Fillable Part I. Durable Power of Attorney for Health

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Part I. Durable Power of Attorney for Health

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7.
Part I. Durable Power of Attorney for Health Care
• If you do NOT wish to name an agent to make health care decisions for you,
write your initials in the box to the right and got to Part II.
Initials
This form has been prepared to comply with the “Durable Power of Attorney for Health Care
Act” of Missouri.
1. Selection of Agent. I appoint:
Name: ______________________________________
Address: ____________________________________
____________________________________________
Telephone: ___________________________________
as my Agent.
2. Alternate Agents. Only an Agent named by me may act under this Durable Power of Attorney.
If my Agent resigns or is not able or available to make health care decisions for me, of if an Agent
named by me is divorced from me or is my spouse and legally separated from me, I appoint the
person(s) named below (in the order named if more than one):
First Alternate Agent Second Alternate Agent
Name: ___________________________________ Name: _______________________________
Address: _________________________________ Address: _____________________________
_________________________________________ ____________________________________
Telephone: ________________________________ Telephone: ___________________________
It is suggested that only one
Agent be named. However,
if more than one Agent is
named, any one may act
individually unless you
specify otherwise.
THIS IS A DURABLE POWER OF ATTORNEY, AND THE AUTHORITY
OF MY AGENT, WHEN EFFECTIVE, SHALL NOT TERMINATE OR BE VOID OR
VOIDABLE IF I AM OR BECOME DISABLED OR INCAPACITATED OR IN THE
EVENT OF LATER UNCERTAINTY AS TO WHETHER I AM DEAD OR ALIVE.
8.
Instructions for Completing Part I. (Continued)
In Section 3 Effective Date and Durability the form lets you choose whether one or two doctors
need to certify that you are incapacitated. Incapacitated means that you are no longer able to
make decisions for yourself and it is time for your agent to act.
Choose whether you want one or two physicians to decide whether you are incapacitated.
If you want two doctors to decide that you are incapacitated, do not write anything in this section.
If you want one doctor to decide that you are incapacitated, write your initials in the shaded box
above the line that says “initials” to the right of the statement “If you want one physician instead
of two to decide whether you are incapacitated, write your initials in the box to the right.” that is
found in Section 3.
In Section 4 Agent’s Powers you decide whether or not your agent can make decisions concern-
ing withholding or withdrawing artificially supplied nutrition and hydration. Please indicate your
decision in the space provided.
9.
Part I. Durable Power of Attorney for Health Care
(Continued)
3. Effective Date and Durability. This Durable Power of Attorney is effective when two physi-
cians decide and certify that I am incapacitated and unable to make and communicate a health
care decision.
• If you want ONE physician, instead of TWO, to decide whether you are
incapacitated, write your initials in the box to the right.
4. Agent’s Powers. I grant to my Agent full authority to:
A. Give consent to, prohibit or withdraw any type of health care, medical care, treatment or
procedure, even if my death may result.
• If you wish to AUTHORIZE your Agent to direct a health care
provider to withhold or withdraw artificially supplied nutrition
and hydration (including tube feeding of food and water), write
your initials in the box to the right.
• If you DO NOT WISH TO AUTHORIZE your Agent to direct
a health care provider to withhold or withdraw artificially supplied
nutrition and hydration, (including tube feeding of food and water),
write your initials in the box to the right.
B. Make all necessary arrangements for health care services on my behalf, and to hire and
fire medical personnel responsible for my care;
C. Move me into or out of any health care facility (even if against medical advice) to obtain
compliance with the decisions of my Agent; and
D. Take any other action necessary to do what I authorize here, including (but not limited
to) granting any waiver or release from liability required by any health care provider, and taking
any legal action at the expense of my estate to enforce this Durable Power of Attorney.
5. Agent’s Financial Liability and Compensation. My Agent acting under this Durable Power
of Attorney will incur no personal financial liability. My Agent shall not be entitled to compensa-
tion for services performed under this Durable Power of Attorney, but my Agent shall be entitled
to reimbursement for all reasonable expenses incurred as a result of carrying out any provision
hereof.
Initials
Initials
Initials
10.
Instruction for Completing Part II.
Health Care Directive
If you decide not to complete the Health Care Directive (Part II), write your initials above the line
that says “initials” in the shaded box which appears below the words “Part II. Health Care
Directive”.
If you decide to complete the Health Care Directive (Part II), please follow the instructions be-
low:
DO NOT initial the shaded box below the words “Part II. Health Care Directive”.
Read the Directive Carefully.
Review the list of life-prolonging procedures and decide which, if any, of these procedures you
would like to have withheld or withdrawn. Write your initials next to each procedure you want to
be withheld or withdrawn if you are persistently unconscious or there is no reasonable expecta-
tion of your recovery from a seriously incapacitating or terminal illness or condition.
11.
Part II. Health Care Directive
• If you DO NOT WISH to make a health care directive, write your
initials in the box to the right, and go to Part III.
I make this HEALTH CARE DIRECTIVE (“Directive”) to exercise my right to determine the
course of my health care and to provide clear and convincing proof of my wishes and instructions
about my treatment.
If I am persistently unconscious or there is no reasonable expectation of my recovery from a
seriously incapacitating or terminal illness or condition, I direct that all of the life-prolonging
procedures that I have initialled below be withheld or withdrawn.
I want the following life-prolonging procedures to be withheld or withdrawn:
• artificially supplied nutrition and hydration (including tube feeding of
food and water) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• surgery or other invasive procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• heart-lung resuscitation (CPR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• antibiotic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• mechanical ventilator (respirator) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• radiation therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• all other “life-prolonging” medical or surgical procedures that are merely
intended to keep me alive without reasonable hope of improving my
condition or curing my illness or injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
However, if my physician believes that any life-prolonging procedure may lead to a significant
recovery, I direct my physician to try the treatment for a reasonable period of time. If it does not
improve my condition, I direct the treatment be withdrawn even if it shortens my life. I also direct
that I be given medical treatment to relieve pain or to provide comfort, even if such treatment
might shorten my life, suppress my appetite or my breathing, or be habit-forming.
IF I HAVE NOT DESIGNATED AN AGENT IN THE DURABLE POWER OF ATTORNEY, THIS
DOCUMENT
IS MEANT TO BE IN FULL FORCE AND EFFECT AS MY
HEALTH CARE DIRECTIVE.
Initials
Initials
Initials
Initials
Initials
Initials
Initials
Initials
Initials
Initials
12.
Instructions for Completing Part III.
General Provisions Included in the Directive and
Durable Power of Attorney
Part III. must be completed for the Durable Power of Attorney for Health
Care (Part I) and the Health Care Directive (Part II) to be effective. Please see
the instructions on the back of the following page.
13.
Part III. General Provisions Included in the Directive
and Durable Power of Attorney
1. Relationship Between Directive and Durable Power of Attorney. If I have executed the
Directive and the Durable Power of Attorney, I encourage my Agent to follow my wishes as
expressed in the Directive in making decisions regarding life-prolonging procedures. However, I
have confidence in my Agent’s ability to make decisions in my best interest, and I authorize my
Agent to make decisions that are contrary to my Directive in his or her best judgment. If the
Durable Power of Attorney is somehow determined to be ineffective, or if my Agent is not able to
serve, the Directive is intended to be used on its own as firm instructions to my health care
providers regarding life-prolonging procedures.
2. Protection of Third Parties Who Rely on My Agent. No person who relies in good faith
upon any representations by my Agent or Alternate Agent shall be liable to me, my estate, my
heirs or assigns, for recognizing the Agent’s authority.
3. Revocation of Prior Directive or Durable Power of Attorney. I revoke any prior LIVING
WILL, Declaration or Health Care Directive executed by me. If I have appointed an Agent in a
prior durable power of attorney, I revoke any health care terms contained in that durable power of
attorney.
4. Validity. This document is intended to be valid in any jurisdiction in which it is presented. The
provisions of this document are separable, so that the invalidity of one or more provisions shall
not affect any others. A copy of this document shall be as valid as the original.
14.
Instructions for Completing Part III. (Continued)
Part III must be completed for the Durable Power of Attorney for Health Care (Part I) and the
Health Care Directive (Part II) to be effective. Please follow the instructions below:
Sign and date in the space provided. Please print your name and address under the signature
line.
Have two witnesses sign and write in their addresses on the lines provided.
If you have completed the Durable Power of Attorney for Health Care (Part I.), you will need
to sign the form in the presence of a notary public who will then complete the notary block. You
will also need to have two witnesses sign the form.
15.
Part III. General Provisions included in the Directive
and Durable Power of Attorney (Continued)
YOU MUST SIGN THIS DOCUMENT IN THE PRESENCE OF TWO WITNESSES.
IN WITNESS WHEREOF, I have executed this document this ______ day of
______________________(month), ______(year).
________________________________________
Signature
Print Name ________________________________________
Address ________________________________________
________________________________________
The person who signed this document is of sound mind and voluntarily signed this document
in our presence. Each of the undersigned witnesses is at least eighteen years of age.
Signature ____________________________ Signature ___________________________
Print Name___________________________ Print Name _________________________
Address ____________________________ Address ____________________________
____________________________ _____________________________
ONLY REQUIRED FOR PART I — DURABLE POWER OF ATTORNEY
STATE OF MISSOURI )
)SS
COUNTY OF _______________ )
On this ______ day of _________________ (month), ______ (year), before me personally
appeared ______________________________________, to me known to be the person described
in and who executed the foregoing instrument and acknowledged that he/she executed the same
as his/her free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the
County of ______________________, State of Missouri, the day and year first above written.
___________________________________
Notary Public
My Commission Expires:
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Ordering Information
Additional copies of this form are available at courthouses, libraries, and University of Missouri
Extension Centers across Missouri at no charge. The form may be photocopied for use by addi-
tional persons. The form may also be ordered directly from The Missouri Bar. Single copies of
the form are available from The Missouri Bar at no charge. However, a charge has been placed on
multiple copies in order to cover the costs of printing, handling and postage. A check or money
order for the correct amount must be sent to The Missouri Bar before multiple copies of the form
may be mailed.
To order multiple copies of the form, refer to the pricing chart below.
PRICE CHART
Single copies No charge
Additional copies 75 cents per copy
Please send a written request for the number of copies you desire, along with a check or money
order for the correct amount, to:
Health Care Proxy Form
The Missouri Bar
P.O. Box 119
Jefferson City, MO 65102-0119
. . . . . From The Missouri Bar To You
This health care decisions form has been developed as a project of The Missouri
Bar, the statewide association for all lawyers. Working for the public good, The Mis-
souri Bar strives to improve the law and the administration of justice.
Revised October, 1998 and reprinted September, 2000
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Part I. Durable Power of Attorney for Health

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Completed 21 May 2021

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