Fillable Printable Durable Power of Attorney for Health Care - Nevada

Durable Power of Attorney for Health Care - Nevada

DPA.HC (1-02) -1- Principal______

NEVADA

DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS

WARNING TO PERSONS EXECUTING THIS DOCUMENT

THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE POWER OF

ATTORNEY FOR HEALTH CARE. BEFORE EXECUTING THIS DOCUMENT, YOU

SHOULD KNOW THESE IMPORTANT FACTS:

1. THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR

ATTORNEY-IN-FACT THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU.

THIS POWER IS SUBJECT TO ANY LIMITATIONS OR STATEMENT OF YOUR

DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. THE POWER TO MAKE HEALTH

CARE DECISIONS FOR YOU MAY INCLUDE CONSENT, REFUSAL OF CONSENT, OR

WITHDRAWAL OF CONSENT TO ANY CARE, TREATMENT, SERVICE, OR PROCEDURE

TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL CONDITION. YOU

MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT OR PLACEMENTS THAT

YOU DO NOT DESIRE.

2. THE PERSON YOU DESIGNATE IN THIS DOCUMENT HAS A DUTY TO

ACT CONSISTENT WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR

OTHERWISE MADE KNOWN OR, IF YOUR DESIRES ARE UNKNOWN, TO ACT IN YOUR

BEST INTERESTS.

3. EXCEPT AS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THE

POWER OF THE PERSON YOU DESIGNATE TO MAKE HEALTH CARE DECISIONS FOR

YOU MAY INCLUDE THE POWER TO CONSENT TO YOUR DOCTOR NOT GIVING

TREATMENT OR STOPPING TREATMENT WHICH WOULD KEEP YOU ALIVE.

4. UNLESS YOU SPECIFY A SHORTER PERIOD IN THIS DOCUMENT, THIS

POWER WILL EXIST INDEFINITELY FROM THE DATE YOU EXECUTE THIS

DOCUMENT AND, IF YOU ARE UNABLE TO MAKE HEALTH CARE DECISIONS FOR

YOURSELF, THIS POWER WILL CONTINUE TO EXIST UNTIL THE TIME WHEN YOU

BECOME ABLE TO MAKE HEALTH CARE DECISIONS FOR YOURSELF.

5. 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 IF

YOU OBJECT.

6. YOU HAVE THE RIGHT TO REVOKE THE APPOINTMENT OF THE PERSON

DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY

NOTIFYING THAT PERSON OF THE REVOCATION ORALLY OR IN WRITING.

7. YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY GRANTED TO THE

PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR

DPA.HC (1-02) -2- Principal______

YOU BY NOTIFYING THE TREATING PHYSICIAN, HOSPITAL, OR OTHER PROVIDER

OF HEALTH CARE ORALLY OR IN WRITING.

8. THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE

DECISIONS FOR YOU HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND

TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS

DOCUMENT.

9. THIS DOCUMENT REVOKES ANY PRIOR DURABLE POWER OF ATTORNEY

FOR HEALTH CARE.

10. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT

UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.

1. DESIGNATION OF HEALTH CARE AGENT.

I, ________________________________________(insert your name),

do hereby designate and appoint:

Name: _____________________________________________________

Address: __________________________________________________

__________________________________________________

Phone: (____)________________

as my attorney-in-fact to make health care decisions for me as

authorized in this document.

(Insert the name and address of the person you wish to

designate as your attorney-in-fact to make health care decision for

you. Unless the person is also your spouse, legal guardian or the

person most closely related to you by blood, none of the following

may be designated as your attorney-in-fact: (1) your treating

provider of health care, (2) an employee of your treating provider

of health care, (3) an operator of a health care facility, or (4) an

employee of an operator of a health care facility.)

2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE.

By this document I intend to create a durable power of attorney

by appointing the person designated above to make health care

decisions for me. This power of attorney shall not be affected by

my subsequent incapacity.

3. GENERAL STATEMENT OF AUTHORITY GRANTED.

In the event that I am incapable of giving informed consent

DPA.HC (1-02) -3- Principal______

with respect to health care decisions, I hereby grant to the

attorney-in-fact named above full power and authority to make health

care decisions for me before, or after my death, including:

consent, refusal of consent, or withdrawal of consent to any care,

treatment,

service, or procedure to maintain, diagnose, or treat a physical or

mental condition, subject only to the limitations and special

provision, if any, set forth in paragraph 4 or 6.

4. SPECIAL PROVISIONS AND LIMITATIONS.

(Your attorney-in-fact is not permitted to consent to any of

the following: commitment to or placement in a mental health

treatment facility, convulsive treatment, psycho surgery,

sterilization, or abortion. If there are any other types of

treatment or placement that you do not want your attorney-in-fact's

authority to give consent for or other restrictions you wish to

place on his or her attorney-in-fact's authority, you should list

them in the space below. If you do not write any limitations, your

attorney-in-fact will have the broad powers to make health care

decisions on your behalf which are set forth in paragraph 3, except

to the extent that there are limits provided by law.)

In exercising the authority under this durable power of

attorney for health care, the authority of my attorney-in-fact is

subject to the following special provisions and limitations:

____________________________________________________________________

5. DURATION.

I understand that this power of attorney will exist

indefinitely from the date I execute this document unless I

establish a shorter time. If I am unable to make health care

decisions for myself when this power of attorney expires, the

authority I have granted my attorney-in-fact will continue to exist

until the time when I become able to make health care decisions for

myself.

(IF APPLICABLE)

I wish to have this power of attorney end on the following

date: _________________________________.

6. STATEMENT OF DESIRES.

DPA.HC (1-02) -4- Principal______

(With respect to decisions to withhold or withdraw life-

sustaining treatment, your attorney-in-fact must make health care

decisions that are consistent with your known desires. You can, but

are not required to, indicate your desires below. If your desires

are unknown, your attorney-in-fact has the duty to act in your best

interests; and, under some circumstances, a judicial proceeding may

be necessary so that a court can determine the health care decision

that is in your best interests. If you wish to indicate your

desires, you may INITIAL the statement or statements that reflect

your desires and/or write your own statements in the space below.)

(IF THE STATEMENT REFLECTS YOUR DESIRES, INITIAL THE

BOX NEXT TO THE STATEMENT.)

(1) I desire that my life be prolonged to the greatest

extent possible, without regard to my condition, the

chances I have for recovery or long term survival,

or the cost of the procedures. [_________]

(2) If I am in a coma which my doctors have

reasonably concluded is irreversible, I desire

that life-sustaining or prolonging treatments

not be used. (Also should utilize provisions of

NRS 449.535 to 449.690, inclusive, if this

subparagraph is initialed.) [_________]

(3) If I have an incurable or terminal condition

or illness and no reasonable hope of long term

recovery or survival, I desire that life-

sustaining or prolonging treatments not be

used. (Also should utilize provisions of

NRS 449.535 to 449.690, inclusive, if this

subparagraph is initialed.) [_________]

(4) Withholding or withdrawal of artificial

nutrition and hydration may result in death

by starvation or dehydration. I want to

receive or continue receiving artificial

nutrition and hydration by way of the

gastro-intestinal tract after all other

treatment is withheld. [_________]

(5) Except as set forth in Paragraph (2)

and/or (3) above, I do not desire treatment

to be provided and/or continued if the burdens

of the treatment outweigh the expected benefits.

My attorney-in-fact is to consider the relief of

DPA.HC (1-02) -5- Principal______

suffering, the preservation or restoration of

functioning, and the quality as well as the

extent of the possible extension of my life. [_________]

(6) I do not desire treatment to be provided

and/or continued if the burdens of the treatment

outweigh the expected benefits. My attorney-in

-fact is to consider the relief of suffering, the

preservation or restoration of functioning, and

the quality as well as the extent of the possible

extension of my life. [_________]

(7) If any of my tissues or organs are sound

and would be of value, I freely give my per-

mission for such donation pursuant to the

Uniform Anatomical Gift Act (NRS 451.500) for

the following purposes:

(a) For transplant to other people. [__________]

(b) For transplant to family, only. [__________]

(8) I want the financial cost of my medical

treatment to be taken into account and weighed

against the likelihood that the treatment will

achieve the goals that I have initialed above. [_________]

(9) If I am disabled, but not in need of nursing

home care, then I direct my attorney-in-fact to

obtain an individualized care plan for me which

is to be prepared by a geriatric care manager

within 60 days of my disability. In making said

plan, I direct that the plan be developed in a

manner so that I can be maintained in the least

restrictive environment. [_________]

(10) If a guardian is appointed of my person and/

or estate, by a court of competent jurisdiction,

then I direct my attorney-in-fact to submit this

Durable Power of Attorney for Health Care Decisions

to said court. I then request that said court

implement my directives contained herein and that

the court direct, by its order, that my designated

attorney-in-fact is to continue to make my health

care and placement decisions in accordance with

this document, even if my attorney-in-fact is not

a Nevada resident. [_________]

DPA.HC (1-02) -6- Principal______

(11) If I am diagnosed as having dementia or the

Alzheimer's type or other dementia that is deemed

by best available medical knowledge to be

progressive and irreversible, and I no longer have

decision-making capacity, I desire that I be allowed

to die of natural causes such as pneumonia or

dehydration if I become ill or fail to take in

enough fluids by mouth. [_________]

(12) It is my desire to be comfortable. If I

cannot communicate with my Doctor, family or

friends, then I want my Attorney-in-fact, family

and friends to know the following:

(a) I ask that medical treatment to alleviate

pain, to provide comfort, and to mitigate

suffering be provided so that I may be as

free of pain and suffering as possible.

When the circumstances are appropriate, and

in accordance with my wishes as I have

expressed them, such pain relief may be

authorized even though its use may lead

to physical damage, addiction, or even

hasten the moment of (but not intentionally

cause) my death. [_________]

(b) If my temperature is above normal, I

want a cool moist cloth put on my head. [_________]

(d) I need to be kept fresh and clean at

all times. I wish to have warm baths

often or warm showers, if I am stable

enough for a shower. [_________]

(e) I desire to be massaged with or without

warm oils as often as you think will help

maintain my skin integrity and provide

for my comfort. [_________]

(f) I want to have my favorite types of

music played when possible. [_________]

(g) I want my personal care such as

nail clipping, hair combing, and teeth

brushing and shaving as long as they do

DPA.HC (1-02) -7- Principal______

not cause me pain. [_________]

(h) I want to have religious readings

read to me when I am near death. [_________]

(i) I want to have my favorite poems

read to me from time to time. [_________]

(j) Please arrange for family pictures to

be placed in my room. [_________]

(13) I hope my family and friends would

consider that:

(a) I enjoy your company and want you

with me when possible. I desire that

one of you stay with me when it seems

that my death may be imminent. [_________]

(b) Please continue to talk to me about

daily happenings and events, even if you

think I don’t understand, because I might

be able to understand. [_________]

hand or hug me. [_________]

(d) Please tell the members of my church

or synagogue I am sick and ask them to

pray for me and visit me. [_________]

(e) Please maintain a cheerful atmosphere

around me. [_________]

(f) Please place pictures of my loved

ones in my room, near my bed, or near

the place I sit during the day. [_________]

(g) My clothes and bed linens are to be

kept clean, and they are to be changed

as soon as possible, if they have been

soiled. [_________]

(h) If at all possible, allow me to die

in my home. [_________]

(i) Please arrange for me to watch on

television, or listen to my favorite

sports events. [_________]

DPA.HC (1-02) -8- Principal______

(j) Let me enjoy the outdoors as often

as possible by letting me spend time

in my yard, garden and other appropriate

outdoor places, even if it causes slight

discomfort to either you or me. [_________]

(14) I want my care to be provided in a manner

that promotes palliative care as set forth on

Attachment 1. [_________]

OTHER OR ADDITIONAL STATEMENTS OF DESIRES:

____________________________________________________________________

7. It is my intention that this instrument serve both as a

self-executing document and as a delegation of power to my attorney-

in-fact. This document shall be deemed an exercise of all rights

that I may have under the United States Constitution, the

Constitution of Nevada, and any other relevant state and federal

laws, rules, regulations and decisions, to refuse medical treatment.

8. I desire that my wishes be carried out through the

authority given to my attorney-in-fact by this document despite any

contrary feelings, beliefs or opinions of other members of my

family, relatives or friends.

9. I realize that the situations described in this document

are subject to various interpretations, and I am confident that the

person(s) named as my attorney-in-fact will exercise the judgment

that I myself would exercise if competent.

10. If my attorney-in-fact or my alternate attorney(s) in fact

is unavailable, I nevertheless request that my instructions and

preferences in this document be observed.

11. DESIGNATION OF ALTERNATE ATTORNEY-IN-FACT.

(You are not required to designate any alternative attorney-in-

fact but you may do so. Any alternative attorney-in-fact you

DPA.HC (1-02) -9- Principal______

designate will be able to make the same health care decisions as the

attorney-in-fact designated in paragraph 1, page 2, in the event

that he or she is unable or unwilling to act as your attorney-in-

fact. Also, if the attorney-in-fact designated in paragraph 1 is

your spouse, his or her designation as your attorney-in-fact is

automatically revoked by law if your marriage is dissolved.)

If the person designated in paragraph 1 as my attorney-in-fact

is unable to make health care decisions for me, then I designate the

following persons to serve as my attorney-in-fact to make health

care decisions for me as authorized in this document, such persons

to serve in the order listed below:

A. First Alternative Attorney-in-fact

Name: _____________________________________________________

Address: __________________________________________________

__________________________________________________

Phone: (____)________________

B. Second Alternative Attorney-in-fact

Name: _____________________________________________________

Address: __________________________________________________

__________________________________________________

Phone: (____)________________

12. PRIOR DESIGNATIONS REVOKED.

I revoke any prior durable power of attorney for health care.

However, this shall not be construed as a revocation of any durable

power of attorney I may have made for the management of my business

and/or personal affairs.

13. WAIVER OF CONFLICT OF INTEREST.

If my designated attorney-in-fact or if any alternate

designated attorney-in-fact is my spouse or is one of my children

then in that event I waive any conflict of interest that said spouse

or child may have in carrying out the provisions of this Durable

Power of Attorney for Health Care, by reason of the fact that said

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spouse or child may be a recipient of my estate whether by Will, the

laws of intestate succession or pursuant to a Trust or other

arrangement.

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)

I sign my name to this Durable Power of Attorney For Health

Care on:

______________________, 200__ at __________________________________

(date) (city and state)

Signature: _____________________________________

Print Name: _____________________________________

Address: _____________________________________

Town, State, Zip: _____________________________________

Telephone number: ( )

Social Security number: _____________________________________

(THIS POWER OF ATTORNEY WILL NOT BE VALID FOR MAKING HEALTH

CARE DECISIONS UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO

QUALIFIED WITNESSES WHO ARE PERSONALLY KNOWN TO YOU AND WHO ARE

PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE, OR (2)

ACKNOWLEDGED BEFORE A NOTARY PUBLIC.)

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

STATE OF NEVADA )

) ss.

COUNTY OF WASHOE )

On this _____ day of ______________, in the year 200__, before

me,___________________________, (here insert name of Notary Public)

personally appeared __________________________________, (here insert

name of principal) personally known to me (or proved to me on the

basis of satisfactory evidence) to be the person who executed the

above instrument, and acknowledged to me that he or she executed the

same for purposes stated therein. I declare under penalty of

perjury that the person whose name is ascribed to this instrument

appears to be of sound mind and under no duress, fraud, or undue

influence.

________________________________

DPA.HC (1-02) -11- Principal______

NOTARY PUBLIC in and for said

County and State.

COPIES: You should retain an executed copy of this document and

give one to your attorney-in-fact. The power of attorney

should be available so a copy may be given to your

providers of health care.