Sunday, March 27, 2005


You want to avoid having a family battle like Terri Schiavo's? Save all of us the grief of listening to media talking heads ad nauseum? Then do a Durable Power of Attorney with Health Care Provisions and an Advance Directive (aka Living Will). Who cares if it indicates your true desires under some future unknown and unknowable situation - just do it and spare us the agony.

I do not practice law anymore, but here's a DPOA form that I used to use. I make no representations that it is good now or ever was, or that it will be valid in your state or in your situation. Use it to identify the issues that you need to document, then consult an attorney, buy a $19.95 "I'm gonna die soon" software package, or just fill in the blanks and hope for the best.

Let's be clear: I do not stand behind this form. Don't ask. Don't allege. Just take the free form and move along.

If you have some time before your incapacitation - like you are going in for an operation or the plane you are on is crashing very slowly - then be sure to speak with the risk management department of the hospital and use their forms (or if you are in the plane, call ahead).

For an Advance Directive, they are all over the net ... this one prepares a form valid state by state (you tell it where it will be signed)... and here is a more detailed discussion.

Here's the DPOA form:

Durable Power of Attorney With
Health-Care Provisions

I, _____________________, of ____________ County, Pennsylvania, do hereby appoint the following person as my true and lawful attorney-in-fact (hereinafter referred to as "my agent") with full power of substitution, for me and in my name, to make medical and related decisions and act for me if I am no longer able to take part in such decisions:


If the person so appointed is unable or unwilling to serve or, once having qualified, is unable or unwilling to continue to serve, I appoint the following person as my agent:


This power shall be effective during any subsequent disability or incapacity. All acts done by my agent pursuant to this power during any period of my disability or incapacity shall have the same effect and inure to the benefit of and bind me and my successors in interest as if I were competent and not disabled.

Health-Care Provisions

In the exercise of the following powers, I direct my agent to consult with my primary-care physician or, if he or she is not available, the physician supervising my medical care at the time that a decision is required. However, the decision of my agent will be determinative.

My agent shall have the following powers:

1. Access to My 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.

2. Employ and Discharge Others. To employ and discharge physicians, psychiatrists, dentists, nurses, therapists and other professionals as my agent deems necessary for my physical, mental and emotional well-being; and to pay them, or any of them, reasonable compensation.

3. Consent, or Refuse Consent, to My Medical Care. To give or withhold consent to my 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 my medical care, surgery, or any other medical procedures or tests, hospitalization, convalescent care, or home care which I or my agent may have previously allowed due to emergency conditions. I ask my agent to be guided in making such decisions by the personal preferences I have expressed regarding such care. Based on those same preferences, my agent may also summon paramedics or other emergency medical personnel and seek emergency treatment for me, or choose not to do so, as my agent deems appropriate given my wishes and my medical status at the time of the decision. My agent is 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 non-treatment.

4. Consent, or Refuse Consent, to My Psychiatric Care. Upon execution of a certificate by two (2) independent psychiatrists who have examined me, and in whose opinion I am in immediate need of hospitalization because of mental disorders, alcoholism or drug abuse, to arrange for my voluntary admission to an appropriate hospital or institution for treatment of the diagnosed problem or disorder; to arrange for private psychiatric and psychological treatment for me; to refuse consent for any such hospitalization, institutionalization, and private psychiatric or psychological care; and to revoke, modify, withdraw or change consent to such hospitalization, institutionalization, and private treatment which I or my agent may have given at an earlier time.

5. 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 damages, addiction or even hasten the moment of, but not intentionally cause, my death.

6. Protect Rights 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. My agent may take appropriate legal action, if necessary to enforce my right in this regard.

7. Third Party Reliance. For the purposes of inducing any physician, hospital, or other party to act in accordance with the powers granted in this document, I hereby represent, warrant and agree that:

A. If this document is revoked or amended for any reason, I, my estate, my heirs, successors, and assigns will hold such party or parties harmless from any loss suffered, or liability incurred, by such party or parties in acting in accordance with this document prior to that party's receipt of written notice of any such termination or amendment or has actual notice of my death.

B. The powers conferred on my agent by this document may be exercised by my agent alone and my agent's signature or act under the authority granted in this document may be accepted by third parties as fully authorized by me and with the same force and effect as if I were personally present, competent, and acting on my own behalf.

C. No person who acts in reliance upon any representation my agent may make regarding the scope or authority granted under this document shall incur any liability to me, my estate, my heirs, successors or assigns for permitting my agent to exercise any such power.

D. All third parties from whom my agent may request information regarding my health or personal affairs are hereby authorized and directed to provide such information without limitation and are released from any legal liability whatsoever to me, my estate, my heirs, successors or assigns for complying with my agent's requests. With specific reference to medical information, including information about my medical condition, I am hereby authorizing in advance all physicians and psychiatrists who have treated me, and all other providers of health care, including hospitals, to release to my agent all information and photocopies of any records which may be requested. 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 me agent's request as that of a legal representative of an incompetent patient 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-pentient, or sexual assault victim-counselor relationship.

E. My agent shall have the right to seek court orders mandating appropriate acts is a third party refuses to comply with actions taken by my agent which are authorized by this document, or enjoining acts by third parties which my agent has not authorized.

I have signed this power of attorney this ______ day of ______________ in the year 2005.


Witness: _______________________

Commonwealth of Pennsylvania : ss.
County of _________________

On this, the _________day of ___________________, 2005, before me, the undersigned officer, personally appeared the signatories above known to me (OR satisfactorily proven) to be the persons whose names are subscribed to the within instrument, and acknowledged that they executed the same for the purposes expressed in it.

I have signed my name and affixed my seal.

Notary Public

My commission expires:

1 comment:

  1. Interesting to hear of all the health care provisions that are being put in place.