Taking Care of Mom and Dad: Sample Health Care Power of Attorney
I, [YOUR PARENT'S FULL NAME], am of sound mind, and I voluntarily make this designation.
I designate [AGENT'S FULL NAME], my [DESCRIPTION OF RELATIONSHIP TO YOUR PARENT] living at [AGENT'S FULL ADDRESS], as my patient advocate to make care, custody and medical treatment decisions for me in the event I become unable to participate in medical treatment decisions. If my first choice cannot serve, I designate [SUCCESSOR'S NAME], living at [SUCCESSOR'S ADDRESS], to serve as patient advocate.
The determination of when I am unable to participate in medical treatment decisions shall be made by my attending physician and another physician or licensed psychologist.
In making decisions for me, my patient advocate shall follow my wishes of which he or she is aware, whether expressed orally, in a living will, or in this designation.
My patient advocate has authority to consent to or refuse treatment on my behalf, to arrange medical services for me, including admission to a hospital or nursing care facility, and to pay for such services with my funds. My patient advocate shall have access to any of my medical records to which I have a right.
I expressly authorize my patient advocate to make decisions to withhold or withdraw treatment which would allow me to die and I acknowledge such decisions could or would allow my death.
My specific wishes concerning health care are the following: (if none, write "none")
I may change my mind at any time by communicating in any manner that this designation does not reflect my wishes.
It is my intent that my family, the medical facility, and any doctors, nurses and other medical personnel involved in my care shall have no civil or criminal liability for honoring my wishes as expressed in this designation or for implementing the decisions of my patient advocate.
Photostatic copies of this document, after it is signed and witnessed, shall have the same legal force as the original document.
I sign this document after careful consideration. I understand its meaning and I accept its consequences.
[DATE]
[YOUR PARENT'S SIGNATURE]
[YOUR PARENT'S FULL ADDRESS]
STATEMENT OF WITNESSES
We sign below as witnesses. This declaration was signed in our presence. The declarant appears to be of sound mind, and to be making this designation voluntarily, without duress, fraud or undue influence.
[WITNESS' SIGNATURE] [WITNESS' FULL LEGAL NAME] [WITNESS' FULL ADDRESS] [WITNESS' SIGNATURE] ACCEPTANCE BY PATIENT ADVOCATE
(A) This designation shall not become effective unless the patient is unable to participate in treatment decisions.
(B) A patient advocate shall not exercise powers concerning the patient's care, custody and medical treatment that the patient, if the patient were able to participate in the decision, could not have exercised in his or her own behalf.
(C) This designation cannot be used to make a medical treatment decision to withhold or withdraw treatment from a patient who is pregnant that would result in the pregnant patient's death.
(D) A patient advocate may make a decision to withhold or withdraw treatment which would allow a patient to die only if the patient has expressed in a clear and convincing manner that the patient advocate is authorized to make such a decision, and that the patient acknowledges that such a decision could or would allow the patient's death.
(E) A patient advocate shall not receive compensation for the performance of his or her authority, rights, and responsibilities, but a patient advocate may be reimbursed for actual and necessary expenses incurred in the performance of his or her authority, rights, and responsibilities.
(F) A patient advocate shall act in accordance with the standards of care applicable to fiduciaries when acting for the patient and shall act consistent with the patient's best interests. The known desires of the patient expressed or evidenced while the patient is able to participate in medical treatment decisions are presumed to be in the patient's best interests.
(G) A patient may revoke his or her designation at any time or in any manner sufficient to communicate an intent to revoke.
(H) A patient advocate may revoke his or her acceptance to the designation at any time and in any manner sufficient to communicate an intent to revoke.
(I) A patient admitted to a health facility or agency has the rights enumerated in Section 20201 of the Public Health Code, Act No. 368 of the Public Acts of 1978, being section 333.20201 of the Michigan Compiled Laws.
I understand the above conditions and I accept the designation as patient advocate for [YOUR PARENT'S FULL NAME]. [DATE] [AGENT'S SIGNATURE]
