Durable Power of
Attorney for Health Care
(Andre & Blaustein,
LLP Format)
NOTICE:
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE
(YOUR AGENT) BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU, INCLUDING
POWER TO REQUIRE, CONSENT TO, OR WITHDRAW ANY TYPE OF PERSONAL CARE OR MEDICAL
TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND TO ADMIT YOU TO OR
DISCHARGE YOU FROM ANY HOSPITAL, HOME, OR OTHER INSTITUTION; BUT NOT INCLUDING
PSYCHOSURGERY, STERILIZATION, OR INVOLUNTARY HOSPITALIZATION OR TREATMENT
COVERED BY TITLE 37 OF THE OFFICIAL CODE OF GEORGIA ANNOTATED.
THIS FORM DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED
POWERS; BUT, WHEN A POWER IS EXERCISED, YOUR AGENT WILL HAVE TO USE DUE CARE
TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS FORM.
A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS THE AGENT IS
NOT ACTING PROPERLY. YOU MAY NAME
CO-AGENTS AND SUCCESSOR AGENTS UNDER THIS FORM, BUT YOU MAY NOT NAME A HEALTH
CARE PROVIDER WHO MAY BE DIRECTLY OR INDIRECTLY INVOLVED IN RENDERING HEALTH
CARE TO YOU UNDER THIS POWER. UNLESS
YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER IN THE MANNER PROVIDED BELOW OR
UNTIL YOU REVOKE THIS POWER OR A COURT ACTING ON YOUR BEHALF TERMINATES IT,
YOUR AGENT MAY EXERCISE THE POWERS GIVEN IN THIS POWER THROUGHOUT YOUR
LIFETIME, EVEN AFTER YOU BECOME DISABLED, INCAPACITATED, OR INCOMPETENT.
THE POWERS YOU GIVE YOUR AGENT, YOUR RIGHT TO REVOKE THOSE POWERS, AND
THE PENALTIES FOR VIOLATING THE LAW ARE EXPLAINED MORE FULLY IN CODE
SECTIONS 31‑36‑6, 31‑36‑9, AND 31‑36‑10
OF THE GEORGIA “DURABLE POWER OF ATTORNEY FOR HEALTH CARE ACT” OF WHICH
THIS FORM IS A PART. THAT ACT
EXPRESSLY PERMITS THE USE OF ANY DIFFERENT FORM OF POWER OF ATTORNEY YOU MAY
DESIRE. IF THERE IS ANYTHING ABOUT
THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO
YOU.
DURABLE POWER OF ATTORNEY made this _____ day of _____________, 2006.
1. I, __________________________ [PRINCIPAL], at present a resident of ______________ County, Georgia, hereby appoint my ___________, __________________________ [AGENT ONE], as my attorney‑in‑fact (my “Agent”), to act for me and in my name, place, and stead, and on my behalf, in any way I could act in person to make any and all decisions for me concerning my personal care, medical treatment, hospitalization, and health care and to require, withhold, or withdraw any type of medical treatment or procedure, even though my death may ensue.
2. If my Agent shall die, become legally disabled, incapacitated or incompetent, or resign, refuse to act, or be unavailable, I appoint __________________________ [AGENT TWO] as successor Agent to act hereunder. If my successor Agent shall be ineligible, or die, become legally disabled, incapacitated or incompetent, or resign, refuse to act, or be unavailable, I appoint __________________________ [AGENT THREE], [in that order], as successor Agent[s] to act hereunder.
Without limiting the foregoing, I expressly authorize that:
(a) My Agent shall have the same access to my medical records that I have, including the right to disclose the contents to others.
(b) My Agent also shall have full power to make a disposition of any part or all of my body for medical purposes, authorize an autopsy of my body, and direct the disposition of my remains; provided, however, my Agent shall not be authorized to make any disposition of my body and/or my remains that is inconsistent with any direction that I may make in my Last Will and Testament as to the disposition of my body and/or my remains.
(c) My Agent may give oral or written consent to the performance of any one or all of such medical applications to be made as to all matters herein described or contemplated.
(d) My Agent may agree to hold and may hold, in my name, any doctor, technician, hospital, or other medical personage free and harmless from any claim, demand, or suit for damages from any injury or complication that may result from such treatment or medical application to me.
(e) My Agent may do and perform all and every act that I legally may do through an agent concerning the subject matter of this power of attorney, and every proper power necessary to carry out the purposes for which this Durable Power of Attorney for Health Care is granted, with full power of substitution and revocation. I hereby ratify and affirm that which my Agent lawfully shall do or cause to be done by virtue of the powers herein conferred upon my Agent.
THE
ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS POSSIBLE SO THAT YOUR AGENT
WILL HAVE AUTHORITY TO MAKE ANY DECISION YOU COULD MAKE TO OBTAIN OR TERMINATE
ANY TYPE OF HEALTH CARE, INCLUDING WITHDRAWAL OF NOURISHMENT AND FLUIDS AND
OTHER LIFE-SUSTAINING OR DEATH-DELAYING MEASURES, IF YOUR AGENT BELIEVES SUCH
ACTION WOULD BE CONSISTENT WITH YOUR INTENT AND DESIRES.
IF YOU WISH TO LIMIT THE SCOPE OF YOUR AGENT’S POWERS OR PRESCRIBE
SPECIAL RULES TO LIMIT THE POWER TO MAKE AN ANATOMICAL GIFT, AUTHORIZE
AUTOPSY, OR DISPOSE OF REMAINS, YOU MAY DO SO IN THE FOLLOWING PARAGRAPHS.
3. The powers granted above shall not include the following powers or shall be subject to the following rules or limitations:
(here
you may include any specific limitations you deem appropriate, such as your
own definition of when life-sustaining or death-delaying measures should be
withheld; a direction to continue nourishment and fluids or other
life-sustaining or death-delaying treatment in all events; or instructions to
refuse any specific type of treatment that are inconsistent with your
religious beliefs or unacceptable to you for any other reasons, such as blood
transfusion, electroconvulsive therapy, or amputation):
_____________________________________________________________________________
_____________________________________________________________________________
THE
SUBJECT OF LIFE-SUSTAINING OR DEATH-DELAYING TREATMENT IS OF PARTICULAR
IMPORTANCE. FOR YOUR CONVENIENCE
IN DEALING WITH THAT SUBJECT, SOME GENERAL STATEMENTS CONCERNING THE
WITHHOLDING OR REMOVAL OF LIFE-SUSTAINING OR DEATH-DELAYING TREATMENT ARE SET
FORTH BELOW. IF YOU AGREE WITH ONE
OF THESE STATEMENTS, YOU MAY INITIAL THAT STATEMENT, BUT DO NOT INITIAL MORE
THAN ONE:
I do not want my life to be prolonged nor do I want life-sustaining or death-delaying treatment to be provided or continued if my Agent believes the burdens of the treatment outweigh the expected benefits. I want my Agent to consider the relief of suffering, the expense involved, and the quality as well as the possible extension of my life in making decisions concerning life‑sustaining or death-delaying treatment. [OPTION: In making any such decision, I direct my Agent to consider my firm conviction and desire that, if at any time I should have a terminal condition, become in a coma with no reasonable expectation of regaining consciousness, or become in a persistent vegetative state with no reasonable expectation of regaining significant cognitive function, as such conditions are defined in and established in accordance with the procedures set forth in paragraphs (2), (9), and (13) of Code Section 31‑32‑2 of the Official Code of Georgia Annotated, the application of life-sustaining procedures to my body should be withheld or withdrawn, including artificial nourishment and hydration, and that I be permitted to die. ]
Initial:__________
I want my life to be prolonged and I want life-sustaining or death‑delaying treatment to be provided or continued unless I am in a coma, including a persistent vegetative state, which my attending physician believes to be irreversible, in accordance with reasonable medical standards at the time of reference. If and when I have suffered such an irreversible coma, I want life‑sustaining or death-delaying treatment to be withheld or discontinued, including artificial nourishment and hydration, and that I be permitted to die.
Initial:__________
I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery, or the cost of the procedures.
Initial:__________
4. This Power of Attorney shall become effective on this date of execution.
5. This Power of Attorney shall not terminate until such time as I execute another Power of Attorney for health care or otherwise revoke this power by written notification to my Agent. I hereby revoke all Powers of Attorney for Health Care previously executed by me.
6. If a guardian of my person is to be appointed, I nominate the person named above as my Agent to serve as such guardian.
7. Pursuant to Chapter 32 of Title 31 of Official Code of Georgia Annotated, I also have executed a Living Will. I understand that by statute this Durable Power of Attorney for Health Care supersedes the Living Will as long as there is an agent able and/or willing to act under this Power of Attorney. My directions concerning my health care and the withdrawal of life-sustaining or death‑delaying treatment set forth in my Living Will, by statute, may be more limited than the powers I am granting to my Agent under this Durable Power of Attorney for Health Care. I do not want the more limited directions set forth in my Living Will to restrict the decisions my Agent may make pursuant to this Durable Power of Attorney for Health Care, but, rather, I want my Agent to exercise the full authority granted to my Agent under this power, if my Agent, in my Agent’s sole judgment, determines that the exercise of such authority is appropriate.
8. My Agent shall not incur any liability for any action or omission taken in good faith pursuant to this Durable Power of Attorney for Health Care.
9. An individual shall be deemed to be unable to serve or to continue serving as an agent hereunder if: (1) such individual dies, is adjudicated incompetent by a court of competent jurisdiction, or notifies me, the agent(s) serving hereunder, and any successor agent(s) named herein in writing of his inability or unwillingness to serve or to continue serving as an agent hereunder; (2) two licensed medical doctors who are familiar with the physical and mental condition of such individual determine in a written instrument, a copy of which shall be delivered to me, to the agent(s) serving hereunder, and to any successor agent(s) named herein, that such individual at the time in question is unable to serve or to continue serving as such agent; or (3) a court having the requisite jurisdiction determines for any reason that such individual is unable to serve or to continue serving as an agent hereunder.
10. I intend this Durable Power of Attorney for Health Care to be exercisable in any state or jurisdiction where I may be at the time in question.
11. I am fully informed as to all the contents of this form and understand the full import of this grant of powers to my Agent.
Signed:___________________________________
[PRINCIPAL]
The principal has had an opportunity to read the above form and has signed the above form in our presence. We, the undersigned, each being over 18 years of age, witness the principal’s signature at the request and in the presence of the principal, and in the presence of each other, on the day and year above set out.
Witnesses:
Addresses:
__________________________________ __________________________________
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__________________________________ __________________________________
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