Fillable Printable Statutory Form Durable Power of Attorney for Health Care - Rhode Island

Statutory Form Durable Power of Attorney for Health Care - Rhode Island

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Rhode Island

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 of Rhode

Island 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. 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 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:

(1) authorizes anything 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 your desire, if any, to be an organ and tissue donor.

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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, (your name)__________________________________________________________________

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

do hereby designate and appoint:

Insert information 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.

(Name of agent)________________________________________________________________

(address of agent)_______________________________________________________________

(phone number(s) of agent)_______________________________________________________

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as my attorney in fact (agent) to make any 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 and 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, 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

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:

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GENERAL PRESUMPTION FOR LIFE

I direct my health care provider(s) and health care attorney in fact(s) 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.

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.

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WHEN MY DEATH IS IMMINENT

1. 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

2. 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.)

3. OTHER SPECIAL CONDITIONS:

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

______________________________________________________________________________

(Cross off any remaining blank lines.)

IF I AM PREGNANT

4. 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

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born alive. I also direct that lifesaving procedures be used even 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 attached 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 the Uniform Anatomical Gift Act.

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 sign

EACH of the additional pages at the same time you date and sign this document.

5. INSPECTION AND DISCLOSURE OF INFORMATION 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 by 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.

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(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 of time 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

(name)________________________________________________________________________

(address)______________________________________________________________________

_____________________________________________________________________________

(phone number)________________________________________________________________

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B. Second Alternate Agent

(name)________________________________________________________________________

(address)______________________________________________________________________

______________________________________________________________________________

(phone number)_________________________________________________________________

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

(Date)________________________________________________________________________

(City, State)___________________________________________________________________

(Signature)____________________________________________________________________

(This power of attorney will not be valid unless it is signed by two (2) qualified witnesses who

are present 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.

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

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

out following the places 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.

First Witness Signature:__________________________________________________________

Residence Address:______________________________________________________________

Print Name:____________________________________________________________________

Date:_________________________________________________________________________

Second Witness Signature:________________________________________________________

Residence Address:______________________________________________________________

Print Name:____________________________________________________________________

Date:_________________________________________________________________________

Notary Public Signature:

State of Rhode Island

County of ______________________

In _____________________ in said County on the _______ day of ________________,

20____, before me personally appeared ________________________________ , known by me

to be the party executing the foregoing instrument and ________________________

acknowledged said instrument by ____________________executed to be

____________________ free act and deed.

______________________________________________

Notary Public

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(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.