Ohio Legal Rights Serviceıs

Durable Power of Attorney for Health Care Form

 

This form helps you to direct your care should your doctor decide that you lack capacity to make your own medical decisions. It is not intended as a substitute for legal advice, and you should contact a lawyer if you have questions about this document or what it does.

 

 

 

Introduction

 

There are two types of advance directives for mental health treatment. One type is the Declaration for Mental Health Treatment under Revised Code chapter 2135. The second type is the Durable Power of Attorney for Health Care under Revised Code chapter 1337. The following form is an advance directive under Revised Code chapter 1337, a Durable Power of Attorney for Health Care form.

 

Ohio Legal Rights Service is partially funded by, and this form was prepared through, a grant under the Protection and Advocacy for Mentally Ill Individuals Act administered through the Center for Mental Health Services of the United States Department of Human Services.

 

Copyright 2004 by Ohio Legal Rights Service, 8 East Long Street, 5th Floor, Columbus, Ohio, 43215.

 

All rights reserved. May be used or reprinted only for advocacy, educational, or other non-profit use, if OLRS is acknowledged as the author and if all copyright information in this paragraph is re-printed in full on each copy.

 

The express written permission of OLRS is required for any other use.

 

 

 

Instructions for filling out this form

 

In this document you name one or more people as your ³agent² or ³attorney-in-fact². You authorize your agent to make all physical and mental health care decisions for you, but only if your attending physician determines that you have lost the capacity to make informed health care decisions for yourself. You should review each section of this form. You must fill in your name and county of residence; the section appointing an agent; and the signature and date. You must sign the form in the presence of the witnesses and/or notary public. The declarations should be filled out only if you want to provide specific instructions to your agent about your treatment.


I. Appointment of Agent

I, _Patrick Alan Risser____, am an adult of sound mind who currently resides in __Ashland__________ County, Ohio. After careful consideration, I knowingly and voluntarily make this durable power of attorney for health care and declaration of treatment preferences. I understand that this is a legally binding document.

I understand that this document will take effect only if my attending physician determines that my ability to receive and evaluate information is impaired to such an extent that I have lost the capacity to make informed health care decisions for myself. My agent can then begin making all physical and mental health care decisions for me. My agent will continue making all health care decisions for me until my attending physician determines that I have regained the capacity to make those decisions for myself.

Designation of my agent

I appoint the following person(s) to act as my agent to make health care decisions for me if my attending physician determines that I have lost the capacity to make informed health care decisions for myself. My agent has authority to make all physical and mental health care decisions for me, including the right to give, to refuse to give, or to withdraw informed consent to any health care treatment, as allowed by law.

I instruct my agent to make health care decisions for me consistent with my wishes as expressed in this document or, if not expressed here, as otherwise made known to my agent by me. If my agent does not know and is not able to determine what I want, I instruct my agent to act in what my agent believes to be my best interest.

I intend each of the individuals named below to succeed to the authority of and serve under this appointment, in the order named, if at any time the prior agent is not readily available or is unwilling to serve or to continue to serve, or is removed by me.

First choice:

 

I appoint _Patricia Sandoval_________, address _154 Ronald Ave., Ashland, OH 44805______________,

 

daytime phone _(503) 655-2530____________, evening phone __(419) 908-9335_____________________,

 

as my agent to make all health care decisions for me.

 

Second choice:

 

I appoint _Dawn Campbell_____________, address __11124 N.E. Hancock, Portland, OR  97220______,

 

daytime phone __(503) 329-9194_________, evening phone __(503) 261-1002________________________,

 

Third choice:

 

I appoint __Heather Stephens_________, address __2150 Fifth Street, Livermore, CA  94550__________,

 

daytime phone _(925) 784-4147______________, evening phone __(925) 449-0789____________________,

 

My ability to revoke this document

 

I understand that I can revoke this document at any time and in any manner merely by expressing my intention to revoke it. This can be done verbally or in writing. If I have given a copy of this document to a physician, my revocation will not be effective as to that physician until the fact of my revocation is communicated to that physician (or the physicianıs staff) by me or by a witness to the revocation. I understand that if I execute a new durable power of attorney for health care, the new document will automatically replace this one.


Expiration date

 

 (Initial one)

 

__X__ This durable power of attorney for health care has no expiration date, and shall not be affected by my disability or by the passage of time.

 

_____ This durable power of attorney for health care shall expire at Midnight on the _____ day of ____________ 20___ , but otherwise is not affected by my disability or by the passage of time.

 

Severability

 

If a court finds any provision of this document to be invalid or unenforceable, that provision shall be severed from this document without affecting any other power or provision of this document, or the appointment of my agent to make health care decisions for me.


II. Declaration of Treatment Instructions

 

You may provide your agent with specific instructions about the choices you want made for you should this POA take effect. If you do not instruct your agent, either in this document or otherwise, the agent will still make choices about your health care and will decide based on your best interests. If you wish to provide instructions about your care to your agent, then fill out those sections of the form below that provide the direction you want to give. If you do not wish to provide instructions to your agent, then go to the signature section at page 11 at the end of this document.

 

Attending physician

 

I name the following doctor as my "attending physician". Under the law, this is the only physician who can make the determination as to whether I have lost the capacity to make informed health care decisions for myself for the purpose of this document.

 

Name: ___________________________________ Phone: _______________________

 

Address: _______________________________________________________________

 

Other physicians I choose to provide treatment to me

 

In addition to the attending physician named above, I prefer to be treated by the following doctors, and I instruct my agent to request medical services for me from the following doctors:

 

Name: ___________________________________ Phone: _______________________

 

Address: _______________________________________________________________

 

Specialty (if any): ________________________________________________________

 

Name: ___________________________________ Phone: _______________________

 

Address: _______________________________________________________________

 

Specialty (if any): ________________________________________________________

 

I do not want to be treated by the following doctors, psychiatrists, or other mental health professionals, and I instruct my agent not to consent to my treatment by these individuals:

 

Name: ___________________________________ Phone: _______________________

 

Address: _______________________________________________________________

 

Name: ___________________________________ Phone: _______________________

 

Address: _______________________________________________________________

 

Medical conditions

 

I may have the following medical condition(s), which may cause or contribute to, or may appear similar to, psychiatric symptoms. I instruct that my agent have these medical conditions ruled out prior to authorizing psychiatric care or treatment. These medical conditions are: _cardiomyopathy, neuropathy______________ _____________________________________________________________________________________

_____________________________________________________________________________________

 

HEALTH CARE INSTRUCTIONS

 

Here are my desires about my health care if my doctor and another knowledgeable doctor confirm that I am in a medical condition described below:

 

1. Close to Death. If I am close to death and life support would only postpone the moment of my death:

 

A. INITIAL ONE:

 

_____ I want to receive tube feeding.

 

_____ I want tube feeding only as my physician recommends.

 

_____ I DO NOT WANT tube feeding.

 

__XX_ I want to decide at the time the issue arises unless I lack capacity. If I am found lacking capacity, I want my agent (substitute decision maker) to decide.

 

B. INITIAL ONE:

 

_____ I want any other life support that may apply.

 

_____ I want life support only as my physician recommends.

 

_____ I want NO life support.

 

__XX_ I want to decide at the time the issue arises unless I lack capacity. If I am found lacking capacity, I want my agent (substitute decision maker) to decide.

 

 

2. Permanently Unconscious. If I am unconscious and it is very unlikely that I will ever become conscious again:

 

A. INITIAL ONE:

 

_____ I want to receive tube feeding.

 

_____ I want tube feeding only as my physician recommends.

 

_____ I DO NOT WANT tube feeding.

 

__XX_ I want to decide at the time the issue arises unless I lack capacity. If I am found lacking capacity, I want my agent (substitute decision maker) to decide.

 

B. INITIAL ONE:

 

_____ I want any other life support that may apply.

 

_____ I want life support only as my physician recommends.

 

_____ I want NO life support.

 

__XX_ I want to decide at the time the issue arises unless I lack capacity. If I am found lacking capacity, I want my agent (substitute decision maker) to decide.

 

 

3. Advanced Progressive Illness. If I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and permanently unable to communicate by any means, swallow food and water safely, care for myself and recognize my family and other people, and it is very unlikely that my condition will be substantially improve:

 

A. INITIAL ONE:

 

_____ I want to receive tube feeding.

 

_____ I want tube feeding only as my physician recommends.

 

_____ I DO NOT WANT tube feeding.

 

__XX_ I want to decide at the time the issue arises unless I lack capacity. If I am found lacking capacity, I want my agent (substitute decision maker) to decide.

 

B. INITIAL ONE:

 

_____ I want any other life support that may apply.

 

_____ I want life support only as my physician recommends.

 

_____ I want NO life support.

 

__XX_ I want to decide at the time the issue arises unless I lack capacity. If I am found lacking capacity, I want my agent (substitute decision maker) to decide.

 

4. Extraordinary Suffering. If life support would not help my medical condition and would make me suffer permanent and severe pain:

 

A. INITIAL ONE:

 

_____ I want to receive tube feeding.

 

_____ I want tube feeding only as my physician recommends.

 

_____ I DO NOT WANT tube feeding.

 

__XX_ I want to decide at the time the issue arises unless I lack capacity. If I am found lacking capacity, I want my agent (substitute decision maker) to decide.

 

B. INITIAL ONE:

 

_____ I want any other life support that may apply.

 

_____ I want life support only as my physician recommends.

 

_____ I want NO life support.

 

__XX_ I want to decide at the time the issue arises unless I lack capacity. If I am found lacking capacity, I want my agent (substitute decision maker) to decide.

 

5. General Instruction.

 

INITIAL IF THIS APPLIES:

 

_____ I DO NOT want my life prolonged by life support. I also DO NOT want tube feeding as life support. I want my doctors to allow me to die naturally if my doctor and another knowledgeable doctor confirm I am in any of the medical conditions listed in Items 1 to 4 above.

 

6. Additional Conditions or Instructions. (Insert description of what you want done.)

_I want no life preserving techniques used which would preserve my life without being able to be a dignified, active participant or live with extreme pain. I have discussed this with and trust my agents to act in accordance with my wishes should I be legally judged and found incompetent to not be able to either give or refuse full informed consent which should be done freely and without coercion, intimidation or persuasion in consultation with my acting agent. Even where I still legally possess the capacity for informed consent, my agent may intervene and employ substituted judgment if they, and they alone, have the slightest suspicion that any form of coercion, intimidation, persuasion or inducement has affected my judgment or ability to make decisions in accordance with the wishes I have expressed or implied to my agent.__________________________________________________

"Family" as used in this document specifically includes my children and other descendants related by blood.  "Family" shall specifically exclude parents, grandparents, aunts, uncles, siblings, cousins or others claiming relation by blood or marriage._____________________________________________

____________________________________________________________________________________

I expressly eliminate the authority of any person to petition a court to challenge this document except under the narrowest exceptions provided by law, such as the rights retained by my agent.__________

 


Medication

 

If my physician proposes that I be given medication, I instruct my agent to (choose one and initial):

 

_____ consent to the medication proposed by my physician

 

_____ consent to medication, except for ______________, which I do not take because (you may wish to explain why you do not wish to take this medication) _________________________________________.

 

_____ not consent to any medications

 

__X__ (other) _My designated agent has been made aware of my wishes and will exercise their best judgment accordingly._________________________________________________________ .

 

Allergies, other physical conditions, health problems, or medications that I want my agent to know about and consider before giving informed consent to medication: _________________________________________.

 

I understand that, if I have instructed my agent not to consent to medication, and if I am involuntarily committed by a court order, it is possible that someone may file an application for forced medication with the probate court and request a court hearing on the question of whether I need to be medicated by court order. If there is a court hearing on the question of whether I am in need of medication, I instruct my agent to inform the court of my instructions as expressed in this document. However, I understand that the court is not required to follow my wishes as expressed in this document.

 

Electroconvulsive therapy

 

Note that ECT is not available in any hospitals operated by the Ohio Department of Mental Health.

 

If my physician proposes that I be given electro-convulsive therapy (ECT), I instruct my agent to (choose one and initial):

 

__X__ not consent to ECT under any circumstances

 

_____ consent to ECT only after all other treatment options have been tried without success

 

_____ consent to ECT

 

__X__ (other) _My designated agent has been made aware of my wishes and will exercise their best judgment accordingly._________________________________________________________ .

 

Restraint or seclusion

 

If it becomes necessary in the opinion of the hospital that I be placed in seclusion or restrained, either physically or chemically, I instruct my agent to (choose one and initial):

 

_____ notwithstanding any other instructions about medication in this document, consent to medication rather than allow me to be placed in physical restraint

 

_____ direct that I be secluded rather than medicated or restrained physically

 

_____ consent only to such seclusion or restraint as are necessary to prevent me from harming myself or others, and this consent should be withdrawn at the point where I am no longer at such risk

 

__X__ (other) _My designated agent has been made aware of my wishes and will exercise their best judgment accordingly._________________________________________________________ .

 


Hospitalization

 

If it is determined that I need to be hospitalized, I instruct my agent as follows.

 

In a general medical hospital

 

If my physician determines that I need care or treatment in a general medical hospital, I instruct my agent to consent to my admission to the following general medical hospital(s):

 

First Choice: __________________________ Second Choice: _____________________

 

I instruct my agent not to consent to my admission to the following general medical hospital(s):

______________________________________________________________________.

 

In a psychiatric hospital (or licensed unit)

 

If my physician determines that I need care or treatment in a psychiatric hospital, I instruct my agent to consent to my admission to the following psychiatric hospital(s):

 

First Choice: __________________________ Second Choice: _____________________

 

I instruct my agent not to consent to my admission to the following psychiatric hospital(s): .

______________________________________________________________________.

 

I understand that, by instructing my agent not to consent to my voluntary admission to the psychiatric hospital(s) named above, it is possible that someone may file with the probate court an affidavit of mental illness and request a court hearing on the question of whether I need to be admitted to a psychiatric hospital by court order, and if so, to which hospital. If there is a court hearing, I understand that the court is not required to follow my wishes as expressed in this document. If there is a court hearing on the question of whether I am in need of psychiatric hospitalization, I instruct my agent to inform the court of my instructions as expressed in this document.

 

Other directions to my agent

 

I instruct my agent to consider the following treatment preferences:

______________________________________________________________________.

 

I do not want the following treatments, and I instruct my agent not to consent to them:

_I want no life preserving techniques used which would preserve my life without being able to be a dignified, active participant or live with extreme pain. I have discussed this with and trust my agents to act in accordance with my wishes should I be legally judged and found incompetent to not be able to either give or refuse full informed consent which should be done freely and without coercion, intimidation or persuasion in consultation with my acting agent. Even where I still legally possess the capacity for informed consent, my agent may intervene and employ substituted judgment if they, and they alone, have the slightest suspicion that any form of coercion, intimidation, persuasion or inducement has affected my judgment or ability to make decisions in accordance with the wishes I have expressed or implied to my agent.__________________________________________________

"Family" as used in this document specifically includes my children and other descendants related by blood.  "Family" shall specifically exclude parents, grandparents, aunts, uncles, siblings, cousins or others claiming relation by blood or marriage._____________________________________________

____________________________________________________________________________________

I expressly eliminate the authority of any person to petition a court to challenge this document except under the narrowest exceptions provided by law, such as the rights retained by my agent.__________

 

(Optional) The reason that I do not want these treatments is:

_I have had painful adverse reactions to psychiatric medications.  Also, I have developed the skill to self-care and be self-determining.  My psychiatric issues were only manifestations of struggles to cope with being a survivor of severe child abuse, trauma and neglect.  All psychiatric treatment misses treating this underlying cause and instead focuses on alleviating what they refer to as symptoms but what are instead coping mechanisms.  If these coping mechanisms are dysfunctional, I will self-correct and manage without psychiatric help._______________________________________________

 

(initial) _____ I wish to be treated by spiritual means through prayer alone, in accordance with a recognized religious method of healing. The recognized religious method of healing is: _____________________________________________________________.

 

I instruct my agent as follows concerning other medical or psychiatric care and treatment, or related issues:

______________________________________________________________________.


Withdrawal of nutrition and hydration when in a permanently unconscious state (required by law to be in capital letters).

 

[X] _____ IF I HAVE MARKED THE FOREGOING BOX AND HAVE PLACED MY INITIALS ON THE LINE ADJACENT TO IT, MY AGENT MAY REFUSE, OR IN THE EVENT TREATMENT HAS ALREADY COMMENCED, WITHDRAW INFORMED CONSENT TO THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIED NUTRITION AND HYDRATION 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 SUCH NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO ME OR ALLEVIATE MY PAIN.

 

Notification

 

If I am hospitalized, I request that my agent notify the following people of the fact of my hospitalization, and the hospitalıs name, address and telephone number (for example, family members, friends and employer):

 

Name: _____________________________, address ____________________________,

 

daytime phone ______________________, evening phone ______________________.

 

Name: _____________________________, address ____________________________,

 

daytime phone ______________________, evening phone ______________________.

 

 

I instruct my agent not to contact the following people:

______________________, ______________________, ______________________.

 

Nomination of Guardian If I need a guardian, I would like the following person to become my guardian, and I make this nomination pursuant to Revised Code Sec. 1337.09 and 2111.02. If there is a guardianship hearing, I instruct my agent to notify the court of my wishes, but I understand that the court is not required to follow my wishes.

 

Name: _Patricia Sandoval__________________, address _154 Ronald Ave., Ashland, OH 44805________,

 

Home phone _(503) 655-2530_____________________, Cell phone _(419) 908-9335________________.

 

I do not recognize the ability of the court to decide what is in my "best" interest.  Therefore, I wish to have my agent appointed as guardian/conservator to carry out my "expressed interests", should the need for a guardian/conservator be found legally necessary.


III. Principalıs Acknowledgement and Signature

 

If I have signed an earlier durable power of attorney for health care, it will be automatically revoked by this document. If I have signed a declaration under Revised Code Chapter 2133 (commonly called a ³Living Will²), it will not be revoked by this document.

 

I understand that if I should execute a Declaration for Mental Health Treatment under Revised Code chapter 2135, that the Declaration for Mental Health Treatment will revoke any provisions for mental health treatment previously stated in a Durable Power of Attorney for Health Care. Any provisions previously stated in the Durable Power of Attorney for Health Care specifically for physical or medical (non-mental health) care will remain in effect.

 

I understand that I should give copies of this document to the agent and alternate agents I have named in this document. I may also give a copy to my physician, psychiatrist, or other health care provider. However, I understand that if I give a copy of this document to my physician or psychiatrist and later revoke this document, my revocation does not become effective as to the physician or psychiatrist until I or a witness to the revocation notifies him/her (or his/her staff) that I have revoked this document. I understand that both my revocation and notice of revocation to my physician or psychiatrist can be done either verbally or in writing. However, it may be easier to prove I revoked it if I do so in writing.

 

I can make changes to this document before I sign it, and I agree to write my initials beside those changes. I understand that I cannot make changes to this document after I have signed it. Instead I must execute a new document.

 

Ohio law requires that I be given the notice printed at the end of this document. I have read this notice before signing this document.

 

I understand that this document will not be valid unless I sign it in the presence of either a notary public or two witnesses who meet the lawıs requirements.

 

THIS DURABLE POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS EITHER (1) SIGNED BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.

 

I understand the terms and purpose of this document, and I sign my name after carefully considering this matter on this __1st___ day of 20 08___ , at _Ashland______________ County, Ohio.

 

____________________________________     __Patrick Alan Risser______________________

Signature of Principal                                                                  Principalıs typed or printed name

 

Witnesses

 

I attest that the principal signed or acknowledged this Durable Power of Attorney for Health Care in my presence, that the principal appears to be of sound mind and not subject to duress, fraud, or undue influence. I also attest that I am not an agent named in this document, I am not the attending physician of the principal, I am not the administrator of a nursing home in which the principal is receiving care, and that I am an adult who is not related to the principal by blood, marriage or adoption.

 

Signature: ________________________________ Date: _________________________

 

Print name: _____________________ Residence Address: ________________________

 

 

Signature: ________________________________ Date: _________________________

 

Print name: _____________________ Residence Address: ________________________

 


Notary Acknowledgement

 

State of Ohio

 

County of __________________________ss:

 

On this the ________day of _____________________________, 200__,

 

______________________________________________, who is known to me or who has provided me with satisfactory proof of identity as the person whose name is subscribed above as the principal, personally appeared before me and acknowledged that s/he executed this document for the purposes described in the document. I attest that the principal appears to be of sound mind and not under or subject to duress, fraud or undue influence.

 

My Commission Expires:____________________

 

________________________________________

Notary Public

 


IV. Statutory Notice

 

Ohio law requires Ohio Revised Code section 1337.17 (Use of printed form; notice to principle) to be included in all Durable Power of Attorney for Health Care forms. The text of that statute follows:

 

1337.17. Use of printed form; notice to principal.

 

A printed form of durable power of attorney for health care may be sold or otherwise distributed in this state for use by adults who are not advised by an attorney. By use of such a printed form, a principal may authorize an attorney in fact to make health care decisions on the principalıs behalf, but the printed form shall not be used as an instrument for granting authority for any other decisions. Any printed form that is sold or otherwise distributed in this state for the purpose described in this section shall include the following notice:

 

Notice to Adult Executing This Document (R.C. Sec.1337.17)

 

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 he 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.


Additionally, when exercising his 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 him 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.