Ohio Durable Power of Attorney for Health Care

OHIO DURABLE POWER OF ATTORNEY FOR HEALTH CARE

(Ohio Revised Code 1337.11 to 1337.17)

The following Notice to Adult Executing This Document (Durable Power of Attorney for Health Care) is required by Ohio Revised Code, Section 1337.17. If, after reading this notice, you still have questions concerning the effect and legal consequences of executing this document, you should speak with a qualified attorney.

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 if 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 health 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 the 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 the 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 the attorney in fact 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, AND ANY OTHER MEDICAL OR NURSING PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE THAT WOULD BE TAKEN 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 refusal 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 OR OTHER CONSPICUOUS TYPE, INCLUDING, BUT NOT LIMITED TO, A DIFFERENT FONT, BIGGER TYPE, OR BOLDFACE TYPE, 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;

(6) Provide, refuse, or withdraw informed consent to life-sustaining treatment, or the provision of artificially or technologically administered sustenance (nutrition) or fluids (hydration) to you, if the attorney in fact is subject to a temporary protection order, civil protection order, or any other protection order in this state or another state in which you are the alleged victim.

Additionally, when exercising 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 the attorney in fact in another manner.

When acting pursuant to this document, the attorney in fact GENERALLY will have the same rights that you have to receive information about proposed health care, to review health care records, and to consent to the disclosure of health care records. You can limit that right in this document if you so choose.

Generally, you may designate any competent adult as the attorney in fact under this document. However, you CANNOT designate your attending physician or the administrator of any nursing home in which you are receiving care as the attorney in fact under this document. Additionally, you CANNOT designate an employee or agent of your attending physician, or an employee or agent of a health care facility at which you are being treated, as the attorney in fact under this document, unless either type of employee or agent is a competent adult and related to you by blood, marriage, or adoption, or unless either type of employee or agent is a competent adult and you and the employee or agent are members of the same religious order.

This document has no expiration date under Ohio law, but you may choose to specify a date upon which your durable power of attorney for health care generally will expire. However, if you specify an expiration date and then lack the capacity to make informed health care decisions for yourself on that date, the document and the power it grants to your attorney in fact will continue in effect until you regain the capacity to make informed health care decisions for yourself.

You have the right to revoke the designation of the attorney in fact and the right to revoke this entire document at any time and in any manner. Any such revocation generally will be effective when you express your intention to make the revocation. However, if you made your attending physician aware of this document, any such revocation will be effective only when you communicate it to your attending physician, or when a witness to the revocation or other health care personnel to whom the revocation is communicated by such a witness communicate it to your attending physician.

If you execute this document and create a valid durable power of attorney for health care with it, it will revoke any prior, valid durable power of attorney for health care that you created, unless you indicate otherwise in this document.

This document is not valid as a durable power of attorney for health care unless it is acknowledged before a notary public or is signed by at least two adult witnesses who are present when you sign or acknowledge your signature. No person who is related to you by blood, marriage, or adoption may be a witness. The attorney in fact, your attending physician, and the administrator of any nursing home in which you are receiving care also are ineligible to be witnesses.

If there is anything in this document that you do not understand, you should ask your lawyer to explain it to you.

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

1. DESIGNATION OF ATTORNEY IN FACT. I designate the following individual as my attorney in fact to make health care decisions for me:

______________________________________________________________________________

(name of individual you choose as attorney in fact)

______________________________________________________________________________

(address; city; state; zip code)

________________________ ________________________

(home phone) (work phone)

2. ALTERNATE ATTORNEYS IN FACT (OPTIONAL). If I revoke the authority of my attorney in fact or if my attorney in fact is not willing, able, or reasonably available to make a health care decision for me, I designate as my first alternate attorney in fact:

______________________________________________________________________________

(name of individual you choose as first alternate attorney in fact)

______________________________________________________________________________

(address; city; state; zip code)

________________________ ________________________

(home phone) (work phone)

If I revoke the authority of my attorney in fact and first alternate attorney in fact or if neither is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate attorney in fact:

______________________________________________________________________________

(name of individual you choose as second alternate attorney in fact)

______________________________________________________________________________

(address; city; state; zip code)

________________________ ________________________

(home phone) (work phone)

3. AUTHORITY OF MY ATTORNEY IN FACT.

Subject to any specific limitations I include in this document, my attorney in fact is authorized to make health care decisions for me, at any time that my attending physician determines that I have lost the capacity to make informed health care decisions for myself, to the same extent that I could make those decisions myself if I had the capacity to do so, including 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.

My attorney in fact is authorized, commencing immediately upon the execution of this instrument, to obtain information concerning my health, including protected health information as defined in 45 C.F.R. 160.103, to review my health care records, and to consent to the disclosure of my health care records.

When exercising this authority, my attorney in fact shall act consistently with my desires as expressed in this document or made known in another manner or, if my desires are unknown, shall act in my best interest.

4. NUTRITION AND HYDRATION AUTHORIZATION (OPTIONAL INITIALS).

BY PLACING MY INITIALS IN THIS SPACE ( ____________ ), I SPECIFICALLY AUTHORIZE MY ATTORNEY IN FACT TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION TO ME 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 NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO ME OR ALLEVIATE MY PAIN.

5. SPECIAL INSTRUCTIONS AND LIMITATIONS.

I may include specific limitations on the authority of my attorney in fact in this document. Any limitations, special instructions, or expressions of my desires concerning my health care are listed here:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

6. EXPIRATION DATE (OPTIONAL).

This document has no expiration date under Ohio law. If I choose to specify an expiration date, this durable power of attorney for health care will expire on:

______________________________

If I lack the capacity to make informed health care decisions for myself on that date, this document will continue in effect until I regain that capacity.

7. NOMINATION OF GUARDIAN (OPTIONAL).

If a guardian of my person needs to be appointed for me by a court, I nominate the attorney in fact designated in this document. If that attorney in fact is not willing, able, or reasonably available to act as guardian, I nominate the alternate attorneys in fact whom I have named, in the order designated. I direct that any person nominated as guardian under this document serve without bond, to the extent permitted by law.

8. PRIOR POWERS OF ATTORNEY FOR HEALTH CARE.

This document revokes any prior, valid durable power of attorney for health care that I created, unless I indicate otherwise here:

____________________________________________________________

9. MY RIGHT TO REVOKE.

I may revoke the designation of my attorney in fact and I may revoke this entire document at any time and in any manner. If I have made my attending physician aware of this document, a revocation will be effective when I communicate it to my attending physician, or when a witness to the revocation or other health care personnel to whom the revocation is communicated by such a witness communicate it to my attending physician.

10. SIGNATURE AND DATE.

I sign this durable power of attorney for health care on the date written below. I understand that this document is not valid as a durable power of attorney for health care unless it is acknowledged before a notary public or is signed by at least two adult witnesses who are present when I sign or acknowledge my signature.

______________________ __________________________________________

(date) (sign your name)

______________________________ __________________________________

(print your name) (address)

________________________ __________ ____________

(city) (state) (zip code)

WITNESS STATEMENTS

(Complete this section only if this document is witnessed rather than acknowledged before a notary public. Two adult witnesses are required, and they must be present when you sign or acknowledge your signature.)

STATEMENT OF WITNESS ONE

I hereby state that the principal, ______________________________, signed this durable power of attorney for health care at the end of the instrument in my presence, or acknowledged the principal's signature to me, and that I am an adult; I am not related to the principal by blood, marriage, or adoption; I am not designated as the attorney in fact or an alternate attorney in fact in this document; I am not the attending physician of the principal; and I am not the administrator of a nursing home in which the principal is receiving care. The principal appeared to me to be of sound mind and not under or subject to duress, fraud, or undue influence.

Signature: ____________________________________________________

Print name: __________________________________________________

Date: __________________________

STATEMENT OF WITNESS TWO

I hereby state that the principal, ______________________________, signed this durable power of attorney for health care at the end of the instrument in my presence, or acknowledged the principal's signature to me, and that I am an adult; I am not related to the principal by blood, marriage, or adoption; I am not designated as the attorney in fact or an alternate attorney in fact in this document; I am not the attending physician of the principal; and I am not the administrator of a nursing home in which the principal is receiving care. The principal appeared to me to be of sound mind and not under or subject to duress, fraud, or undue influence.

Signature: ____________________________________________________

Print name: __________________________________________________

Date: __________________________

NOTARY ACKNOWLEDGMENT

(Complete this section only if this document is acknowledged before a notary public rather than witnessed.)

STATE OF OHIO

COUNTY OF ______________________________

The foregoing instrument was acknowledged before me this __________ day of __________________, 20____, by __________________________________, the principal, who acknowledged executing the instrument, and who appeared to me to be of sound mind and not under or subject to duress, fraud, or undue influence.

Notary Public — Signature: __________________________________________

My commission expires: ______________________________________