Fillable Printable Health Care Power of Attorney - Rhode Island

Health Care Power of Attorney - Rhode Island

Rhode Island Statute

CHAPTER 23-4.10

Health Care Power of Attorney

§ 23-4.10-1 Purpose. – (a) The legislature finds that adult persons have the fundamental

right to control the decisions relating to the rendering of their own medical care.

(b) In order that the rights of patients may be respected even after they are no longer

able to participate actively in decisions about themselves, the legislature declares that the

laws of the state shall recognize the right of an adult person to make a written durable

power of attorney which might include instructing his or her physician to withhold or

withdraw life-sustaining procedures in the event of a terminal condition.

§ 23-4.10-1.1 Definitions. – The following definitions govern the construction of this

chapter:

(1) "Advance directive protocol" means a standardized, state-wide method developed

for emergency service personnel by the department of health and approved by the

ambulance service advisory board, of providing palliative care to, and withholding life-

sustaining procedures from, a qualified patient.

(2) "Artificial feeding" means the provision of nutrition or hydration by parenteral,

nasogastric, gastric, or any means other than through per oral voluntary sustenance.

(3) "Attending physician" means the physician who has primary responsibility for the

treatment and care of the patient.

(4) "Director" means the director of health.

(5) "Durable power of attorney" means a witnessed document executed in accordance

with the requirements of § 23-4.10-2.

(6) "Emergency medical services personnel" means paid or volunteer firefighters, law

enforcement officers, first responders, emergency medical technicians, or other

emergency services personnel acting within the ordinary course of their professions.

(7) "Health-care provider" means a person who is licensed, certified, or otherwise

authorized by the law of this state to administer health care in the ordinary course of

business or practice of a profession.

(8) "Life-sustaining procedure" means any medical procedure or intervention that,

when administered to a patient, will serve only to prolong the dying process. "Life-

sustaining procedure" shall not include any medical procedure or intervention considered

necessary by the attending physician or emergency service personnel to provide comfort,

care, or alleviate pain.

(9) "Person" means an individual, corporation, business trust, estate, trust, partnership,

association, government, governmental subdivision or agency, or any other legal entity.

(10) "Physician and/or doctor" means an individual licensed to practice medicine in this

state.

(11) "Terminal condition" means an incurable or irreversible condition that, without the

administration of life-sustaining procedures, will, in the opinion of the attending

physician, result in death.

§ 23-4.10-2 Statutory form of durable power of attorney. – The statutory form of durable

power of attorney is as follows:

STATUTORY FORM DURABLE POWER OF ATTORNEY FOR HEALTH CARE

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 (18) years of age and a resident of the state 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 m edical 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 at

the time, and health care necessary to keep you alive may not be stopped or withheld if

you object at the time.

This document gives your agent authority to consent, to refuse to consent, or to

withdraw consent to 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 limitation 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:

(1) Authorizes anything that is illegal,

(2) Acts contrary to your known desires, or

(3) Where your desires are not known, does anything that is clearly contrary to your

best interests.

Unless you specify a specific period, this power will exist until you revoke it. Your

agent's power and authority ceases upon your death except to inform your family or next

of kin of your desire, if any, to be an organ and tissue owner.

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 or give each of them an

executed copy of this document. You may also want to give your doctor an executed

copy of this document.

(1) DESIGNATION OF HEALTH CARE AGENT. I,

____________________________________________________________________

(insert your name and address)

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: (1) your treating health care provider, (2) a nonrelative employee of your treating

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

employee of an operator of a community 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 m ental 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, but not limited to, my desires concerning

obtaining or refusing or withdrawing life-prolonging care, treatment, services, and

procedures and informing my family or next of kin of my desire, if any, to be an organ or

tissue donor.

(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) ("Statement of Desires, Special Provisions,

and Limitations") 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 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 consisten tly 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:

(b) Additional statement of desires, special provisions, and limita tions regarding health

care decisions:

Initial if applicable:

[ ] In the event of my death, I request that my agent inform my family/next of kin of

my desire to be an organ and tissue donor, if possible.

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

you attach additional pages, you must date and s ign EACH of the additional pages at the

same time you date and sign this docum ent.)

(5) INSPECTION AND DISCLOSURE OF INFORMAT ION RELATING TO MY

PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my

agent has the power and authority to do all of the following:

(a) Request, review, and receive any information, verbal or written, regarding my

physical or mental health, including, but not limited to, medical and hospital records.

(b) Execute on my behalf any releases or other documents that may be required in order

to obtain this information.

(If you want to limit the authority of your agent to receive and disclose information

relating to your health, you must state the limitations in paragraph (4) ("Statement of

desires, special provisions, and limitations") above.)

(6) SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary to

implement the health care decisions that my agent is authorized by this document to

make, my agent has the power and authority to execute on my behalf all of the following:

(a) Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving

Hospital Against Medical Advice. "

(b) Any necessary waiver or release from liability required by a hospital or physician.

(7) DURATION. (Unless you specify a shorter period in the space below, this power of

attorney will exist until it is revoked.)

This durable power of attorney for health care expires on ________________________

(Fill in this space ONLY if you want the authority of your agent to end on a specific

date.)

(8) DESIGNATION OF ALTERNATE AGENTS. (You are not required to designate

any alternate agents but you may do so. Any alternate agent you designate will be able to

make the same health care decisions as the agent you designated in paragraph (1), above,

in the event that agent is unable or ineligible to act as your agent. If the agent you

designated is your spouse, he or she becomes ineligible to act as your agent if your

marriage is dissolved.)

If the person designated as my agent in paragraph (1) is not available or becomes

ineligible to act as my agent to make a health care decision for me or loses the mental

capacity to make health care decisions for me, or if I revoke that person's appointment or

authority to act as my agent to make health care decisions for me, then I designate and

appoint the following persons to serve as my agent to make health care decisions for me

as authorized in this document, such persons to serve in the order listed below:

(A) First Alternate Agent: _________________________________________________

(Insert name, address, and telephone number of first alternate agent.)

(B) Second Alternate Agent: _______________________________________________

(Insert name, address, and telephone number of second alternate agent.)

(9) PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of

attorney for health care.

DATE AND SIGNATURE OF PRINCIPAL

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)

I sign my name to this Statutory Form Durable Power of Attorney for Health Care on

__________________ at ____________________

(Date) (City)

__________________

(State)

_______________________________

(You sign here)

(THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED

BY TWO (2) QUALIFIED WITNESSES WHO ARE PRES ENT WHEN YOU SIGN

OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY

ADDITIONAL PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF

THE ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS

POWER OF ATTORNEY.) YOU ARE NOT REQUIRED TO HAVE THIS POWER OF

ATTORNEY NOTARIZED

STATEMENT OF WITNESSES

(This document must be witnessed by two (2) qualified adult witnesses or one (1)

notary public. None of the following may be used as a witness:

(1) A person you designate as your agent or alternate agent,

(2) A health care provider,

(3) An employee of a health care provider,

(4) The operator of a community care facility,

(5) An employee of an operator of a community care facility.

You are not required to have this document witnessed by a notary public.

At least one of the qualified witnesses or the notary public must make the additional

declaration set out following the place where the witnesses sign.)

I declare under penalty of perjury that the person who signed or acknowledged this

document is personally known to me to be the principal, that the principal signed or

acknowledged this durable power of attorney in my presence, that the principal appears to

be of sound mind and under no duress, fraud, or undue influence, that I am not the person

appointed as attorney in fact by this document, and that I am not a health care provider,

an employee of a health care provider, the operator of a community care facility, nor an

employee of an operator of a community care facility.

Signature: _____________________Residence Address:________________________

Print Name: ___________________________________

Date: _________________________

Signature: _____________________Residence Address:________________________

Print Name: ___________________________________

Date: _________________________

(AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE

FOLLOWING DECLARATION.)

I further declare under penalty of perjury that I am not related to the principal by blood,

marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of

the estate of the principal upon the death of the principal under a will now existing or by

operation of law.

Signature: _______________________ Signature:__________________________

Print Name: ______________________Print Name:_________________________

§ 23-4.10-3 Revocation. – (a) A durable power of attorney may be revoked at any time

and in any manner by which the declarant is able to communicate an intent to revoke,

without regard to mental or physical condition. A revocation is only effective as to the

attending physician or any health care provider or emergency medical services personnel

upon communication to that physician or health care provider or emergency medical

services personnel by the declarant or by another who witnessed the revocation.

(b) The attending physician or health care provider shall make the revocation a part of

the declarant's medical record.

shall constitute a revocation of a durable power of attorney

§ 23-4.10-4 Recording contents of durable power of attorney. – The attending physician

who had knowledge of the existence of a durable power of attorney shall note in the

medical record the existence of the durable power of attorney. In the instance where the

durable power of attorney includes a DNR (do not resuscitate) order, that should also be

entered into the medical record.

§ 23-4.10-5 Treatment of patients. – (a) A patient has the right to make decisions

regarding use of life sustaining procedures as long as the patient is able to do so. If a

patient is not able to make those decisions, the durable power of attorney governs

decisions regarding use of life sustaining procedures.

(b) This chapter does not prohibit any action considered necessary by the attending

physician, health care provider, or emergency medical services personnel for comfort,

care, or alleviation of pain.

pregnant shall be given no force or effect as long as it is probable that the fetus could

develop to the point of live birth with continued application of life sustaining procedures.

§ 23-4.10-6 Transfer of patients. – An attending physician or health-care provider who

refuses to comply with the durable power of attorney of a patient pursuant to this chapter

shall make the necessary arrangements to effect the transfer of the patient to another

physician who will effectuate the durable power of attorney of the patient.

§ 23-4.10-7 Immunities. – (a) In the absence of actual notice of the revocation of a

durable power of attorney, the following, while acting in accordance with the

requirements of this chapter, are not subject to civil or criminal liability or charges of

unprofessional conduct:

(1) A physician who acts pursuant to the terms of a durable power of attorney or

at the direction of the agent so designated by a durable power of attorney.

(2) A person who acts under the direction or with the authorization of a

physician.

(3) The health-care provider owning or operating the facility in which the terms

of durable power of attorney are implemented.

(4) Emergency medical services personnel who act pursuant to an advanced

directive protocol.

(5) Emergency medical services personnel who proceed to provide life-

sustaining treatment to a patient pursuant to a revocation communicated to them.

(6) An agent acting in accordance with a valid durable power of attorney.

(b) A physician is not subject to civil or criminal liability for actions under this chapter

which are in accordance with reasonable medical standards.

§ 23-4.10-8 Penalties. – (a) Failure of a physician to transfer a patient pursuant to § 23-

4.10-6 shall constitute "unprofessional conduct" as that term is used in § 5-37-5.1.

(b) Any person who willfully conceals, cancels, defaces, or obliterates the durable

power of attorney of another absent the declarant's consent or direction or who falsifies or

forges a revocation of the durable power of attorney of another shall be imprisoned for no

less than six (6) months but no more than one year, or shall be fined not less than two

thousand dollars ($2,000) but no more than five thousand dollars ($5,000).

willfully conceals or withholds personal knowledge of a revocation as provided in § 23-

4.10-3 with the intent to cause a withholding or withdrawal of life sustaining procedures,

shall be imprisoned for no less than one year but no more than five (5) years, or shall be

fined not less than five thousand dollars ($5,000) but no more than ten thousand dollars

($10,000).

(d) In addition to the sanctions and/or penalties previously mentioned in this section,

any physician or person referred to in this section or in violation of this section, shall be

civilly liable.

§ 23-4.10-9 General provisions. – (a) Death resulting from the withholding or

withdrawal of life-sustaining procedures pursuant to a durable power of attorney and in

accordance with this chapter does not constitute, for any purpose, a suicide or homicide.

(b) The making of a durable power of attorney pursuant to § 23-4.10-3 does not affect

in any manner the sale, procurement, or issuance of any policy of life insurance, nor does

it modify the terms of an existing policy of life insurance. A policy of life insurance is not

legally impaired or invalidated in any manner by the withholding or withdrawal of life-

sustaining procedures from an insured qualified patient, notwithstanding any term of the

policy to the contrary.

a condition for being insured for, or receiving, health care services.

(d) This chapter creates no presumption concerning the intention of an individual who

has revoked or has not executed a durable power of attorney with respect to the use,

withholding, or withdrawal of life-sustaining procedures in the event of a terminal

condition.

(e) This chapter does not increase or decrease the right of a patie nt to make decisions

regarding use of life-sustaining procedures so long as the patient is able to do so, or

impair or supersede any right or responsibility that any person has to effect the

withholding or withdrawal of medical care.

(f) This chapter does not condone, authorize, or approve mercy-killing or euthanasia.

§ 23-4.10-10 Presumption of validity of durable power of attorney. – A physician or

health care provider or emergency medical services personnel may presume, in the

absence of actual notice to the contrary, that a durable power of attorney complies with

the requirements of this chapter and is valid.

§ 23-4.10-11 Recognition of durable power of attorney executed in another state. – A

durable power of attorney executed in another state in compliance with the law of that

state is validly executed for purposes of this chapter.

§23-4.10-12 Severability. – If any provision of this chapter or its application to any

person or circumstance is held invalid, the invalidity does not affect other provisions or

applications of this chapter which can be given effect without the invalid provision or

application, and to this end the provisions of this chapter are severable.