Health Care Power of Attorney (Sample)
Sample Health Care Power of Attorney Overview
As you are exploring how to put your estate planning wishes into a legally binding documents, you'll want to be mindful of using precise language and always following the law in your state. The health care power of attorney is one of the most important decisions you can make when deciding how you want your medical decisions handling and by whom. Simply put, this document allows you to designate someone to be your representative in the event you are unable to make or communicate decisions about all aspects of your health care.
Below you will find sample language to help you compose a health care power of attorney. However easy this may look, you should always consider consulting with a local attorney to make sure your wishes are clearly conveyed and comply with the law.
I, _______, residing at [address]; make, constitute and appoint _______, _______, residing at [address] (hereinafter referred to as my "Health Care Representative"), my true and lawful attorney-in-fact to be my Health Care Representative with respect to all health care matters, upon the terms and conditions hereinafter set forth.
1. Although I wish to live and enjoy life as long as possible, I do not wish to receive futile medical treatment, which I define as treatment that will provide little or no benefit to me and will only prolong my inevitable death or irreversible coma.
2. I desire that my wishes with respect to all health care matters be carried out through the authority given to my Health Care Representative under this Health Care Power of Attorney despite any contrary feelings, beliefs or opinions of other members of my family, relatives or friends. I have thoroughly discussed my personal preferences and desires with my Health Care Representative, and his or her successor. I am fully satisfied that each will know best what I would wish and I have the utmost faith and confidence in their respective good judgments.
3. In exercising the authority herein given to my Health Care Representative, my Health Care Representative should try to discuss with me the specifics of any proposed health care decision if I am able to communicate in any manner whatsoever, even by blinking my eyes. I hereby further direct and instruct my Health Care Representative that if I am unable to give an informed consent to my medical treatment or if the physician(s) providing me with medical care determine that I lack capacity to make a particular health care decision, my Health Care Representative shall make such health care decision for me based upon any treatment choices or other desires that I have previously expressed while competent, whether under this Health Care Power of Attorney or otherwise.
4. In order to aid my Health Care Representative in making decisions under this Health Care Power of Attorney, but in no way to limit the absolute authority and discretion granted herein to my Health Care Representative, if:
5. The rights and authority conferred on my Health Care Representative herein appointed shall include, but is by no means limited to, the right to receive information and reports from all treating physicians, other health care professionals, health care institutions, etc., regarding proposed health care, surgery, or any other aspect of my medical treatment; the right to receive and review my medical records and information to the same extent that I am entitled to and to disclose or consent to the disclosure of my medical records to others; to contract on my behalf for any health care related service or facility (without my Health Care Representative incurring personal financial liability for such contracts); and to hire and fire medical, social service and other support personnel responsible for my care.
6. This instrument is to be construed and interpreted as an "advance directive for health care" as such term is defined in [state statute ] (hereinafter the "Act"). In determining the rights of my Health Care Representative herein appointed, the enumeration of the specific items, rights, acts or powers set forth herein is not intended to nor does it limit, and it is not to be construed or interpreted as limiting, the specific power of my Health Care Representative to do and perform any and all acts with respect to my health care which I would be able to perform if I were competent and able to do so and as are within the bounds of authority granted by the Act.
7. In the event _______, _______, shall become unable to act as my Health Care Representative hereunder for any reason whatsoever, including, but not limited to, death, incapacity, or resignation, then I do hereby make, constitute and appoint _______ as successor Health Care Representative to serve in the place of the Health Care Representative first above named.
8. No person who relies in good faith upon any representations by my Health Care Representative or any successor Health Care Representative shall be liable to me, my estate, my heirs or my assigns, for recognizing the Health Care Representative's authority. The directions of my Health Care Representative shall be binding in all respects upon all those involved in my care. My Health Care Representative and all those acting upon his or her directions shall be entitled to indemnification from my estate in connection with all claims asserted against them, unless the directions given and relied on are wholly inconsistent with my intentions as expressed above.
9. If a guardian of my person should for any reason be appointed, I hereby nominate my Health Care Representative (or his or her successor), named above.
10. ADMINISTRATIVE PROVISIONS.
11. By this instrument, I intend to create a durable power of attorney effective upon and only during any period of incapacity in which, in the opinion of (i) my Health Care Representative and (ii) one or more other confirming physicians, I lack capacity to make a particular health care decision (i.e. "Period of Incapacity"). The rights, powers and authority of my Health Care Representative herein appointed shall commence and shall be in full force and effect upon any such determination as to the commencement of a Period of Incapacity, and such rights, powers and authority shall remain in full force and effect from the above-mentioned date until such time as I have regained my capacity to make such health care decision(s) or until my death, as the case may be; PROVIDED, HOWEVER, that this Health Care Power of Attorney may be revoked by me by a written instrument duly acknowledged before a notary public or by such other manner as shall be allowed under the Act; and PROVIDED, FURTHER, that my regaining capacity following any Period of Incapacity shall not be treated as an event causing the revocation of this Health Care Power of Attorney and this Health Care Power of Attorney shall be construed as if such Period of Incapacity never occurred.
I UNDERSTAND THE PURPOSE AND EFFECT OF THIS HEALTH CARE POWER OF ATTORNEY AND SIGN IT AFTER CAREFUL DELIBERATION THIS _______ DAY OF _______, 20___.
Each of the undersigned declares that the person who signed this Health Care Power of Attorney did so in the presence of the undersigned; that said person is personally known to the undersigned and appears to be of sound mind and acting willingly and free from duress or undue influence; and that each of the undersigned and the person executing this Health Care Power of Attorney is 18 years of age or older; and the undersigned is not designated as the person's Health Care Representative under this Health Care Power of Attorney.
______________________________ residing at
______________________________ residing at
STATE OF )
COUNTY OF )
I hereby certify that on [date ] _______ personally came before me and acknowledged under oath, to my satisfaction, that [he/she ] is the person named in and personally signed this Health Care Power of Attorney, and that [he/she ] signed, sealed and delivered this Health Care Power of Attorney as [his/her ] act and deed for the uses and purposes therein expressed.
Need Additional Help With a Power of Attorney? Call a Legal Professional
Health care powers of attorney require careful consideration. They should clearly express your desires, while also obeying the procedural requirements of your state. Contact a local estate planning attorney to learn how they can help you prepare documents to direct doctors in case of an unexpected crisis.