5.2011
DURABLE POWER of ATTORNEY for
HEALTH CARE and HEALTH CARE DIRECTIVE,
and LIVING WILL
for
NAME
PART I
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
1.1
SELECTION OF AGENT/ATTORNEY-IN-FACT:
KNOW ALL MEN BY THESE PRESENTS that I, Name, address, hereby
appoint as my Attorney-in-Fact hereinafter also called Agent, relationship, Name,
address. Home Phone:
1.2
ALTERNATE AGENTS/ATTORNEYS-IN-FACT:
Only an Agent named by me may act under this Durable Power of Attorney. If
my Agent resigns or is not able or available to make health care decisions for me,
I appoint the person(s) named below in the priority listed:
FIRST ALTERNATE AGENT:
Name, Relationship
Address
City, State, Zip
Phone
SECOND ALTERNATE AGENT:
Name, Relationship
Address
City, State, Zip
Phone
THIRD ALTERNATE AGENT:
Name, Relationship
Address
City, State, Zip
Phone
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1.3
TERMINATION:
THIS IS A DURABLE POWER OF ATTORNEY, PURSUANT TO
R.S.M.O. 404.700 AND THE FOLLOWING SECTIONS.
THIS IS A DURABLE POWER OF ATTORNEY AND THE AUTHORITY
OF MY ATTORNEY- IN -FACT, WHEN EFFECTIVE, SHALL NOT
TERMINATE OR BE VOID OR VOIDABLE IF I AM OR BECOME
DISABLED OR INCAPACITATED OR IN THE EVENT OF LATER
UNCERTAINTY AS TO WHETHER I AM DEAD OR ALIVE.
1.4
EFFECTIVE DATE AND DURABILITY:
(OPTION)
IMMEDIATE POWER
A.
THIS GENERAL DURABLE POWER OF ATTORNEY SHALL
TAKE EFFECT WHEN EXECUTED BY ME. Further, this General
Durable Power of Attorney shall be binding not only upon me, but also
upon my heirs, executor, and administrator up to the time of the receipt by
my said Attorney-in-Fact of a written revocation signed by me or of
reliable intelligence of my death.
CONFIDENTIALITY
B.
In order to effectuate the terms of this instrument, I hereby waive any
confidentiality obligations under any state or Federal law relating to my
incapacity, and I specifically direct that any physician freely transmit and
release “Protected Health Information” (as defined in the Health Insurance
Portability and Accountability Act of 1996 privacy rules) to any Attorneyin-Fact named herein.
ONE PHYSICIAN
C.
If a certification is necessary or required by anyone, then it shall be by
ONE licensed physician, who has examined or seen me. The duties shall
cease upon certification by ONE licensed physician that I am no longer
incapacitated. The certifying physician may be my family doctor, treating
or attending doctor.
(OPTION)
SPRINGING POWER
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A.
THIS INSTRUMENT SHALL BECOME EFFECTIVE ONLY UPON
MY
SUBSEQUENT
DISABILITY,
INCAPACITY,
OR
DISAPPEARANCE AND SHALL COMMENCE UPON A
CERTIFICATION BY A LICENSED PHYSICIAN THAT I AM
INCAPACITATED PURSUANT TO RSMo. § 404.825. After such
certification, this instrument shall remain in effect until I communicate a
desire to revoke this instrument after a physician has examined me and
certified that I am no longer incapacitated.
CONFIDENTIALITY
B.
In order to effectuate the terms of this instrument, I hereby waive any
confidentiality obligations under any state or Federal law relating to my
incapacity, and I specifically direct that any physician freely transmit and
release “Protected Health Information” (as defined in the Health Insurance
Portability and Accountability Act of 1996 privacy rules) to any Attorneyin-Fact named herein.
ONE PHYSICIAN
C.
If a certification is necessary or required by anyone, then it shall be by
ONE licensed physician, who has examined or seen me. The duties shall
cease upon certification by ONE licensed physician that I am no longer
incapacitated. The certifying physician may be my family doctor, treating
or attending doctor.
(OPTION)
IMMEDIATE POWER TO SPOUSE/SPRINGING POWER TO
ALTERNATE
A.
My spouse is to receive an Immediate Power under this document. All
other alternates shall receive a Springing Power herein.
IMMEDIATE POWER
B.
THIS GENERAL DURABLE POWER OF ATTORNEY SHALL
TAKE EFFECT WHEN EXECUTED BY ME. Further, this General
Durable Power of Attorney shall be binding not only upon me, but also
upon my heirs, executor, and administrator up to the time of the receipt by
my said Attorney-in-Fact of a written revocation signed by me or of
reliable intelligence of my death.
SPRINGING POWER
C.
THIS INSTRUMENT SHALL BECOME EFFECTIVE ONLY UPON
MY
SUBSEQUENT
DISABILITY,
INCAPACITY,
OR
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DISAPPEARANCE AND SHALL COMMENCE UPON A
CERTIFICATION BY A LICENSED PHYSICIAN THAT I AM
INCAPACITATED PURSUANT TO RSMo. § 404.825. After such
certification, this instrument shall remain in effect until I communicate a
desire to revoke this instrument after a physician has examined me and
certified that I am no longer incapacitated.
CONFIDENTIALITY
D.
In order to effectuate the terms of this instrument, I hereby waive any
confidentiality obligations under any state or Federal law relating to my
incapacity, and I specifically direct that any physician freely transmit and
release “Protected Health Information” (as defined in the Health Insurance
Portability and Accountability Act of 1996 privacy rules) to any Attorneyin-Fact named herein.
ONE PHYSICIAN
E.
1.5
If a certification is necessary or required by anyone, then it shall be by
ONE licensed physician, who has examined or seen me. The duties shall
cease upon certification by ONE licensed physician that I am no longer
incapacitated. The certifying physician may be my family doctor, treating
or attending doctor.
AGENT’S POWERS: I grant to my Agent full authority to:
A.
To give consent to or prohibit or withdraw any type of health care,
medical care, treatment or procedure, even if my death may result, to the
extent authorized by the Missouri Durable Power of Attorney for Health
Care Act;
B.
To direct a health care provider to withhold or withdraw artificially
supplied nutrition and hydration, including but not limited to, tube feeding
of food and water;
C.
To make all necessary arrangements for home care or care by a hospital,
clinic, nursing home, or other physical or mental health treatment facility
or clinic, to include any type of hospice services (even if against medical
advice);
D.
To employ or discharge health care personnel necessary and proper for my
physical and mental health, provided such personnel are properly licensed,
certified or otherwise authorized to provide health care;
E.
To request, receive and review any verbal or written information regarding
my physical and mental condition, including medical records;
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F.
To move me into or out of any treatment facility or into or out of any state
for the purpose of complying with the health care decisions of my agent
(even if against medical advice);
G.
To make decisions in advance of my death regarding organ donation,
autopsy and the disposition of my body;
OPTION:
It is my specific intent to donate my organs and/or tissue, therefore, my
Agent is authorized to keep me alive for a period no longer than thirty six
(36) hours including the use artificial means in order to make the
necessary arrangements to accomplish this organ and/or tissue donation.
H.
To authorize health care providers to apply for direct payments of ,
Medicare, Medicaid and or any other medical insurance which I may have
or benefits for which I may be entitled;
I.
To take any legal action reasonable and proper to accomplish any act
performed pursuant hereto;
J.
Take any action necessary to do what I authorize here, including (but not
limited to) granting any waiver or release from liability required by any
health care provider, and taking any legal action at the expense of my
estate to enforce this Durable Power of Attorney;
K.
To consent, 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, including (but not limited to) artificial respiration, nutritional
support and hydration, and cardiopulmonary resuscitation;
L.
To have authority to make decisions regarding any emotional, mental or
psychological condition and make any decision affecting any institution or
facility that may treat or be treating me for any of the above conditions or
related conditions;
M.
To have access to medical records and all health care information to the
same extent that I am entitled to, including the right to disclose the
contents to others.
N.
To have all rights of sepulcher as a “Next of Kin” as defined in Section
194.119 RSMo (2008) and as hereafter amended.
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O.
If my eyes, organ, bone, skin, or tissue are usable, it is my desire to make
them available for the donation to qualified recipients. My body or any
parts thereof shall not be used for or donated to medical research.
OPTION 1
If my eyes, organ, bone, skin or tissue are usable, it is my desire to make them
available for donation to qualified recipients.
OPTION II
I direct that only my ________________ may be donated to qualified recipients.
OPTION III
I direct that my body be donated to medical research at
_____________________________(Specific Entity or Qualified Institution.
RESTRICTIONS:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
PART II
HEALTH CARE DIRECTIVE
and
LIVING WILL DECLARATION
2.1
HEALTH CARE DIRECTIVE: I make this HEALTH CARE DIRECTIVE to
exercise my right to determine the course of my health care and to provide clear
and convincing proof of my wishes and instructions about my treatment.
2.2
AGENT UNAVAILABLE: If any Agent in Part I of this document entitled
Durable Power of Attorney for Health Care is unable to serve for any reason,
THIS PART II IS INTENDED TO BE IN FULL FORCE AND EFFECT AS MY
HEALTH CARE DIRECTIVE.
2.3
PROCEDURES: If I am persistently unconscious or there is no reasonable
expectation of my recovery from a seriously incapacitating or terminal illness or
condition or extreme mental deterioration, I specifically direct that all of the
following life-prolonging procedures, be withheld or withdrawn at my Agent’s
discretion:
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A.
Artificially supplied nutrition and hydration (including tube feeding of
food and water);
1)
2)
3)
4)
I know that nutrition and hydration means food and water. I
understand that a decision to withhold artificially supplied
hydration and nutrition will result in my death.
If I should have a terminal condition as defined by standard
medical practice and not as defined in RSMo 459.010, and I am
unable to participate in decisions regarding my medical treatment
and/or the provision, withholding or withdrawing of artificially
supplied nutrition and hydration, it is my clear and unequivocal
intent that artificially supplied nutrition and hydration should be
withdrawn or withheld from me.
If I am in a persistent vegetative state or if I am otherwise
permanently comatose, even though I may not meet the diagnosis
of terminally ill or injured, and if the physician who is treating me
or my Agent believes there is no reasonable chance of
significant recovery such that I will thereafter regain any
meaningful, cognitive existence, it is my clear and unequivocal
intent that artificially supplied nutrition and hydration should be
withdrawn or withheld from me.
I direct all doctors and other medical personnel in a position to
make decisions regarding my care to follow the directions of my
Agent with regard to the provision, withholding or
withdrawing of artificially supplied nutrition and hydration. I
specifically authorize the withholding of nutrition and hydration to
permit the natural process of dying. I specifically confer upon my
Agent the authority to direct a health care provider to
withhold or withdraw artificially supplied nutrition and hydration.
B.
Surgery or other invasive procedures;
C.
Heart-lung resuscitation (CPR);
D.
Antibiotics;
E.
Dialysis;
F.
Mechanical ventilator (Respirator);
G.
Chemotherapy;
H.
Radiation therapy;
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I.
All other life-prolonging medical or surgical procedures that are merely
intended to keep me alive without reasonable hope of improving my
condition or curing my illness or injury;
J.
However, if my physician believes that any life prolonging procedure may
lead to a significant recovery, I direct my physician to try the treatment for
a reasonable period of time. If it does not improve my condition, I direct
the treatment be withdrawn even if it shortens my life. I also direct that I
be given medical treatment to relieve pain or to provide comfort, even if
such treatment might shorten my life, suppress my appetite or my
breathing, or be habit forming.
(OPTION I)
2.4
QUALITY OF LIFE:
A.
A meaningful quality of life means, to me, to be able to communicate with
others, to recognize family members; and to be able to understand the
simple details of daily life.
B.
I prefer to live out my last days at home rather than in a hospital or a
nursing home if it is not a burden to my family.
(OPTION II)
2.4
QUALITY OF LIFE:
A.
It is my wish NOT to have my life sustained if I have permanently lost
higher mental functions and the awareness of my friends and loved ones.
Likewise, other than the administration of treatment designed to provide
comfort, I wish to face terminal illness without any efforts to delay the
inevitable death. If able to understand, I wish to be told frankly of the
facts of my condition or prognosis. I wish to emphasize that no treatments
shall be carried out without my permission, if I am able to understand.
Also, I instruct my Agents NOT to authorize life sustaining treatment for
any hopeless situation which because of high costs, would exceed
insurance coverage grossly and deplete my assets.
B.
My medical directive shall be taken to represent my general philosophy on
excessive use of medical treatments in any hopeless or terminal illness. I
charge my Agents not to waste my assets on unproductive treatments or
extensions of life in situations like those of the medical directive or other
situations which in their judgment, treatment would be against my wishes.
C.
As a specific clarification, I do not wish repeated use of cardiopulmonary
resuscitation (CPR) in any of the procedures listed in 2.3, A-I, or in any
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other situations when in my Agents’ judgment would be against my
wishes.
2.5
D.
In summary, when the situation is terminal or life without mental
awareness, I wish to die with dignity and with my assets intact.
E.
I prefer to live out my last days at home rather than in a hospital or a
nursing home if it is not a burden to my family.
DEMENTIA PROVISION
If I have a progressive illness affecting my thought processes, and the
illness is in an advanced stage, and I am consistently and permanently
unable to communicate, swallow food and water safely, care for myself
and recognize my family and other people, and it is very unlikely that my
condition will substantially improve, I would like my wishes regarding
specific life-sustaining treatments that have been set forth in Sections 1.5
and 2.3 of this document that deal with permanent unconsciousness to be
followed.
If I am unable to eat and drink for myself while in this condition:
OPTION 1:
I DO NOT want to be fed or given liquids (hydration) by any means
including artificial techniques.
OPTION 2:
I DO want to be fed and given liquids by any means necessary
including artificial techniques.
2.6
PAIN CONTROL/PAIN MEDICATION
My Agent shall have full authority:
A.
To make any decision to refuse or to administer any type of
medication, especially pain medication.
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B.
2.7
To have complete ability to manage any issues of pain and/or comfort
control by administration or refusal of any medicine or treatment, even if
said treatment or medicine would or could hasten my death.
I want a DO NOT RESUSCITATE action followed involving my health care.
No health care provider, physician or emergency response personnel shall provide
any type of resuscitation by any means at anytime.
2.8
FAITH STATEMENT
2.9
CREMATION OF BODY:
A.
After my death, it is my wish to be cremated.
B.
My agent shall make all necessary decisions and arrangements.
C.
I desire for my ashes (cremains) to be scattered _____________________.
D.
I desire for my ashes (cremains) to be buried _______________________.
PART III
GENERAL PROVISIONS
and
INSTRUCTIONS
3.1
RELATIONSHIP BETWEEN DIRECTIVE AND DURABLE POWER OF
ATTORNEY:
If I have executed the Directive and the Durable Power of Attorney, I encourage
my Agent to follow my wishes as expressed in the Directive in making decisions
regarding life-prolonging procedures. However, I have confidence in my Agent’s
ability to make decisions in my best interest, and I authorize my Agent to make
decisions that are contrary to my Directive in his or her best judgment. If the
Durable Power of Attorney is somehow determined to be ineffective, or if my
Agent is not able to serve, the Directive is intended to be used on its own as firm
instructions to my health care providers regarding life-prolonging procedures.
3.2
PROTECTION OF THIRD PARTIES WHO RELY ON MY AGENT:
No person who relies in good faith upon any representations by my Agent or
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Alternate Agent, shall be liable to me, my estate, my heirs or assigns, for
recognizing the Agent’s authority.
3.3
REVOCATION OF PRIOR DIRECTIVE OR DURABLE POWER OF
ATTORNEY:
I revoke any prior Living Will, Declaration or Health Care Directive executed by
me. If I have appointed an Agent in a prior Durable Power of Attorney, I revoke
any health care terms contained in that Durable Power of Attorney.
3.4
AGENT’S FINANCIAL LIABILITY AND COMPENSATION:
My Agent acting under this Durable Power of Attorney will incur no personal
financial liability. My Agent shall not be entitled to compensation for services
performed under this Durable Power of Attorney, but my Agent shall be entitled
to reimbursement for all reasonable expenses incurred as a result of carrying out
any provision hereof.
3.5
VALIDITY:
This document is intended to be valid in any jurisdiction in which it is presented.
The provisions of this document are separable, so that the invalidity of one or
more provisions shall not affect any others. A photocopy or facsimile copy of
this document, properly signed, dated, and acknowledged, shall be deemed to
be as valid and effective as the original. I direct that anyone dealing with any
Trustee or Agent, hereunder, accepts said copy as if it were the original.
3.6
HIPAA RELEASE AUTHORITY:
A.
I intend for my Agent to be treated as I would be with respect to my rights
regarding the use and disclosure of my individually identifiable health
information or other medical records to include any records or information
dealing with mental, emotional or psychological conditions. This release
authority applies to any information governed by the Health Insurance
Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1320d
and 45 CFR 160-164. My Agent is hereby designated as my “Personal
Representative” or any other designation or title under HIPAA or as later
amended for purposes of obtaining, reviewing or receiving any of my
health information or medical records. My Agent shall have
Representative or any other appropriate designation under HIPAA for
purposes of obtaining and receiving any of my health or medical records.
My Agent shall have the same access to my health care and treatment
information as I would have if I were able to act for myself, and shall have
the authority on my behalf to execute and revoke releases to confidential
information and to review, use and obtain such confidential and
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individually identifiable health information for and from medical and
dental providers, insurers and other third party payers.
B.
I authorize full and complete disclosure and release to my Agent without
restriction, to include but not limited to, any of the following;
1)
2)
C.
D.
3.7
Any physician, healthcare professional, dentist, health plan,
hospital, clinic, laboratory, pharmacy or other covered health care
provider, any insurance company and the Medical Information
Bureau Inc. or other health care clearinghouse that has provided
treatment or services to me or that has paid for or is seeking
payment from me for such services and;
All of my individually identifiable health information and medical
records regarding any past, present or future medical or mental
health condition, to include all information relating to the diagnosis
and treatment of HIV/AIDS, sexually transmitted diseases, mental
illness and drug or alcohol abuse.
The authority given my Agent shall supersede any prior agreement that I
may have made with my health care providers to restrict access to or
disclosure of my individually identifiable health information. The
authority given my Agent has no expiration date and shall expire only in
the event that I revoke the authority in writing and deliver it to my health
care provider.
In order to induce the disclosing party to disclose the aforesaid private
and/or protected confidential information, I forever release and hold
harmless said disclosing party who relies upon this instrument from any
liability under confidentiality rules arising under HIPAA as a consequence
of said disclosure. I authorize my Agent to execute on my behalf any
release or other documents that may be required in order to obtain this
information.
AGENT AND ATTORNEY-IN-FACT:
Throughout this document the terms “Agent” or “Attorney-in-Fact” are
interchangeable and are intended to refer to the person or persons I have
designated as my Agent for health care directives.
IN WITNESS WHEREOF, I have executed this document this _______ day of
_____________________________________________, 2013.
___________________________________
NAME
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The person who signed this document is of sound mind and voluntarily signed this
document in our presence. Each of the undersigned witnesses is at least eighteen (18)
years of age.
_________________________________
Signed Name
______________________________
Signed Name
_________________________________
Printed Name
______________________________
Printed Name
_________________________________
Address
______________________________
Address
_________________________________
City, State, Zip
______________________________
City, State, Zip
STATE OF MISSOURI
)
) ss.
COUNTY OF __________________ )
On this ______ day of ________________________________, 2013, before me
personally appeared _____________________, personally known to me to be the person
who executed the foregoing Medical Durable Power of Attorney as principal and
acknowledged to me that he/she executed the foregoing instrument as his/her free act and
deed for the purpose therein stated; and at the time of this acknowledgement he/she
appeared mentally alert and of full mental capacity.
IN TESTIMONY WHEREOF, I have subscribed my name and affixed my
official seal in the City or County and State aforesaid, on the day and year above written.
____________________________________
Notary Public
My Commission Expires:
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