Durable Power of Attorney for Health Care
Declaration of a Durable Power of Attorney for Health Care Only
1. Declaration.
A. Life Sustaining Procedures. Declaration made on this date, _________, I, ________ (“Declarant”), being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition or a permanently unconscious condition by two (2) physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized, or that I will remain in a permanently unconscious condition, and where the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide me with comfortable care.
B. Hydration and Nutrition. I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial nutrition and hydration. In carrying out any instruction I have given under this section, I authorize that artificial nutrition and hydration BE STARTED, or if started, BE CONTINUED.
C. Pregnancy. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy. However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point. If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this Declaration shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
2. Declaration of Health care Agent. I, the Declarant, hereby appoint: _______________ (“Agent”) as my Agent to make any and all health care decisions for me, except to the extent I state otherwise in this document or as prohibited by law. My agent must act consistently with my desires as stated in this document or otherwise made known. This Durable Power of Attorney for Health Care shall take effect in the event I become unable to make my own health care decisions.
3. Statement of Desires, Special Provisions, and Limitations regarding Health Care Decisions and Options. I give my Agent power to act in these specified circumstances: If I become permanently incompetent to make health care decisions, and if I am also suffering from a terminal illness, I authorize my Agent to direct that life-sustaining treatment be discontinued. Whether terminally ill or not, if I become permanently unconscious I authorize my Agent to direct that life-sustaining treatment be discontinued. I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial feeding (artificial nutrition and hydration). In carrying out any instructions I have given in this power of attorney, I authorize my Agent to direct that artificial nutrition and hydration not to be started or, if started, be discontinued.
4. Designation of an Alternate Agent. In the event the person I appoint above is unable, unwilling or unavailable, or ineligible to act as my Health Care Agent, I hereby appoint the following persons as Alternate Agent:
First Alternate Agent
Agent Name:
Address:
Phone: Home: Work:
Second Alternate Agent
Agent Name:
Address:
Phone: Home: Work:
5. Other Provisions. I hereby acknowledge that I have been provided with a disclosure statement explaining the effect of this document. I have read and understand the information contained in the disclosure statement. I understand the full import of this Declaration and Durable Power of Attorney for Health Care and I am emotionally and mentally competent to make this Declaration and Durable Power of Attorney for Health Care.
6. Notices.
Any notice required by this Agreement or given in connection with it, shall be in writing and shall be given to the appropriate party by personal delivery or a recognized over night delivery service such as FedEx.
If to the Declarant: _____________________________________________________.
If to My Physician: ___________________________________________________.
7. No Waiver.
The waiver or failure of either party to exercise in any respect any right provided in this Agreement shall not be deemed a waiver of any other right or remedy to which the party may be entitled.
8. Entirety of Agreement.
The terms and conditions set forth herein constitute the entire agreement between the parties and supersede any communications or previous agreements with respect to the subject matter of this Agreement. There are no written or oral understandings directly or indirectly related to this Agreement that are not set forth herein. No change can be made to this Agreement other than in writing and signed by both parties.
9. Governing Law.
This Agreement shall be construed and enforced according to the laws of the State of ____________________ and any dispute under this Agreement must be brought in this venue and no other.
10. Headings in this Agreement
The headings in this Agreement are for convenience only, confirm no rights or obligations in either party, and do not alter any terms of this Agreement.
11. Severability.
If any term of this Agreement is held by a court of competent jurisdiction to be invalid or unenforceable, then this Agreement, including all of the remaining terms, will remain in full force and effect as if such invalid or unenforceable term had never been included.
In Witness whereof, the parties have executed this Agreement as of the date first written above.
_________________________ _______________________
Declarant My Physician
___________________
Date
We, the following witnesses, being duly sworn, each declare to the notary public or justice of the peace or other official signing below as follows:
1. Declarant affirmed that he or she is aware of the nature of the document and signed the instrument as a free and voluntary act for the purposes expressed, or expressly directed another to sign for him or her.
2. Each witness signed at the request of Declarant, in his or her presence, and in the presence of the other witness.
3. To the best of my knowledge, at the time of the signing, Declarant was at least 18 years of age, and was of sane and sound mind and under no constraint, duress, or undue influence.
4. Neither of the undersigned witnesses is (i) Declarant’s spouse, or (ii) Declarant’s attending physician, or person acting under the direction or control of the attending physician or any other person who has a claim against Declarant’s estate.
_________________
Witness Signature:
Name:
Address:
_________________
Witness Signature:
Name:
Address:
State of New Hampshire
County of
The foregoing instrument was acknowledged before me this Date: ________________.
______________________________
Notary Public or Justice of the Peace
My Commission Expires: _____________.
Copy List: Must include Physician; list them here: _____________________________.
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