********************* ********************* ** ** ** WARNING ** ** ** ********************* ********************* TO ANY PERSON EXECUTING A DURABLE POWER OF ATTORNEY THIS IS NOT A TRIVIAL MATTER. This is an IMPORTANT LEGAL DOCUMENT. It creates a durable power of attorney for health care. Before executing this document, you should know these important facts: 1. This document gives the person you designate as your attorney-in-fact the power to make health care decisions for you, subject to any limitations or statement of your demands that you include in this document. The power to make health care decisions for you may include consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. You may state in this document any types of treatment or placements that you do not desire. 2. The person you designate in this document has a duty to act consistently with your demands as stated in this document or otherwise made known or, if your demands are unknown, to act in your best interests. 3. Except as you other wise specify in this document, the power of the person you designate to make health care decisions for you may include the power to consent to your doctor not giving treatment or stopping treatment which would keep you alive. 4. Unless you specify a shorter period in this document, this power will exist for Seven Years from the date you execute this document and, if you are unable to make health care decisions for yourself at the time when this seven-year period ends, this power will continue to exist until the time when you become able to make health care decisions for yourself. 5. Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped if you object. 6. You have the right to revoke the designation of the person named in this document by notifying that person of the revocation orally or in writing. 7. You have the right to revoke the authority granted to the person designated in this document to make health care decisions for you by notifying the treating physician, hospital, or other health care provider orally or in writing. 8. The person designated in this document to make health care decisions for you has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document. 9. If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. This power of attorney will not be valid for making health care decisions unless it is either (1) signed by two qualified witnesses who are personally known to you and who are present when you sign or acknowledge your signature or (2) acknowledged before a notary public in California. A DURABLE POWER OF ATTORNEY FOR HEALTH CARE To my family, relatives, my friends, my physicians, health care providers, community care facilities, and any other person who may have an interest or duty: I, (name), of (address), City of (city), County of (county), State of (state), being of sound mind, freely, willfully, and voluntarily hereby appoint (name of person), of (address), City of (city), County of (county), State of (state), as my attorney-in-fact/proxy to make health care decisions in my stead and behalf. He/she is not a treating health care provider nor an employee of such, nor is he/she an operator of a community health care facility which is treating me, or an employee of such, nor is he/she conservator of my person or estate; and I hereby request that he/she never be appointed such a conservator. In the event that (name) is unable or unwilling to serve at my attorney-in- fact for the purpose of making health care decisions for me, I designate (name of alternate) of (address), City of (city), County of (county), State of (state), to serve as my attorney-in-fact. At any time that I should for any reason be unable to make such decisions for myself, I hereby authorize (name) my attorney-in-fact, to make any decisions I otherwise could make involving consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat me for any physical or mental condition whatever, except for commitment to or placement in a mental health treatment facility, convulsive treatment, psychosurgery, sterilization, or abortion. This appointment shall have no legal force or effect after expiration of seven years from the date of its execution. It shall have no effect if I revoke it by giving notice of such revocation either orally or in writing. This document revokes any prior Durable Power of Attorney for Health Care. SPECIAL PROVISIONS AND LIMITATIONS ************************************************************************* If there is any type of treatment or placement that you do not want your attorney-in-fact to consent to or other restrictions you want to place on his/her authority, you should list them in the space below. If you do not write in any limitations, your attorney-in-fact will have the broad powers to make health care decisions on your behalf which are included above. *************************************************************************** In exercising authority under this Durable Power of Attorney, the authority of my attorney-in-fact is limited as stated below: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ STATEMENT OF DEMANDS *************************************************************************** Your attorney-in-fact must make decisions consistent with your known demands. You may, BUT ARE NOT REQUIRED TO, indicate your demands below. If your demands are unknown, he/she must act in your best interests. A judicial proceeding may be necessary to determine what is in your best interests. To reduce the risk of the need for court proceedings, you may want to initial the statement or statements below that reflect your demands and/or write your own statements in the space below. *************************************************************************** 1. I desire that my life be prolonged to the greatest extent possible, without regard to my condition, the chances I have for recovery or long term survival, or the cost of the procedures. ( Yes _____ No _____ ) 2. If I am in a coma, which my doctors have reasonably concluded is irreversible, I demand that life-sustaining or prolonging treatments or procedures NOT be used. ( Yes _____ No _____ ) 3. If I have an incurable or terminal condition or illness and no reasonable hope of long term recovery or survival, I demand that life sustaining or prolonging treatments NOT be used. ( Yes _____ No _____ ) 4. If deciding any questions under this document, my attorney-in-fact is to consider the relief of suffering, the preservation or restoration of functioning, and the quality as well the possible extension of my life. ( Yes _____ No _____ ) OTHER OR ADDITIONAL STATEMENTS OF DEMANDS ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ **************************************************************************** BEFORE SIGNING THIS DOCUMENT, YOU MUST READ THE "WARNING" THAT PRECEDES IT. IT IS PRINTED IN FULL AT THE START OF THIS DOCUMENT. **************************************************************************** ______________________________ ____________________ (Name) Date WITNESS SIGNATURES Under penalty of perjury under the laws of (state), I hereby declare that the principal who signed or acknowledged this Durable Power of Attorney for Health Care Decisions in my presence is known to me personally; that he/she appears to be of sound mind and to be under no duress, fraud, or undue influence; that I am not the person designated as attorney-in-fact by this document; that I am not a health care provider, an employee of a health care provider, the operator of a community care facility, nor an employee of a community care facility. I am not related to the principal by blood, marriage, or adoption; and to the best of my knowledge, I am not entitled to any part of the estate of the principal upon his/her death either under a will now existing, by a revocable living trust now existing, nor by operation of law. **************************************************************************** Under California law, only one witness is required to sign this document. However, it is advisable that two witnesses sign it. **************************************************************************** ______________________________ ______________________________ Witness One Date ______________________________ ______________________________ Witness Two Date SPECIAL REQUIREMENTS ***************************************************************************** For patients in a skilled nursing facility in the state of California. ***************************************************************************** The principal is a patient in a skilled nursing facility in California as defined in subdivision (c) of Section 1250 of the Health and Safety Code of California at the time he/she executed this document. Therefore, and in order to make it legally effective in California (or other state), I, (full legal name of witness), ("a patient-advocate" or "an ombudsman") as designated by the State Department of Aging or other duly authorized person, am serving as a witness pursuant to Section 2432 (f) of the California Civil Code. ************************************************************************** If not a resident of California, strike out either term "patient-advocate" or "ombudsman" or enter an appropriate alternative term. Additionally alter the previous paragraph as necessary. Although any other state may have no such requirement, it can do no harm to take the precaution of having the additional witness described in the previous paragraph. ************************************************************************** I declare under the penalty of perjury under the laws of California that I am not the person designated as attorney-in-fact/proxy by this document; that I am not a health care provider, an employee of a health care provider, the operator of a community care facility, nor an employee of a community care facility; that I am not related to the principal by blood, marriage, or adoption; and to the best of my knowledge I am not entitled to any part of the estate of the principal under a will now existing, a revocable living trust now existing, nor by operation of law. ______________________________ ______________________________ Witness Date Sworn to and subscribed before me this (day) day of (month), 19(year). My commission expires: _________________________ Notary Public _________________________ Date