Fillable Printable Durable Power of Attorney Form - North Dakota

Durable Power of Attorney Form - North Dakota

Some states use the terms “attorney in fact,” “surrogate,” “designee,” and “representative” instead of “agent.” They

are synonymous for purposes of these suggestions.

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SUGGESTIONS

FOR PREPARING WILL TO LIVE

DURABLE POWER OF ATTORNEY

(Please read the document itself before reading this.

It will help you better understand the suggestions.)

YOU ARE NOT REQUIRED TO FILL OUT ANY PART OF THIS "WILL TO LIVE" OR

ANY OTHER DOCUMENT SUCH AS A LIVING WILL OR DURABLE POWER OF

ATTORNEY FOR HEALTH CARE. NO ONE MAY FORCE YOU TO SIGN THIS

DOCUMENT OR ANY OTHER OF ITS KIND.

The Will to Live form starts from the principle that the presumption should be for life. If

you sign it without writing any "SPECIAL CONDITIONS," you are giving directions to your

health care provider(s) and health care agent to do their best to preserve your life.

Some people may wish to continue certain types of medical treatment when they are

terminally ill and in the final stages of life. Others may not.

If you wish to refuse some specific medical treatment, the Will to Live form provides

space to do so ("SPECIAL CONDITIONS"). You may make special conditions for your

treatment when your death is imminent, meaning you will live no more than a week even if given

all available medical treatment; or when you are incurably terminally ill, meaning you will live

no more than three months even if given all available medical treatment. There is also space for

you to write down special conditions for circumstances you describe yourself.

The important thing for you to remember if you choose to fill out any part of the

"SPECIAL CONDITIONS" sections of the Will to Live is that you must be very specific in

listing what treatments you do not want. Some examples of how to be specific will be given

shortly, or you may ask your physician what types of treatment might be expected in your

specific case.

Why is it important to be specific? Because, given the pro-euthanasia views widespread

in society and particularly among many (not all) health care providers, there is great danger that a

vague description of what you do not want will be misunderstood or distorted so as to deny you

treatment that you do want.

Many in the medical profession as well as in the courts are now so committed to the

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quality of life ethic that they take as a given that patients with severe disabilities are better off

dead and would prefer not to receive either life-saving measures or nutrition and hydration. So

pervasive is this "consensus" that it is accurate to say that in practice it is no longer true that the

"presumption is for life" but rather for death. In other words, instead of assuming that a now

incompetent patient would want to receive treatment and care in the absence of clear evidence to

the contrary, the assumption has virtually become that since any "reasonable" person would want

to exercise a "right to die," treatment and care should be withheld or withdrawn unless there is

evidence to the contrary. The Will to Live is intended to maximize the chance of providing that

evidence.

It is important to remember that you are writing a legal document, not holding a

conversation, and not writing a moral textbook. The language you or a religious or moral leader

might use in discussing what is and is not moral to refuse is, from a legal standpoint, often much

too vague. Therefore, it is subject to misunderstanding or deliberate abuse.

The person you appoint as your health care agent may understand general terms in the

same way you do. But remember that the person you appoint may die, or become incapacitated,

or simply be unavailable when decisions must be made about your health care. If any of these

happens, a court might appoint someone else you don't know in that person's place. Also

remember that since the agent has to follow the instructions you write in this form, a health care

provider could try to persuade a court that the agent isn't really following your wishes. A court

could overrule your agent's insistence on treatment in cases in which the court interprets any

vague language you put in your "Will to Live" less protectively than you meant it.

So, for example, do not simply say you don't want "extraordinary treatment." Whatever

the value of that language in moral discussions, there is so much debate over what it means

legally that it could be interpreted very broadly by a doctor or a court. For instance, it might be

interpreted to require starving you to death when you have a disability, even if you are in no

danger of death if you are fed.

For the same reason, do not use language rejecting treatment which has a phrase like

"excessive pain, expense or other excessive burden." Doctors and courts may have a very

different definition of what is "excessive" or a "burden" than you do. Do not use language that

rejects treatment that "does not offer a reasonable hope of benefit." "Benefit" is a legally vague

term. If you had a significant disability, a health care provider or court might think you would

want no medical treatment at all, since many doctors and judges unfortunately believe there is no

"benefit" to life with a severe disability.

What sort of language is specific enough if you wish to write exclusions? Here are some

examples of things you might--or might not--want to list under one or more of the "Special

Conditions" described on the form. Remember that any of these will prevent treatment ONLY

under the circumstances--such as when death is imminent--described in the "Special Condition"

you list it under. (The examples are not meant to be all inclusive--just samples of the type of

thing you might want to write.)

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"Cardiopulmonary resuscitation (CPR)." (If you would like CPR in some but not all

circumstances when you are terminally ill, you should try to be still more specific: for example,

you might write "CPR if cardiopulmonary arrest has been caused by my terminal illness or a

complication of it." This would mean that you would still get CPR if, for example, you were the

victim of smoke inhalation in a fire.) "Organ transplants." (Again, you could be still more

specific, rejecting, for example, just a "heart transplant.")

"Surgery that would not cure me, would not improve either my mental or my physical

condition, would not make me more comfortable, and would not help me to have less pain, but

would only keep me alive longer."

"A treatment that will itself cause me severe, intractable, and long-lasting pain but will

not cure me."

Pain Relief

Under the "General Presumption for Life," of your Will to Live, you will be given

medication necessary to control any pain you may have "as long as the medication is not used in

order to cause my death." This means that you may be given pain medication that has the

secondary, but unintended, effect of shortening your life. If this is not your wish, you may want

to write something like one of the following under the third set of "Special Conditions" (the

section for conditions you describe yourself):

"I would like medication to relieve my pain but only to the extent the medication would

not seriously threaten to shorten my life." OR

"I would like medication to relieve my pain but only to the extent it is known, to a

reasonable medical certainty, that it will not shorten my life."

Think carefully about any special conditions you decide to write in your "Will to Live."

You may want to show them to your intended agent and a couple of other people to see if they

find them clear and if they mean the same thing to them as they mean to you. Remember that

how carefully you write may literally be a matter of life or death--your own.

AFTER WRITING DOWN YOUR SPECIAL CONDITIONS, IF ANY, YOU SHOULD MARK OUT

THE REST OF THE BLANK LINES LEFT ON THE FORM FOR THEM (JUST AS YOU DO AFTER

WRITING OUT THE AMOUNT ON A CHECK) TO PREVENT ANY DANGER THAT SOMEBODY OTHER

THAN YOU COULD WRITE IN SOMETHING ELSE.

IT IS WISE TO REVIEW YOUR WILL TO LIVE PERIODICALLY TO ENSURE THAT IT STILL

GIVES THE DIRECTIONS YOU WANT FOLLOWED.

Robert Powell Center for Medical Ethics

National Right to Life

www.nrlc.org ~ (202) 378-8862

How to use the North Dakota Will to Live Form

SUGGESTIONS AND REQUIREMENTS

1. This document allows you to appoint an “attorney in fact” for health care – someone who

does NOT have to be a lawyer, who will make health care decisions for you whenever

you are unable to make them for yourself. It also allows you to give instructions

concerning medical treatment decisions that the health care agent must follow. Any

resident of North Dakota who is at least 18 years old may designate a health care agent

through this document.

2. The “Warning to Person Executing This Document” and the rest of the document, contain

important information about who cannot be named as your agent and about witnessing

requirements. You should read them carefully before you begin to fill it out.

3. It is helpful to designate successor health care agent(s), to take over if your first choice is

unable to serve. There is space on the form for you to designate two successor health care

agents.

4. If you are resident of a “long-term care facility” such as a nursing home, one of the

following must sign a statement that the person has explained the nature and effect of this

document to you:

– recognized member of the clergy

– lawyer licensed in North Dakota

– person designated by the North Dakota Department of Human Services or the

county court from the county in which the facility is located.

A form for that statement is on the next page. If this applies to you, you should keep it

with your Will to Live.

5. If you are a patient in a hospital, or being admitted to a hospital, when you complete this

document, a person designated by the hospital must sign a statement that the person has

explained the nature and effect of this document to you. A form for that statement is also

on the next page. If this applies to you, you should keep it with your Will to Live.

6. This type of document has been authorized by the North Dakota Durable Power of

Attorney for Health Care Act, N.D. Cent. Stat. §§ 23-06.501 to -18.

7. You should periodically review your document to be sure it complies with your wishes.

Before making changes, be aware that it is possible that the statues controlling this

document have changed since this form was prepared. Contact the Will to Live Project

by visiting www.nrlc.org (Click on “Will to Live”) or an attorney to determine if this

form can still be used.

8. If you have any questions about this document, or want assistance in filling it out, please

consult an attorney.

For additional copies of the Will to Live, please visit www.nrlc.org

form prepared 2002

*clerical changes made 11/05

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If you are in a nursing home, the following form must also be completed at the time you

sign your Will to Live:

Affirmation of Explanation to Resident of Nursing Home

I, ______________________________, affirm that I have explained the nature and effect of the

durable power of attorney for health care to _______________________, who is currently a

resident of a long term care facility named __________________________, in the County of

_________________________, North Dakota, that I have done so at the time she or he is

executing the durable power of attorney for health care, and that I am (mark one):

___ a recognized member of the clergy

___ an attorney licensed to practice in North Dakota

___ a person designated by the North Dakota Department of Human Services

___ a person designated by the County Court of _____________ County

Signed on ___________ (date) __________________________________________

Signature

Address:______________________________________________

_____________________________________________________

If you are being admitted to or are a patient in a hospital, the following form must also be

completed at the time you sign your Will to Live:

Affirmation of Explanation to Resident of Nursing Home

I, ______________________________, affirm that I have explained the nature and effect of the

durable power of attorney for health care to _______________________, who is a patient being

admitted to __________________________ Hospital, that I have done so at the time she or he is

executing the durable power of attorney for health care, and that I have been designated by the

hospital to do this.

Signed on ___________ (date) __________________________________________

Signature

__________________________________________

Hospital Position

Address:______________________________________________

_____________________________________________________

Phone Number_________________________________________

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North Dakota

Statutory Form Durable Power of Attorney for Health Care

Will to Live Form

WARNING TO PERSON EXECUTING THIS DOCUMENT

This is an important legal document which is authorized by the general laws of

this state. Before executing this document, you should know these important

facts:

You must be at least eighteen years

of age for this document to be legally valid

and binding.

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 giving treatment or stopping 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.

This document gives your agent

authority to request, to consent to, or

withdraw consent for 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

authorizes anything is illegal, acts contrary

to your known desires, or where your

desires are not known, does anything that

is clearly contrary to your best interest.

Unless you specify a specific period,

this power will exist until you revoke it.

Your agent’s power and authority ceases

upon your death.

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.

This document revokes any prior

durable power of attorney for health care.

You should carefully read and

follow the witnessing procedure described

at the end of this form. This document will

not be valid unless you comply with the

witnessing procedure.

If there is anything in this document

that you do not understand, you should ask

a lawyer to explain it to you.

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, if any, or give each of

them an executed copy of this document.

You should give your doctor an executed

copy of this document.

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1. DESIGNATION OF HEALTH CARE AGENT.

I, (your name)__________________________________________________________________

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

do hereby designate and appoint: __________________________________________________

______________________________________________________________________________

(insert name, address, and telephone number of one individual only as your agent to make health care decisions for

you. None of the following may be designated as your agent: your treating health care provider, a nonrelative

employee of your treating health care provider, an operator of a long-term health care facility; or a nonrelative

employee of an operator of a long-term care facility)

as my attorney in fact (agent) to make health care decisions for me as authorized in this

document. For the purposes of this document, “health care decision” means consent, refusal of

consent or withdrawal of consent to any care, treatment, service, or procedure to maintain,

diagnose, or treat an individual’s physical or mental condition.

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

this document I intend to create a durable power of attorney for health care.

3. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations

in this document, I hereby grant to my agent full power and authority to make health care

decisions for me to the same extent that I could make such decisions for myself if I had the

capacity to do so. In exercising this authority, my agent shall make health care decisions that are

consistent with my desires as stated in this document or otherwise made known to my agent,

including my desires concerning obtaining or refusing or withdrawing life-prolonging care,

treatment, services, and procedures.

(If you want to limit the authority of your agent to make health care decisions for you, you can

state the limitations in paragraph 4 below. You can indicate your desires by including a

statement of your desires in the same paragraph.)

4. STATEMENT OF DESIRES, SPECIAL PROVISIONS AND LIMITATIONS.

(Your agent must make health care decisions that are consistent with your known desires. You

can, but are not required to, state your desires in the space provided below. You should consider

whether you want to include a statement of your desires concerning life-prolonging care,

treatment, services, and procedures. You can also include a statement of your desires

concerning other matters relating to your health care. You can also make your desires known to

your agent by discussing your desires with your agent or by some other means. If there are any

types of treatment that you do not want to be used, you should state them in the space below. If

you want to limit in any other way the authority given your agent by this document, you should

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state the limits in the space below. If you do not state any limits, your agent will have broad

powers to make health care decisions for you, except to the extent that there are limits provided

by law.)

In exercising the authority under this durable power of attorney for health care, my agent shall act

consistently with my desires as stated below and is subject to the special provisions and

limitations stated below:

a. Statement of desires concerning life-prolonging care, treatment, services and

procedures:

GENERAL PRESUMPTION FOR LIFE

I direct my health care provider(s) and health care agent to make health care decisions consistent

with my general desire for the use of medical treatment that would preserve my life, as well as

for the use of medical treatment that can cure, improve, reduce or prevent deterioration in, any

physical or mental condition.

Food and water are not medical treatment, but basic necessities. I direct my health care

provider(s) and health care attorney in fact to provide me with food and fluids, orally,

intravenously, by tube, or by other means to the full extent necessary both to preserve my life and

to assure me the optimal health possible.

I direct that medication to alleviate my pain be provided, as long as the medication is not used in

order to cause my death.

I direct that the following be provided:

C the administration of medication;

C cardiopulmonary resuscitation (CPR); and

C the performance of all other medical procedures, techniques, and technologies,

including surgery,

–all to the full extent necessary to correct, reverse, or alleviate life-threatening or health

impairing conditions or complications arising from those conditions.

I also direct that I be provided basic nursing care and procedures to provide comfort care.

I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of

an unborn or newborn child, who has been subject to an induced abortion. This rejection does

not apply to the use of tissues or organs obtained in the course of the removal of an ectopic

pregnancy.

I also reject any treatments that use an organ or tissue of another person obtained in a manner that

causes, contributes to, or hastens that person’s death.

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I request and direct that medical treatment and care be provided to me to preserve my life without

discrimination based on my age or physical or mental disability or the “quality” of my life. I

reject any action or omission that is intended to cause or hasten my death.

I direct my health care provider(s) and health care attorney in fact to follow the policy above,

even if I am judged to be incompetent.

During the time I am incompetent, my attorney in fact, as named below, is authorized to make

medical decisions on my behalf, consistent with the above policy, after consultation with my

health care provider(s), utilizing the most current diagnoses and/or prognosis of my medical

condition, in the following situations with the written special instructions.

WHEN MY DEATH IS IMMINENT

A. If I have an incurable terminal illness or injury, and I will die imminently – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only a week or less even

if lifesaving treatment or care is provided to me – the following may be withheld or withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

WHEN I AM TERMINALLY ILL

B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even

though death is not imminent I am in the final stage of that terminal condition – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only three months or less,

even if lifesaving treatment or care is provided to me – the following may be withheld or

withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

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C. OTHER SPECIAL CONDITIONS:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

IF I AM PREGNANT

D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and

health care attorney in fact(s) to use all lifesaving procedures for myself with none of the above

special conditions applying if there is a chance that prolonging my life might allow my child to

be born alive. I also direct that lifesaving procedures be used even if I am legally determined to

be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I

specify by writing my signature in the box below, no one is authorized to consent to any

procedure for me that would result in the death of my unborn child.

If I am pregnant, and I am not in the final stage of a terminal condition as defined above,

medical procedures required to prevent my death are authorized even if they may result in the

death of my unborn child provided every possible effort is made to preserve both my life and the

life of my unborn child.

____________________________________

Signature of Declarant

b. Additional Statement of desires, special provisions, and limitations regarding health

care decisions:

See above instructions

(You may attach additional pages if you need more space to complete your statement. If you

attach additional pages, you must date and sign EACH of the additional pages at the same time

you date and sign this document.)

If you wish to make a gift of any bodily organ you may do so pursuant to North Dakota

Century Code chapter 23-06.2, the Uniform Anatomical Gift Act.