I,           Jane Marie Doe        , of        211 Alaska Way, Cecely, Alaska  99999   , do hereby designate and appoint         Ralph B. Doe         , of    211 Alaska Way, Cecely, Alaska  99999 (telephone #) (907)   888-2901   as my attorney-in-fact for health care decisions (hereafter, Agent).  I authorize this Agent to represent me in all health care decisions.  I intend my Agent to have full authority to consent to giving, withholding, or stopping any health care treatment, service, or procedure.

 

Further, my Agent may consent to my admission to a medical, nursing, residential or other facility and may enter into agreement for my care. My Agent has the authority to talk with health care personnel, to access and disclose to other medical and related information and records, and to sign forms on my behalf.

Section 2

 

My agent shall make decisions with my desires as expressed here.

 

(Select any of the following statements that reflect your desires. You may choose more than one, but should cross out and initial those statements you DO NOT agree with.)

 

JMD I want my life to be prolonged to the greatest extent possible without regard to pain, discomfort, or cost incurred or the chances I have for recovery.

 

JMD I want my life to be prolonged and I want life prolonging treatment to be provided unless, in my Agent’s judgment, the pain, discomfort, or probable outcome of the treatment outweigh any benefit the treatment may have for me.

 

þ          If I should be in an incurable, irreversible physical condition with no hope of survival, I do not want any treatment that will merely prolong my dying.  Thus, I want my treatment limited to medical and nursing measures that are intended to keep me comfortable to relive pain and to maintain my dignity.

 

þ          If I am in a coma or vegetative state which my doctor reasonably believes to be permanent, I do not want any life-prolonging treatment to be started or continued, including devices to provide artificial nutrition or hydration.

 

þ          I have other instructions for my care. They are listed below:

(You may add any other instructions here. Put a line through the space that you do not use.)

 

      No cardiopulmonary resuscitation or respirators.  Please medicate for pain control.  Do not transport me from my home.----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

 

By completing this document, I intend to create a durable power of attorney for health care under Alaska Statutes 13.26.325. It shall take effect upon my incapacity to make my own health care decisions and shall continue during that incapacity to the extent permitted by law or until I revoke it.

 

This durable power of attorney may be revoked by me at any time so long as I am mentally competent to do so.

 

Please initial appropriate box.

 

JMD I have executed a separate “Living Will” under AS 18.12.010.

 

o          I have not executed a separate “Living Will” under AS 18.12.010.

 

My wishes concerning the kinds of medical care I do or do not wish to receive if I should have an incurable or irreversible condition are incorporated herein.

 

Section 3

 

If the person designated as my Agent in Section 1 is unable or unwilling to act as my Agent, or if I revoke that person’s authority to act as my Agent, I then designate and appoint, in the order listed below, the following persons to serve as my Agent to make health care decisions for me.

 

First Alternate Agent:

Name:                           Marie Ann Doe                                           

Street Address:            1590 King Street                                         

City, State and Zip Code: Northfield, Vermont  05556                    

Phone:    (802)                  765-2030                                               

              Area Code

 

Second Alternate Agent:

Name:                    Steven Christopher Doe                                    

Street Address:          2000 Holster Road                                        

City, State and Zip Code: Rome, New Hampshire  05566                 

Phone:    (807)                  204-3210                                               

              Area Code

 

By signing this document, I indicate that I understand the purpose and effect of this durable power of attorney for health care.

 

(You must sign this in the presence of a Notary Public.)

 

Dated this        22nd           day of               November           , 199 5      .

 

            Jane Marie Doe                                  Jane Marie Doe          

Signature                                         Print Name

 

            211 Alaska Way                            Cicely, Alaska  99999    

Address                                            City, State and Zip

 

State of Alaska               )

                                      )      ss

   Fourth   Judicial District)

 

The foregoing instrument was acknowledged before me by            Donald A. May  

 

This  22nd  day of November        , 199  5          , at      Cicely , Alaska.

 

 

             Donald A. May                                                   Notary                

(Signature of Person Taking Acknowledgment)         (Title or Rank)

 

My commission Expires:             11-20-2005            

 

This Declaration Must Be Acknowledged By A Person Qualified To Take Acknowledgments under Alaska Statutes 09.63.010.