Link17



		DURABLE POWER OF ATTORNEY FOR HEALTH CARE
	I, [NAME], a resident of ____________ County, California, hereby designate and appoint: [AGENT] Address _____________________________ ( ) Telephone Number as my attorney-in-fact (agent) to act for me in my name as authorized in this document. By this document, I intend to create a Durable Power of Attorney for Health Care under California Probate Code Section 4600 et. seq. I. GENERAL PROVISIONS. A. This Durable Power of Attorney for Health Care shall take effect on my inability to give informed consent with respect to health care decisions and shall not be affected by my subsequent disability or incapacity. For the purpose of this document, I shall be deemed unable to give informed consent if it is determined that I do not understand the nature and consequences of that to which I am asked to consent. B. As used in this document, the first person pronoun "I" and its variations, "me", "mine" and "myself", shall refer to the principal, [NAME], and the second person pronoun "you" and its variations, "your" and "yourself", shall refer to my agent, [AGENT], and to any successor agent named herein. 1. If you shall resign, die, become incapacitated, or fail to act as agent for any other reason, then I designate and appoint the following individuals as my co-agents, with all the same powers granted to you: [SUCCESSOR AGENT 1] Address _____________________________ ( ) Telephone Number and [SUCCESSOR AGENT 2] Address _____________________________ ( ) Telephone Number If either [SUCCESSOR AGENT 1] or [SUCCESSOR AGENT 2] shall resign, die, become incapacitated, or fail to act as agent for any other reason, then I designate and appoint the remaining co-agent as my sole agent. If both [SUCCESSOR AGENT 1] and [SUCCESSOR AGENT 2] shall resign, die, become incapacitated, or fail to act as agent for any other reason, then I designate and appoint the following individual as my agent: [ALTERNATE SUCCESSOR AGENT] Address _____________________________ ( ) Telephone Number 2. Your resignation as my agent, or the declination of any of the named successor agents, shall be made in writing and shall be attached to the original of this document and recorded in the same county or counties as the original, if the original is recorded. C. If it becomes necessary to appoint a conservator of my person, then I nominate my agent as such conservator. D. When you sign on my behalf under the powers I give you in this document, you shall use the following form authorized in California Civil Code Section 1095: "[NAME] by [Your Signature], [his/her] attorney-in-fact." II. YOUR POWERS. Subject to any limitations in this document, I hereby grant you full power and authority, to make health care decisions for me to the same extent I could make such decisions for myself if I had the capacity to do so. In exercising this authority, you shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to you, including, but not limited to, my desire to have or refuse life-prolonging care, treatment, services and procedures. A. With respect to my personal care, you shall have the power to: 1. Gain Access to Medical and Other Personal Information - To request, review and receive any information, verbal or written, regarding my personal affairs or my physical or mental health, including medical and hospital records, and to execute any releases or other documents that may be required in order to obtain this information. In order to assist you in exercising these powers I have made detailed waivers and authorizations in Paragraph B of this Article II. 2. Employ and Discharge Others - To employ and discharge physicians, dentists, nurses, therapists and other professionals as you may deem necessary for my physical and mental well-being; and to pay them, or any of them, reasonable compensation. 3. Provide or Refuse Consent to Medical Care - To give or withhold consent to medical care, surgery or any other medical procedures or tests; to arrange for my hospitalization, convalescent care or home care; and to revoke, withdraw, modify or change consent to such medical care or home care which I or you, as my agent, may have previously allowed or consented to, or which allowance or consent may have been implied due to emergency conditions. I ask you to be guided in making such decisions by what I have told you about my personal preferences regarding such care. Based on those same preferences, you may also summon paramedics or other emergency medical personnel and seek emergency treatment for me, or choose not to do so, as you deem appropriate given my wishes and my medical status at the time of the decision. You are authorized, when dealing with hospitals and physicians, to sign documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advice", as well as any necessary waivers of or releases from liability required by the hospitals or physicians to implement my wishes regarding medical treatment or nontreatment. 4. Provide or Refuse Consent to Psychiatric Care - Upon the execution of a certificate by two (2) independent psychiatrists who have examined me, who are licensed to practice in the state of my residence, and in whose opinions I am in immediate need of care because of mental disorders, alcoholism or drug abuse, to arrange for private psychiatric and psychological treatment (to the extent allowable under California Probate Code Section 4722) for the diagnosed problem or disorder; to refuse consent for any hospitalization, institutionalization, and private psychiatric and psychological care; and to revoke, modify, or withdraw consent to such hospitalization, institutionalization and private treatment which I may have given at an earlier time. 5. Consent to or Refuse Life-Prolonging Procedures - To consent to instituting aggressive medical therapy or to request that it not be instituted or be discontinued, including (but not limited to) cardiopulmonary resuscitation, the implantation of a cardiac pacemaker, renal dialysis, parenteral feeding, the use of respirators or ventilators, blood transfusions, nasogastric tube use, intravenous feedings, endotracheal tube use, antibiotics, and organ transplants; and to request and concur with the writing of a "no code" (do not resuscitate) order by the attending or treating physician. You should try to discuss the specifics of such decision with me if I am able to communicate with you in any manner, even by blinking my eyes. If I am unconscious, comatose, senile, or otherwise unreachable by such communication, you should make the decision guided by any preference which I may have previously expressed, as well as those desires expressed in this document, and the information given by the physicians treating me as to my medical diagnosis and prognosis. [OPTION #1] I express the desire that my life be prolonged to the greatest possible extent without regard for my physical or mental condition, chance of recovery, likelihood of suffering, or expense, and I authorize my agent to consent to whatever medical procedures are necessary to accomplish this end. I trust you, who knows my desires well, and in whose judgment I have absolute faith to exercise your discretion in a manner that would be satisfactory to me. [OPTION #2] (a) If I am irreversibly unconscious and the extension of my life would result in a mere biological existence, then I do not desire any form of life-sustaining procedures[, including nutrition and hydration,] unless necessary for my comfort or alleviation of pain. If life-sustaining treatment has been instituted, I desire that it be withdrawn. It is also my desire that you consider relief from suffering, preservation or restoration of functioning, and the quality as well as extent of the life being preserved when decisions are made concerning life-sustaining care, treatment, services, and procedures. In making the decision to withhold or remove treatment, my agent should ask the questions: "Is the proposed treatment an aid to recovery or merely a prolongation of inevitable death?" What is "reasonable," "an aid to recovery" and "merely a prolongation of inevitable death" shall be determined by you after consulting with my attending physicians. Unless you, in your sole discretion, feel that I should receive or would want to receive further medical treatment if I were capable of deciding for myself, it is my wish to be left alone to die without interference as soon as possible, without having administered to me any medical care of life support whatsoever. [OPTION #3] (a) If I should have an incurable injury, disease, or illness certified by two (2) physicians to be a terminal condition, and if the application of life-sustaining procedures would serve only to artificially prolong the moment of my death, and if my treating physician determines that my death is imminent, whether or not life-sustaining procedures are utilized, then I desire that all life-sustaining treatment[, including nutrition and hydration,] be withheld or removed. [OPTION #3B]: Further, if] If I am in a coma and have been for at least _____ (__) days, which two (2) physicians familiar with my condition have diagnosed as irreversible (that is, there is no reasonable possibility that I will regain consciousness), then I desire that all life-sustaining treatment[, including nutrition and hydration,] be withheld or removed. [USE ONLY W/ #2 OR #3] (b) Regarding the decision to withhold or withdraw life-sustaining treatment, it is my desire that you act only after allowing a reasonable period of time for observation and diagnosis. [REMOVE ALL OR PART IF CONTRADICTS #2 OR #3] (c) Regardless of my condition, it is my desire to receive nutrition and hydration in all ways possible. 6. Provide Relief From Pain - To consent to and arrange for the administration of pain-relieving drugs of any type or other surgical or medical procedures calculated to relieve my pain, even though their use may lead to permanent physical damage, addiction or even hasten the moment of (but not intentionally cause) my death. You may also consent to and arrange for unconventional pain relief therapies, such as biofeedback, guided imagery, relaxation therapy, acupuncture, skin stimulation or cutaneous stimulation, and other therapies which I or you believe may be helpful to me. 7. Protect My Right of Privacy - To exercise my right of privacy to make decisions regarding my medical treatment and my right to be left alone even though the exercise of my right might hasten death or be against conventional medical advice. You may take appropriate legal action, if necessary in your judgment, to enforce my right in this regard. 8. Arrange for My Funeral and Make Anatomical Gifts - To make advance arrangements for my funeral and burial, including the purchase of a burial plot and marker, and such other related arrangements, including anatomical gifts, as you deem advisable. I shall seek to communicate my wishes to you with respect to these matters, and you should rely upon such wishes in exercising this power. [OR] 8. Arrange for My Funeral - To make advance arrangements for my funeral and burial, including the purchase of a burial plot and marker, and such other related arrangements as you deem advisable. I shall seek to communicate my wishes to you with respect to these matters, and you should rely upon such wishes in exercising this power. [AND] 9. Refuse Contribution of Anatomical Gifts or Autopsy - As I do not wish to make a gift under the Uniform Anatomical Gift Act [Chapter 3.5 (commencing with Section 7150) of Part 1 of Division 7 of the Health and Safety Code], unless contrary to the laws of the State of California, you shall have no authority to (i) make any disposition of a part or parts of my body under the Uniform Anatomical Gift Act, or (ii) consent to an examination of my body after my death to determine the cause of my death. [OR] 9. Arrange for Autopsy - To consent to an examination of my body after my death to determine the cause of my death. [WITH] 10. Arrange for Contribution of Anatomical Gifts - To make any disposition of a part or parts of my body under the Uniform Anatomical Gift Act [Chapter 3.5 (commencing with Section 7150) of Part 1 of Division 7 of the Health and Safety Code]. [OR] 9. Refuse Contribution of Anatomical Gifts - As I do not wish to make a gift under the Uniform Anatomical Gift Act [Chapter 3.5 (commencing with Section 7150) of Part 1 of Division 7 of the Health and Safety Code], unless contrary to the laws of the State of California, you shall have no authority to make any disposition of a part or parts of my body under the Uniform Anatomical Gift Act. B. Release of Information to Agent - All third parties from whom you may request information regarding my health or personal affairs are hereby authorized to provide such information to you without limitation and are released from any legal liability whatsoever to me, my estate, my heirs, successors or assigns for complying with your requests. With specific reference to medical information, including information about my mental condition, I am authorizing in advance all physicians and psychiatrists who have treated me, and all other providers of health care, including hospitals, to release to you all information or photocopies of any records which you request. If I have the capacity to confirm this authorization at the time of the request, third parties may seek such confirmation from me if they so desire. If I do not have the capacity to make such a confirmation, all physicians, hospitals, and other health care providers are hereby authorized to treat your request as that of a legal representative of an incompetent patient (as contemplated by Section 56.11(c)(2) of the California Civil Code, or any successor section thereto) and to honor such requests on that basis. I hereby waive all privileges which may be applicable to such information and records, and to any communication pertaining to me and made in the course of a lawyer-client, physician-patient, psychiatrist-patient, clergyman-penitent, or sexual assault victim-counselor relationship. C. Failure of Third Party to Comply with Actions of Agent - You shall have the right to seek appropriate court orders mandating acts which you deem appropriate if a third party refuses to comply with actions taken by you which are authorized by this document or enjoining acts by third parties which you have not authorized. In addition, to the extent not precluded under California Probate Code Section 4750, you may sue a third party who fails to comply with actions I have authorized you to take and demand damages, including punitive damages, on my behalf for such noncompliance. III. REVOCATION AND AMENDMENT. I revoke all prior Durable Powers of Attorney for Health Care that I may have executed, and I retain the right to revoke or amend this document and to substitute other agents in your place. Amendments to this document shall be made in writing by me personally (not by you), and they shall be attached to the original of this document and recorded in the same county or counties as the original, if the original is recorded. IV. DURATION. This Durable Power of Attorney for Health Care shall exist and be effective for an indefinite period until revoked by me (not by you) pursuant to Article III hereof; in the event that I am unable to make health care decisions, this Durable Power of Attorney for Health Care shall continue in force until I regain such capacity to make health care decisions for myself. V. WAIVER OF PRIVILEGE. I hereby voluntarily waive any physician-patient privilege or psychiatrist-patient privilege that may exist in my favor, and I authorize physicians to examine me and disclose my physical or mental condition for purposes of this document. VI. SEVERABILITY. If any provision of this document is not enforceable or is not valid, the remaining provisions shall remain effective. VII. EXCULPATION. Neither you nor any of your successors shall incur any liability to me, my estate, my heirs, successors, or assigns for acting or refraining from acting hereunder, except for willful misconduct or gross negligence. VIII. GOVERNING LAWS. This document shall be governed by the laws of the State of California in all respects, including its validity, construction, interpretation, and termination. IX. DECLARATION OF PRINCIPAL. I declare that my lawyer has explained to me my rights in connection with this document and the consequences of signing it, and that I have read the warnings contained in California Probate Code Section 4703(a), which state as follows: WARNING TO PERSON EXECUTING A DURABLE POWER OF ATTORNEY FOR HEALTH CARE THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR AGENT (THE ATTORNEY-IN-FACT) THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU. YOUR AGENT MUST ACT CONSISTENTLY WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN. EXCEPT AS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THIS DOCUMENT GIVES YOUR AGENT THE POWER TO CONSENT TO YOUR DOCTOR NOT TO GIVE TREATMENT OR TO STOP TREATMENT NECESSARY TO KEEP YOU ALIVE. NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF SO LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION. IN ADDITION, NO TREATMENT MAY BE GIVEN TO YOU OVER YOUR OBJECTION, AND HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY NOT BE STOPPED OR WITHHELD IF YOU OBJECT AT THE TIME. THIS DOCUMENT GIVES YOUR AGENT AUTHORITY TO CONSENT, TO REFUSE TO CONSENT, OR TO WITHDRAW CONSENT TO ANY CARE, TREATMENT, SERVICE, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL CONDITION. THIS POWER IS SUBJECT TO ANY STATEMENT OF YOUR DESIRES AND ANY LIMITATIONS THAT YOU INCLUDE IN THIS DOCUMENT. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT THAT YOU DO NOT DESIRE. IN ADDITION, A COURT CAN TAKE AWAY THE POWER OF YOUR AGENT TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOUR AGENT (1) AUTHORIZES ANYTHING THAT IS ILLEGAL, (2) ACTS CONTRARY TO YOUR KNOWN DESIRES, OR (3) WHERE YOUR DESIRES ARE NOT KNOWN, DOES ANYTHING THAT IS CLEARLY CONTRARY TO YOUR BEST INTERESTS. THIS POWER WILL EXIST FOR AN INDEFINITE PERIOD OF TIME UNLESS YOU LIMIT ITS DURATION IN THIS DOCUMENT. YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY OF YOUR AGENT BY NOTIFYING YOUR AGENT OR YOUR TREATING DOCTOR, HOSPITAL, OR OTHER HEALTH CARE PROVIDER ORALLY OR IN WRITING OF THE REVOCATION. YOUR AGENT HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT. UNLESS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THIS DOCUMENT GIVES YOUR AGENT THE POWER AFTER YOU DIE TO (1) AUTHORIZE AN AUTOPSY, (2) DONATE YOUR BODY OR PARTS THEREOF FOR TRANSPLANT OR THERAPEUTIC, EDUCATIONAL OR SCIENTIFIC PURPOSES, AND (3) DIRECT THE DISPOSITION OF YOUR REMAINS. THIS DOCUMENT REVOKES ANY PRIOR DURABLE POWER OF ATTORNEY FOR HEALTH CARE. THIS DOCUMENT HAS BEEN PREPARED BY YOUR LAWYER, AND BY SIGNING THIS DOCUMENT, YOU ARE ACKNOWLEDGING THAT HE HAS EXPLAINED IT TO YOU AND YOU UNDERSTAND IT. YOUR AGENT MAY NEED THIS DOCUMENT IMMEDIATELY IN CASE OF AN EMERGENCY THAT REQUIRES A DECISION CONCERNING YOUR HEALTH CARE. EITHER KEEP THIS DOCUMENT WHERE IT IS IMMEDIATELY AVAILABLE TO YOUR AGENT AND ALTERNATE AGENTS OR GIVE EACH OF THEM AN EXECUTED COPY OF THIS DOCUMENT. YOU MAY ALSO WANT TO GIVE YOUR DOCTOR AN EXECUTED COPY OF THIS DOCUMENT. This Durable Power of Attorney for Health Care is executed this ____ day of _____________, 1999, in ________________ County, California. _________________________________________ [NAME] STATE OF CALIFORNIA COUNTY OF LOS ANGELES On ______________________, 1999, before me, __________________________________________, the undersigned Notary Public in and for said County and State, personally appeared [NAME], known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument, and acknowledged to me that such person executed the same in [his/her] authorized capacity and that by such signature, the person and the entity on behalf of which [he/she] acted executed the instrument. I declare under penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence. WITNESS my hand and notarial seal. __________________________________________________ Notary Public in and for said County and State I am a lawyer authorized to practice law in the state where this power of attorney was executed, and [NAME] was my client at the time when this power of attorney was executed. I have advised my client concerning [his/her] rights in connection with this power of attorney and the applicable law and the consequences of signing or not signing this power of attorney, and my client, after being so advised, has executed this power of attorney. Dated: _________________, 1999 _________________________________________ [ATTORNEY] 10384.3