Fill - Free fillable Ohio Legal Rights Services Durable Power of Attorney PDF form

Ohio Legal Rights Service’s

Durable Power of Attorney for Health Care Form

This form helps you to direct your care should your doctor decide that you lack capacity to make your own medical decisions.

It is not intended as a substitute for legal advice, and you should contact a lawyer if you have questions about this document

or what it does.

Introduction

There are two types of advance directives for mental health treatment. One type is the Declaration for Mental Health Treatment

under Revised Code chapter 2135. The second type is the Durable Power of Attorney for Health Care under Revised Code

chapter 1337. The following form is an advance directive under Revised Code chapter 1337, a Durable Power of Attorney for

Health Care form.

Ohio Legal Rights Service is partially funded by, and this form was prepared through, a grant under the Protection and

Advocacy for Mentally Ill Individuals Act administered through the Center for Mental Health Services of the United States

Department of Human Services.

as the author and if all copyright information in this paragraph is re-printed in full on each copy.

The express written permission of OLRS is required for any other use.

Instructions for ﬁ lling out this form

In this document you name one or more people as your “agent” or “attorney-in-fact”. You authorize your agent to make all

physical and mental health care decisions for you, but only if your attending physician determines that you have lost the

capacity to make informed health care decisions for yourself. You should review each section of this form. You must ﬁ ll in

your name and county of residence; the section appointing an agent; and the signature and date. You must sign the form in

the presence of the witnesses and/or notary public. The declarations should be ﬁ lled out only if you want to provide speciﬁ c

instructions to your agent about your treatment.

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 1 of 12

I. Appointment of Agent

I, , am an adult of sound mind who currently resides in

County, Ohio. After careful consideration, I knowingly and voluntarily make this durable power of attorney for health care and

declaration of treatment preferences. I understand that this is a legally binding document.

I understand that this document will take effect only if my attending physician determines that my ability to receive and evaluate

information is impaired to such an extent that I have lost the capacity to make informed health care decisions for myself. My

agent can then begin making all physical and mental health care decisions for me. My agent will continue making all health

care decisions for me until my attending physician determines that I have regained the capacity to make those decisions for

myself.

Designation of my agent

I appoint the following person(s) to act as my agent to make health care decisions for me if my attending physician determines

that I have lost the capacity to make informed health care decisions for myself. My agent has authority to make all physical

and mental health care decisions for me, including the right to give, to refuse to give, or to withdraw informed consent to any

health care treatment, as allowed by law.

I instruct my agent to make health care decisions for me consistent with my wishes as expressed in this document or, if not

expressed here, as otherwise made known to my agent by me. If my agent does not know and is not able to determine what I

want, I instruct my agent to act in what my agent believes to be my best interest.

I intend each of the individuals named below to succeed to the authority of and serve under this appointment, in the order

named, if at any time the prior agent is not readily available or is unwilling to serve or to continue to serve, or is removed by

me.

First choice:

I appoint , address ,

daytime phone , evening phone ,

as my agent to make all health care decisions for me.

Second choice:

I appoint , address ,

daytime phone , evening phone ,

Third choice:

I appoint , address ,

daytime phone , evening phone ,

My ability to revoke this document

I understand that I can revoke this document at any time and in any manner merely by expressing my intention to revoke it. This

can be done verbally or in writing. If I have given a copy of this document to a physician, my revocation will not be effective

as to that physician until the fact of my revocation is communicated to that physician (or the physician’s staff) by me or by a

witness to the revocation. I understand that if I execute a new durable power of attorney for health care, the new document will

automatically replace this one.

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 2 of 12

Expiration date

(Initial one)

This durable power of attorney for health care has no expiration date, and shall not be affected by my disability or by the

passage of time.

This durable power of attorney for health care shall expire at Midnight on the day of

20 , but otherwise is not affected by my disability or by the passage of time.

Severability

If a court ﬁ nds any provision of this document to be invalid or unenforceable, that provision shall be severed from this

document without affecting any other power or provision of this document, or the appointment of my agent to make health care

decisions for me.

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 3 of 12

II. Declaration of Treatment Instructions

You may provide your agent with speciﬁ c instructions about the choices you want made for you should this POA take effect.

If you do not instruct your agent, either in this document or otherwise, the agent will still make choices about your health care

and will decide based on your best interests. If you wish to provide instructions about your care to your agent, then ﬁ ll out those

sections of the form below that provide the direction you want to give. If you do not wish to provide instructions to your agent,

then go to the signature section at page 11 at the end of this document.

Attending physician

I name the following doctor as my “attending physician”. Under the law, this is the only physician who can make the

determination as to whether I have lost the capacity to make informed health care decisions for myself for the purpose of this

document.

Name: Phone:

Address:

Other physicians I choose to provide treatment to me

In addition to the attending physician named above, I prefer to be treated by the following doctors, and I instruct my agent to

request medical services for me from the following doctors:

Name: Phone:

Address:

Specialty (if any):

Name: Phone:

Address:

Specialty (if any):

I do not want to be treated by the following doctors, psychiatrists, or other mental health professionals, and I instruct my agent

not to consent to my treatment by these individuals:

Name: Phone:

Address:

Name: Phone:

Address:

Medical conditions

I may have the following medical condition(s), which may cause or contribute to, or may appear similar to, psychiatric

symptoms. I instruct that my agent have these medical conditions ruled out prior to authorizing psychiatric care or treatment.

These medical conditions are:

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 4 of 12

Medication

If my physician proposes that I be given medication, I instruct my agent to (choose one and initial):

consent to the medication proposed by my physician

consent to medication, except for , which I do not take because

(you may wish to explain why you do not wish to take this medication) .

not consent to any medications

(other) .

Allergies, other physical conditions, health problems, or medications that I want my agent to know about and consider before

giving informed consent to medication: .

I understand that, if I have instructed my agent not to consent to medication, and if I am involuntarily committed by a court

order, it is possible that someone may ﬁ le an application for forced medication with the probate court and request a court

hearing on the question of whether I need to be medicated by court order. If there is a court hearing on the question of whether

I am in need of medication, I instruct my agent to inform the court of my instructions as expressed in this document. However,

I understand that the court is not required to follow my wishes as expressed in this document.

Electroconvulsive therapy

Note that ECT is not available in any hospitals operated by the Ohio Department of Mental Health.

If my physician proposes that I be given electro-convulsive therapy (ECT), I instruct my agent to (choose one and initial):

not consent to ECT under any circumstances

consent to ECT only after all other treatment options have been tried without success

consent to ECT

(other) .

Restraint or seclusion

If it becomes necessary in the opinion of the hospital that I be placed in seclusion or restrained, either physically or chemically,

I instruct my agent to (choose one and initial):

notwithstanding any other instructions about medication in this document, consent to medication rather than allow me to

be placed in physical restraint

direct that I be secluded rather than medicated or restrained physically

consent only to such seclusion or restraint as are necessary to prevent me from harming myself or others, and this consent

should be withdrawn at the point where I am no longer at such risk

(other) .

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 5 of 12

Hospitalization

If it is determined that I need to be hospitalized, I instruct my agent as follows.

In a general medical hospital

If my physician determines that I need care or treatment in a general medical hospital, I instruct my agent to consent to my

admission to the following general medical hospital(s):

First Choice:

Second Choice:

I instruct my agent not to consent to my admission to the following general medical hospital(s):

In a psychiatric hospital (or licensed unit)

If my physician determines that I need care or treatment in a psychiatric hospital, I instruct my agent to consent to my admission

to the following psychiatric hospital(s):

First Choice: Second Choice:

I instruct my agent not to consent to my admission to the following psychiatric hospital(s):

I understand that, by instructing my agent not to consent to my voluntary admission to the psychiatric hospital(s) named above,

it is possible that someone may ﬁ le with the probate court an afﬁ davit of mental illness and request a court hearing on the

question of whether I need to be admitted to a psychiatric hospital by court order, and if so, to which hospital. If there is a court

hearing, I understand that the court is not required to follow my wishes as expressed in this document. If there is a court hearing

on the question of whether I am in need of psychiatric hospitalization, I instruct my agent to inform the court of my instructions

as expressed in this document.

Other directions to my agent

I instruct my agent to consider the following treatment preferences:

I do not want the following treatments, and I instruct my agent not to consent to them:

(Optional) The reason that I do not want these treatments is:

(initial) I wish to be treated by spiritual means through prayer alone, in accordance with a recognized religious method of

healing. The recognized religious method of healing is: .

I instruct my agent as follows concerning other medical or psychiatric care and treatment, or related issues:

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 6 of 12

Withdrawal of nutrition and hydration when in a permanently unconscious state (required by law to be in capital letters).

[ ] IF I HAVE MARKED THE FOREGOING BOX AND HAVE PLACED MY INITIALS ON THE LINE ADJACENT

TO IT, MY AGENT MAY REFUSE, OR IN THE EVENT TREATMENT HAS ALREADY COMMENCED, WITHDRAW

INFORMED CONSENT TO THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIED NUTRITION

AND HYDRATION IF I AM IN A PERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN

AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED ME DETERMINE, TO A REASONABLE DEGREE

OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT SUCH

NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO ME OR

ALLEVIATE MY PAIN.

Notiﬁ cation

If I am hospitalized, I request that my agent notify the following people of the fact of my hospitalization, and the hospital’s

name, address and telephone number (for example, family members, friends and employer):

Name:

, address ,

daytime phone , evening phone ,

Name: , address ,

daytime phone , evening phone ,

I instruct my agent not to contact the following people:

, , .

Nomination of Guardian

If I need a guardian, I would like the following person to become my guardian, and I make this nomination pursuant to Revised

Code Sec. 1337.09 and 2111.02. If there is a guardianship hearing, I instruct my agent to notify the court of my wishes, but I

understand that the court is not required to follow my wishes.

Name: , address ,

daytime phone , evening phone .

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 7 of 12

III. Principal’s Acknowledgement and Signature

If I have signed an earlier durable power of attorney for health care, it will be automatically revoked by this document. If I

have signed a declaration under Revised Code Chapter 2133 (commonly called a “Living Will”), it will not be revoked by this

document.

I understand that if I should execute a Declaration for Mental Health Treatment under Revised Code chapter 2135, that the

Declaration for Mental Health Treatment will revoke any provisions for mental health treatment previously stated in a Durable

Power of Attorney for Health Care. Any provisions previously stated in the Durable Power of Attorney for Health Care

speciﬁ cally for physical or medical (non-mental health) care will remain in effect.

I understand that I should give copies of this document to the agent and alternate agents I have named in this document. I

may also give a copy to my physician, psychiatrist, or other health care provider. However, I understand that if I give a copy

of this document to my physician or psychiatrist and later revoke this document, my revocation does not become effective as

to the physician or psychiatrist until I or a witness to the revocation notiﬁ es him/her (or his/her staff) that I have revoked this

document. I understand that both my revocation and notice of revocation to my physician or psychiatrist can be done either

verbally or in writing. However, it may be easier to prove I revoked it if I do so in writing.

I can make changes to this document before I sign it, and I agree to write my initials beside those changes. I understand that I

cannot make changes to this document after I have signed it. Instead I must execute a new document.

Ohio law requires that I be given the notice printed at the end of this document. I have read this notice before signing this

document.

I understand that this document will not be valid unless I sign it in the presence of either a notary public or two witnesses who

meet the law’s requirements.

THIS DURABLE POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS EITHER (1) SIGNED BY TWO

QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2)

ACKNOWLEDGED BEFORE A NOTARY PUBLIC.

I understand the terms and purpose of this document, and I sign my name after carefully considering this matter on this

day of 20 , at County, Ohio.

Signature of Principal Principal’s typed or printed name

Witnesses

I attest that the principal signed or acknowledged this Durable Power of Attorney for Health Care in my presence, that the

principal appears to be of sound mind and not subject to duress, fraud, or undue inﬂ uence. I also attest that I am not an agent

named 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 that I am an adult who is not related to the principal by blood, marriage or adoption.

Signature: Date:

Print name: Residence Address:

Signature: Date:

Print name: Residence Address:

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 8 of 12

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Notary Ackknowledgement

State of Ohio

County of __________________________ss:

On this the ________day of _____________________________, 20__,

______________________________________________, who is known to me or who has provided me with satisfactory proof

of identity as the person whose name is subscribed above as the principal, personally appeared before me and acknowledged

that s/he executed this document for the purposes described in the document. I attest that the principal appears to be of sound

mind and not under or subject to duress, fraud or undue inﬂ uence.

My Commission Expires:____________________

_______________________________________

Notary Public

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 9 of 12

IV. Statutory Notice

Ohio law requires Ohio Revised Code section 1337.17 (Use of printed form; notice to principle) to be included in all Durable

Power of Attorney for Health Care forms. The text of that statute follows:

1337.17. Use of printed form; notice to principal.

A printed form of durable power of attorney for health care may be sold or otherwise distributed in this state for use by adults

who are not advised by an attorney. By use of such a printed form, a principal may authorize an attorney in fact to make health

care decisions on the principal’s behalf, but the printed form shall not be used as an instrument for granting authority for any

other decisions. Any printed form that is sold or otherwise distributed in this state for the purpose described in this section shall

include the following notice:

Notice to Adult Executing This Document (R.C. Sec.1337.17)

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 speciﬁ c limitations in this document on the authority of the attorney in fact to make health care decisions for

you.

Subject to any speciﬁ c 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.

(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);

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 10 of 12

DURABLE POWER OF ATTORNEY FOR HEALTH CARE Page 11 of 12

(2) Refuse or withdraw informed consent to health care necessary to provide you with comfort care (except that, if he 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.

(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.

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

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