Chapter 2: Estate Planning: Documents

Chapter 2a Table of Contents Chapter 3

TEXAS DURABLE POWER OF
ATTORNEY FOR HEALTH CARE*

*The Texas Durable Power of Attorney for Health Care, the New York Health Care Proxy, and the Florida Living Will are all reprinted by permission of Choice In Dying, 200 Varick Street, New York, NY 10014. Anyone who wishes further information about materials and services related to end-of-life medical care can contact the organization at the address noted or at (212)366-5540.

Information Concerning the Durable Power of Attorney for Health Care

This is an important legal document. Before signing this document, you should know these important facts:

Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself. Because "health care" means any treatment, service, or procedure to maintain, diagnose, or treat your physical or mental condition, your agent has the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment. Your agent may not consent to voluntary inpatient mental health services, convulsive treatment, psychosurgery, or abortion. A physician must comply with your agent’s instructions or allow you to be transferred to another physician.

Your agent’s authority begins when your doctor certifies that you lack the capacity to make health care decisions.

Your agent is obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent has the same authority to make decisions about your health care as you would have had.

It is important that you discuss this document with your physician or other health care provider before you sign it to make sure that you understand the nature and range of decisions that may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgeable about these issues and can answer your questions. You do not need a lawyer’s assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.

The person you appoint as agent should be someone you know and trust. The person must be 18 years of age or older or a person under 18 years of age who has had the disabilities of minority removed. If you appoint your health or residential care provider (e.g., your physician or an employee of a home health agency, hospital, nursing home, or residential care home, other than a relative), that person has to choose between acting as your agent or as your health or residential care provider; the law does not permit a person to do both at the same time.

TEXAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE—PAGE 2 OF 6

You should inform the person you appoint that you want the person to be your health care agent. You should discuss this document with your agent and your physician and give each a signed copy. You should indicate on the document itself the people and institutions who have signed copies. Your agent is not liable for health care decisions made in good faith on your behalf.

Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing your agent of your health or residential care provider orally or in writing, or by your execution of a subsequent durable power of attorney for health care. Unless you state otherwise, your appointment of a spouse dissolves on divorce.

This document may not be changed or modified. If you want to make changes in the document, you must make an entirely new one.

You may wish to designate an alternate agent in the event that your agent is unwilling, unable, or ineligible to act as your agent. Any alternate agent you designate has the same authority to make health care decisions for you.

This power of attorney is not valid unless it is signed in the presence of two or more qualified witnesses. The following persons may not act as witnesses:

(1) the person you have designated as your agent;

(2) your health or residential care provider or an employee of your health or residential

care provider;

(3) your spouse;

(4) your lawful heirs or beneficiaries named in your will or a deed; or

(5) creditors or persons who have a claim against you.

TEXAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE - PAGE 3 OF 6

INSTRUCTIONS

TEXAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE

DESIGNATION OF HEALTH CARE AGENT.

PRINT YOUR NAME

I,

(name)
appoint:

PRINT THE NAME, ADDRESS AND HOME AND WORK TELEPHONE NUMBERS OF YOUR AGENT

(name of agent)

(address)

(work telephone number) (home telephone number)

as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. This durable power of attorney for health care takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician.

STATE LIMITATIONS ON YOUR AGENT’S POWER (IF ANY)

LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS.

TEXAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE - PAGE 4 OF 6

PRINT THE NAME, ADDRESS AND HOME AND WORK TELEPHONE NUMBERS OF YOUR FIRST AND SECOND ALTERNATE AGENTS

DESIGNATION OF ALTERNATE AGENT.

( You are not required to designate an alternate agent but you may do so. An alternate agent may make the same health care decisions as the designated agent if the designated agent is unable or unwilling to act as your agent. If the agent designated is your spouse, the designation is automatically revoked by law if your marriage is dissolved.)

If the person designated as my agent is unable or unwilling to make health care decisions for me, I designate the following persons to serve as my agent to make health care decisions for me as authorized by this document, who serve in the following order:

FIRST ALTERNATE

A. First Alternate Agent

(name of first alternate agent)

(home address)

(work telephone number) (home telephone number)

SECOND ALTERNATE

B. Second Alternate Agent

(name of second alternate agent)

(home address)

(work telephone number and home telephone number)

LOCATION OF ORIGINAL

The original of this document is kept at:

TEXAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE - PAGE 5 OF 6

LOCATION OF COPIES
The following individuals or institutions have signed copies:

Name:

Address:

Name:

Address:

DURATION.

I understand that this power of attorney exists indefinitely from the date I execute this document unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent continues to exist until the time I become able to make health care decisions for myself.

EXPIRATION DATE (IF ANY)
(IF APPLICABLE) This power of attorney ends on the following date:

PRIOR DESIGNATIONS REVOKED.

I revoke any prior power of attorney for health care.

ACKNOWLEDGMENT OF DISCLOSURE STATEMENT.

I have been provided with a disclosure statement explaining the effect of this document. I have read and understood that information contained in the disclosure statement.

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)

PRINT THE DATE

I sign my name to this durable power of attorney for health care on

(date)

PRINT YOUR LOCATION

day of
19
, at
.

(month)
(city and state)

SIGN THE DOCUMENT

(signature)

PRINT YOUR NAME

(print name)

TEXAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE - PAGE 6 OF 6

WITNESSING PROCEDURE

YOUR TWO WITNESSES MUST SIGN AND DATE YOUR DOCUMENT BELOW

THEY MUST ALSO PRINT THEIR NAMES AND ADDRESSES

STATEMENT OF WITNESSES.

I declare under penalty of perjury that the principal has identified himself or herself to me, that the principal signed or acknowledged this durable power of attorney in my presence, that I believe the principal to be of sound mind, that the principal has affirmed that the principal is aware of the nature of the document and is signing it voluntarily and free from duress, that the principal requested that I serve as witness to the principal’s execution of this document, that I am not the person appointed as agent by this document, and that I am not a provider of health or residential care, an employee of a provider of health or residential care, the operator of a community care facility, or an employee of an operator of a health care facility.

I declare that I am not related to the principal by blood, marriage, or adoption and that to the best of my knowledge I am not entitled to any part of the estate of the principal on the death of the principal under a will or by operation of law.

WITNESS #1

Witness Signature:

Print Name:
Date:

Address:

WITNESS #2

Witness Signature:

Print Name:
Date:

Address:

INSTRUCTIONS

NEW YORK HEALTH CARE PROXY

PRINT YOUR NAME

(1) I,
, hereby appoint:

PRINT YOUR NAME

PRINT NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR AGENT

(name, home address and telephone number of agent)

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.

This Health Care Proxy shall take effect in the event I become unable to make my own health care decisions.

ADD PERSONAL INSTRUCTIONS (IF ANY)

(2) Optional instructions: I direct my agent to make health care decisions in accord with my wishes and limitations as stated below, or as he or she otherwise knows.

(Unless your agent knows your wishes about artificial nutrition and hydration [feeding tubes], your agent will not be allowed to make decisions about artificial nutrition and hydration.)

NEW YORK HEALTH CARE PROXY - PAGE 2 OF 2

PRINT NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR ALTERNATE AGENT

(3) Name of substitute or fill-in agent if the person I appoint above is unable, unwilling or unavailable to act as my health care agent.

(name, home address and telephone number of alternate agent)

ENTER A DURATION OR A CONDITION
(IF ANY)

(4) Unless I revoke it, this proxy shall remain in effect indefinitely, or until the date or condition I have stated below. This proxy shall expire (spcific date or conditions, if desired):

SIGN AND DATE THE DOCUMENT AND PRINT YOUR ADDRESS

(5) Signature
Date

Address

WITNESSING PROCEDURE

YOUR WITNESSES MUST SIGN AND PRINT THEIR ADDRESSES

Statement by Witnesses (must be 18 or older)

I declare that the person who signed this document appeared to execute the proxy willingly and free from duress. He or she signed (or asked another to sign for him or her) this document in my presence. I am not the person appointed as proxy by this document.

Witness 1

Address

Witness 2

Address

INSTRUCTIONS

Florida Living Will

PRINT THE DATE

Declaration made this
day of
, 19
.

PRINT YOUR NAME

I,_________________________________________________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare:

If at any time I have a terminal condition and if my attending or treating physician and another consulting physician have determined that there is no medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:

PRINT THE NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR SURROGATE

Name:

Address:

Zip Code:

Phone:

FLORIDA LIVING WILL - PAGE 2 OF 2

PRINT NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR ALTERNATE SURROGATE

I wish to designate the following person as my alternate surrogate, to carry out the provisions of this declaration should my surrogate be unwilling or unable to act on my behalf:

Name:

Address:

Zip Code:

Phone:

ADD PERSONAL INSTRUCTIONS (IF ANY)

Additional instructions (optional):

I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.

SIGN THE DOCUMENT

Signed:

WITNESSING PROCEDURE

Witness 1:

     Signed:

     Address:

TWO WITNESSES MUST SIGN AND PRINT THEIR ADDRESSES

Witness 2:

     Signed:

     Address:

EXHIBIT 1*Organ Donor Declaration

This is to inform you that I want to be an organ and tissue donor if the occasion ever arises. Please see that my wishes are carried out by informing the attending medical personnel that I am a donor. My desires are indicated below:

In the hopes that I may help others, I hereby make this gift for the purpose of transplant, medical study, or education, to take effect upon my death. I give:

/      / Any needed organs/tissues

/      / Only the following organs/tissues

Specify the organ(s)/tissue(s)

Limitation or special wishes, if any

This is a legal document under the Uniform Anatomical Gift Act or similar laws, signed by the donor and the following two witnesses in the presence of each other.

Donor’s signature

Donor’s date of birth City and state

Witness Witness

Next of kin Telephone

* Reprinted with permission of Warren, Gorham & Lamont of the RIA Group.

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