38918_Book

State of Ohio

Health Care Power of Attorney

_____________________________

(Print Full Name)

________________________

(Birth Date)

I state that this is my Health Care Power of Attorney and I revoke any prior Health Care

Power of Attorney signed by me. I understand the nature and purpose of this document.

If any provision is found to be invalid or unenforceable, it will not affect the rest of

this document.

This Health Care Power of Attorney is in effect only when I cannot make health care

decisions for myself. However, this does not require or imply that a court must declare

me incompetent.

Definitions. Several legal and medical terms are used in this document. For convenience

they are explained below.

Agent or attorney-in-fact means the adult I name in this Health Care Power of

Attorney to make health care decisions for me.

Anatomical gift means a donation of all or part of a human body to take effect upon or

after death.

Artificially or technologically supplied nutrition or hydration means the providing

of food and fluids through intravenous or tube “feedings.”

Cardiopulmonary resuscitation or CPR means treatment to try to restart breathing

or heartbeat. CPR may be done by breathing into the mouth, pushing on the chest,

putting a tube through the mouth or nose into the throat, administering medication,

giving electric shock to the chest, or by other means.

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE ONE OF TWELVE

Ohio State Bar Association

Comfort care means any measure taken to diminish pain or discomfort, but not to

postpone death.

Donor Registry Enrollment Form means a form that has been designed to allow

individuals to specifically register their wishes regarding organ, tissue and eye donation

with the Ohio Bureau of Motor Vehicles Donor Registry.

Do Not Resuscitate or DNR Order means a medical order given by my physician

and written in my medical records that cardiopulmonary resuscitation or CPR is

not to be administered to me.

Health care means any medical (including dental, nursing, psychological, and

surgical) procedure, treatment, intervention or other measure used to maintain,

diagnose or treat any physical or mental condition.

Health Care Power of Attorney means this document that allows me to name an

adult person to act as my agent to make health care decisions for me if I become

unable to do so.

Life-sustaining treatment means any health care, including artificially or

technologically supplied nutrition and hydration, that will serve mainly to prolong

the process of dying.

Living Will Declaration or Living Will means another document that lets me

specify the health care I want to receive if I become terminally ill or permanently

unconscious and cannot make my wishes known.

Permanently unconscious state means an irreversible condition in which I am

permanently unaware of myself and surroundings. My physician and one other

physician must examine me and agree that the total loss of higher brain function

has left me unable to feel pain or suffering.

Principal means the person signing this document.

Terminal condition or terminal illness means an irreversible, incurable and

untreatable condition caused by disease, illness or injury. My physician and one

other physician will have examined me and believe that I cannot recover and that

death is likely to occur within a relatively short time if I do not receive life-sustaining

treatment.

[Instructions and other information to assist in completing this document are set forth

within brackets and in italic type.]

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE TWO OF TWELVE

Naming of My Agent. The person named below is my agent who will make health care

decisions for me as authorized in this document.

Agent’s Name: ____________________________________________________________

Agent’s Current Address: ____________________________________________________

Agent’s Current Telephone Number: ___________________________________________

Naming of Alternate Agents. [Note: You do not need to name alternate agents. You

also may name just one alternate agent. If you do not name alternate agents or name

just one alternate agent, you may wish to cross out the unused lines.]

Should my agent named above not be immediately available or be unwilling or unable

to make decisions for me, then I name, in the following order of priority, the following

persons as my alternate agents:

First Alternate Agent: Second Alternate Agent:

Name: _____________________________ Name: ______________________________

Address: ___________________________ Address: ____________________________

___________________________________ ____________________________________

Telephone:__________________________ Telephone:___________________________

Any person can rely on a statement by any alternate agent named above that he or she

is properly acting under this document and such person does not have to make any

further investigation or inquiry.

Guidance to Agent. My agent will make health care decisions for me based on the

instructions that I give in this document and on my wishes otherwise known to my

agent. If my agent believes that my wishes as made known to my agent conflict with

what is in this document, this document will control. If my wishes are unclear or

unknown, my agent will make health care decisions in my best interests. My agent

will determine my best interests after considering the benefits, the burdens, and the

risks that might result from a given decision. If no agent is available, this document

will guide decisions about my health care.

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE THREE OF TWELVE

Authority of Agent. My agent has full and complete authority to make all health care

decisions for me whenever I cannot make such decisions, unless I have otherwise

indicated below. This authority includes, but is not limited to, the following: [Note:

Cross out any authority that you do not want your agent to have.]

1. To consent to the administration of pain-relieving drugs or treatment or procedures

(including surgery) that my agent, upon medical advice, believes may provide

comfort to me, even though such drugs, treatment or procedures may hasten my

death. My comfort and freedom from pain are important to me and should be

protected by my agent and physician.

2. If I am in a terminal condition, to give, to withdraw or to refuse to give informed

consent to life-sustaining treatment, including artificially or technologically

supplied nutrition or hydration.

3. To give, withdraw or refuse to give informed consent to any health care procedure,

treatment, intervention or other measure.

4. To request, review, and receive any information, verbal or written, regarding my

physical or mental health, including, but not limited to, all my medical and

health care records.

5. To consent to further disclosure of information, and to disclose medical and

related information concerning my condition and treatment to other persons.

6. To execute for me any releases or other documents that may be required in order

to obtain medical and related information.

7. To execute consents, waivers, and releases of liability for me and for my estate

to all persons who comply with my agent’s instructions and decisions. To

indemnify and hold harmless, at my expense, any third party who acts under

this Health Care Power of Attorney. I will be bound by such indemnity entered

into by my agent.

8. To select, employ, and discharge health care personnel and services providing

home health care and the like.

9. To select, contract for my admission to, transfer me to, or authorize my discharge

from any medical or health care facility, including, but not limited to, hospitals,

nursing homes, assisted living facilities, hospices, adult homes and the like.

10. To transport me or arrange for my transportation to a place where this Health

Care Power of Attorney is honored, should I become unable to make health care

decisions for myself in a place where this document is not enforced.

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE FOUR OF TWELVE

11. To complete and sign for me the following:

(a) Consents to health care treatment, or the issuance of Do Not Resuscitate

(DNR) Orders or other similar orders; and

(b) Requests for my transfer to another facility, to be discharged against health

care advice, or other similar requests; and

agent is authorized to make pursuant to this document.

Special Instructions. By placing my initials at number 3 below, I want

to specifically authorize my agent to refuse, or if treatment has

commenced, to withdraw consent to, the provision of artificially or

technologically supplied nutrition or hydration if:

1. I am in a permanently unconscious state; and

2. My physician and at least one other physician who has examined

me have determined, to a reasonable degree of medical certainty,

that artificially or technologically supplied nutrition and hydration

will not provide comfort to me or relieve my pain; and

3. I have placed my initials on this line: _________________

Limitations of Agent’s Authority. I understand that under Ohio law, there are five

limitations to the authority of my agent:

1. My agent cannot order the withdrawal of life-sustaining treatment unless I am

in a terminal condition or a permanently unconscious state, and two physicians

have confirmed the diagnosis and have determined that I have no reasonable

possibility of regaining the ability to make decisions; and

2. My agent cannot order the withdrawal of any treatment given to provide comfort

care or to relieve pain; and

3. If I am pregnant, my agent cannot refuse or withdraw informed consent to health

care if the refusal or withdrawal would end my pregnancy, unless the pregnancy

or health care would create a substantial risk to my life or two physicians

determine that the fetus would not be born alive; and

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE FIVE OF TWELVE

4. My agent cannot order the withdrawal of artificially or technologically supplied

nutrition or hydration unless I am terminally ill or permanently unconscious

and two physicians agree that nutrition or hydration will no longer provide

comfort or relieve pain and, in the event that I am permanently unconscious, I

have given a specific direction to withdraw nutrition or hydration elsewhere in

this document; and

5. If I previously consented to any health care, my agent cannot withdraw that

treatment unless my condition has significantly changed so that the health care

is significantly less beneficial to me, or unless the health care is not achieving

the purpose for which I chose the health care.

Additional Instructions or Limitations. I may give additional instructions or impose

additional limitations on the authority of my agent. [Note: On the lines below you may

write in additional instructions or limitations. Here you may include any specific

instructions or limitations you consider appropriate, such as instructions to refuse

specific types of treatment that are inconsistent with your religious beliefs or unacceptable

to you for any other reason. If the space below is not sufficient, you may attach

additional pages. If you include additional instructions or limitations here and your

wishes change, you should complete a new Health Care Power of Attorney and tell your

agent about the changes. If you do not have any additional instructions or limitations,

you may wish to write “None” below or cross out the unused lines.]

_________________________________________________________________________

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PAGE SIX OF TWELVE

No Expiration Date. This Health Care Power of Attorney will have no expiration date

and will not be affected by my disability or by the passage of time.

Guardian. I intend that the authority given to my agent will eliminate the need for any

court to appoint a guardian of my person. However, should such proceedings start, I

nominate my agent to serve as the guardian of my person, without bond.

Enforcement by Agent. My agent may take for me, at my expense, any action my agent

considers advisable to enforce my wishes under this document.

Release of Agent’s Personal Liability. My agent will not incur any personal liability to

me or my estate for making reasonable choices in good faith concerning my health care.

Copies the Same as Original. Any person may rely on a copy of this document.

Out of State Application. I intend that this document be honored in any jurisdiction

to the extent allowed by law.

Living Will. I have completed a Living Will:______________ Yes _____________ No

Anatomical Gift(s). I have made my wishes known regarding organ and tissue donation in

my Living Will:_____________Yes _____________ No

Donor Registry Enrollment Form. I have completed the Donor Registry Enrollment Form:

________ Yes ___________ No

SIGNATURE

[See next page for witness or notary requirements.]

I understand the purpose and effect of this document and sign my name to this Health

Care Power of Attorney on ____________________, 20 _______, at _______, Ohio.

_________________________________

PRINCIPAL

[You are responsible for telling members of your family and your physician about this

document and the name of your agent. You also may wish, but are not required to tell

your religious advisor and your lawyer that you have signed a Health Care Power of

Attorney. You may wish to give a copy to each person notified.]

[You may choose to file a copy of this Health Care Power of Attorney with your county

recorder for safekeeping.]

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE SEVEN OF TWELVE

WITNESSES OR NOTARY ACKNOWLEDGMENT

[Choose one.]

[This Health Care Power of Attorney will not be valid unless it either is signed by two eligible

witnesses who are present when you sign or are present when you acknowledge your signature,

or it is acknowledged before a Notary Public.]

[The following persons cannot serve as a witness to this Health Care Power of Attorney: the

agent; any successor agent named in this document; your spouse; your children; anyone else

related to you by blood, marriage or adoption; your attending physician; or, if you are in a

nursing home, the administrator of the nursing home.]

Witnesses. I attest that the Principal signed or acknowledged this Health Care Power of

Attorney in my presence, that the Principal appears to be of sound mind and not under or

subject to duress, fraud or undue influence. I further attest that I am not an agent designated

in this document, I am not the attending physician of the Principal, I am not the administrator

of a nursing home in which the Principal is receiving care, and I am an adult not related to

the Principal by blood, marriage or adoption.

________________________________ residing at ______________________________

Signature

________________________________ __________________ , __________

Print Name

Dated: __________________________ , 20_______

________________________________ residing at ______________________________

Signature

________________________________ __________________ , __________

Print Name

Dated: __________________________ , 20______

Notary Acknowledgment.

State of Ohio

County of _________________ ss.

On _________________________, 20_______, before me, the undersigned Notary Public,

personally appeared _________________________________, known to me or satisfactorily

proven to be the person whose name is subscribed to the above Health Care Power of Attorney

as the Principal, and who has acknowledged that (s)he executed the same for the purposes

expressed therein. I attest that the Principal appears to be of sound mind and not under or

subject to duress, fraud or undue influence.

_______________________________________

Notary Public

My Commission Expires: __________________

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE EIGHT OF TWELVE

[This notice is included in this printed form as required by Ohio Revised Code § 1337.17.]

NOTICE TO ADULT EXECUTING THIS DOCUMENT

This is an important legal document. Before executing this document, you should know

these facts:

This document gives the person you designate (the attorney in fact) the power to make

MOST health care decisions for you if you lose the capacity to make informed health

care decisions for yourself. This power is effective only when your attending physician

determines that you have lost the capacity to make informed health care decisions for

yourself and, notwithstanding this document, as long as you have the capacity to make

informed health care decisions for yourself, you retain the right to make all medical

and other health care decisions for yourself.

You may include specific limitations in this document on the authority of the attorney

in fact to make health care decisions for you.

Subject to any specific limitations you include in this document, if your attending

physician determines that you have lost the capacity to make an informed decision on

a health care matter, the attorney in fact GENERALLY will be authorized by this

document to make health care decisions for you to the same extent as you could make

those decisions yourself, if you had the capacity to do so. The authority of the attorney

in fact to make health care decisions for you GENERALLY will include the authority

to give informed consent, to refuse to give informed consent, or to withdraw informed

consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a

physical or mental condition.

HOWEVER, even if the attorney in fact has general authority to make health care

decisions for you under this document, the attorney in fact NEVER will be authorized

to do any of the following:

(1) Refuse or withdraw informed consent to life-sustaining treatment (unless

your attending physician and one other physician who examines you determine,

to a reasonable degree of medical certainty and in accordance with reasonable

medical standards, that either of the following applies:

(a) You are suffering from an irreversible, incurable and untreatable condition

caused by disease, illness, or injury from which (i) there can be no recovery

and (ii) your death is likely to occur within a relatively short time if life-

sustaining treatment is not administered, and your attending physician

additionally determines, to a reasonable degree of medical certainty and in

accordance with reasonable medical standards, that there is no reasonable

possibility that you will regain the capacity to make informed health care

decisions for yourself.

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE NINE OF TWELVE

(b) You are in a state of permanent unconsciousness that is characterized by

you being irreversibly unaware of yourself and your environment and by a

total loss of cerebral cortical functioning, resulting in you having no capacity

to experience pain or suffering, and your attending physician additionally

determines, to a reasonable degree of medical certainty and in accordance

with reasonable medical standards, that there is no reasonable possibility

that you will regain the capacity to make informed health care decisions for

yourself);

(2) Refuse or withdraw informed consent to health care necessary to provide

you with comfort care (except that, if the attorney in fact is not prohibited from

doing so under (4) below, the attorney in fact could refuse or withdraw informed

consent to the provision of nutrition or hydration to you as described under (4)

below). (You should understand that comfort care is defined in Ohio law

to mean artificially or technologically administered sustenance (nutrition)

or fluids (hydration) when administered to diminish your pain or discomfort,

not to postpone your death, and any other medical or nursing procedure,

treatment, intervention, or other measure that would be taken to diminish

your pain or discomfort, not to postpone your death. Consequently, if your

attending physician were to determine that a previously described medical

or nursing procedure, treatment, intervention, or other measure will not or

no longer will serve to provide comfort to you or alleviate your pain, then,

subject to (4) below, your attorney in fact would be authorized to refuse or

withdraw informed consent to the procedure, treatment, intervention, or

other measure.);

(3) Refuse or withdraw informed consent to health care for you if you are

pregnant and if the refusal or withdrawal would terminate the pregnancy (unless

the pregnancy or health care would pose a substantial risk to your life, or unless

your attending physician and at least one other physician who examines you

determine, to a reasonable degree of medical certainty and in accordance with

reasonable medical standards, that the fetus would not be born alive);

(4) Refuse or withdraw informed consent to the provision of artificially or

technologically administered sustenance (nutrition) or fluids (hydration) to

you, unless:

(a) You are in a terminal condition or in a permanently unconscious

state.

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE TEN OF TWELVE

[This notice is included in this printed form as required by Ohio Revised Code § 1337.17.]

(b) Your attending physician and at least one other physician who has

examined you determine, to a reasonable degree of medical certainty

and in accordance with reasonable medical standards, that nutrition or

hydration will not or no longer will serve to provide comfort to you or

alleviate your pain.

authorize the attorney in fact to refuse or withdraw informed consent

to the provision of nutrition or hydration to you by doing both of the

following in this document:

(i) Including a statement in capital letters or other conspicuous type,

including, but not limited to, a different font, bigger type, or boldface

type, that the attorney in fact may refuse or withdraw informed consent

to the provision of nutrition or hydration to you if you are in a

permanently unconscious state and if the determination that nutrition

or hydration will not or no longer will serve to provide comfort to you

or alleviate your pain is made, or checking or otherwise marking a

box or line (if any) that is adjacent to a similar statement on this

document;

(ii) Placing your initials or signature underneath or adjacent to the

statement, check, or other mark previously described.

(d) Your attending physician determines, in good faith, that you authorized

the attorney in fact to refuse or withdraw informed consent to the

provision of nutrition or hydration to you if you are in a permanently

unconscious state by complying with the above requirements of (4)(c)(i)

and (ii) above.

(5) Withdraw informed consent to any health care to which you previously

consented, unless a change in your physical condition has significantly decreased

the benefit of that health care to you, or unless the health care is not, or is no

longer, significantly effective in achieving the purposes for which you consented

to its use.

Additionally, when exercising authority to make health care decisions for you, the

attorney in fact will have to act consistently with your desires or, if your desires are

unknown, to act in your best interest. You may express your desires to the attorney in

fact by including them in this document or by making them known to the attorney in

fact in another manner.

When acting pursuant to this document, the attorney in fact GENERALLY will have

the same rights that you have to receive information about proposed health care, to

review health care records, and to consent to the disclosure of health care records. You

can limit that right in this document if you so choose.

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE ELEVEN OF TWELVE

[This notice is included in this printed form as required by Ohio Revised Code § 1337.17.]

Generally, you may designate any competent adult as the attorney in fact under this

document. However, you CANNOT designate your attending physician or the

administrator of any nursing home in which you are receiving care as the attorney in

fact under this document. Additionally, you CANNOT designate an employee or agent

of your attending physician, or an employee or agent of a health care facility at which

you are being treated, as the attorney in fact under this document, unless either type

of employee or agent is a competent adult and related to you by blood, marriage, or

adoption, or unless either type of employee or agent is a competent adult and you and

the employee or agent are members of the same religious order.

This document has no expiration date under Ohio law, but you may choose to specify

a date upon which your durable power of attorney for health care will expire. However,

if you specify an expiration date and then lack the capacity to make informed health

care decisions for yourself on that date, the document and the power it grants to your

attorney in fact will continue in effect until you regain the capacity to make informed

health care decisions for yourself.

You have the right to revoke the designation of the attorney in fact and the right to

revoke this entire document at any time and in any manner. Any such revocation

generally will be effective when you express your intention to make the revocation.

However, if you made your attending physician aware of this document, any such

revocation will be effective only when you communicate it to your attending physician,

or when a witness to the revocation or other health care personnel to whom the revocation

is communicated by such a witness communicates it to your attending physician.

If you execute this document and create a valid durable power of attorney for health

care with it, it will revoke any prior, valid durable power of attorney for health care

that you created, unless you indicate otherwise in this document.

This document is not valid as a durable power of attorney for health care unless it is

acknowledged before a notary public or is signed by at least two adult witnesses who

are present when you sign or acknowledge your signature. No person who is related

to you by blood, marriage, or adoption may be a witness. The attorney in fact, your

attending physician, and the administrator of any nursing home in which you are

receiving care also are ineligible to be witnesses.

If there is anything in this document that you do not understand, you should ask your

lawyer to explain it to you.

OHIO HEALTH CARE POWER OF ATTORNEY

PAGE TWELVE OF TWELVE

[This notice is included in this printed form as required by Ohio Revised Code § 1337.17.]

hospitals, bar associations, medical societies, and nonprofit associations and organizations. It may not be reproduced

commercially for sale at a profit.