Michigan Durable Power of Attorney for Health Care

I, ________________________________________, am of sound mind and I voluntarily

(Print or type your full name)

make this designation.

APPOINTMENT OF PATIENT ADVOCATE

I designate ___________________________, my _________________________, living

(Insert name of patient advocate) (Spouse, child, friend)

at ____________________________________________________________________

(Address of patient advocate)

as my patient advocate.

If my first choice cannot serve, I designate the person listed below as my patient advocate:

Successor Patient Advocate

Name: ______________________________

Address: _____________________________

Telephone

Number: ______________________________

My patient advocate or successor patient advocate must sign an acceptance before he or she can act. The acceptance form is included at the end of this document.
GENERAL POWERS OF PATIENT ADVOCATE

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 durable power of attorney for health care.

My patient advocate or successor patient advocate shall have power to make care, custody, and medical treatment decisions for me if my attending physician and another physician or licensed psychiatrist or psychologist determine I am unable to participate in medical treatment decisions.

My patient advocate has authority to consent to or to refuse treatment on my behalf, to arrange medical and personal services for me, including admission to a nursing 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, immediately upon signing an Acceptance. This shall serve as a release under the Health Insurance Portability and Accountability Act.

Immediately upon signing an Acceptance, my patient advocate shall have access to my birth certificate and other legal documents needed to apply for Medicare, Medicaid, and other governmental programs.

STATEMENT OF WISHES

My patient advocate has authority to make decisions on a wide variety of circumstances. In this section, I can express general wishes regarding conditions such as terminal illness, permanent unconsciousness, or other disability; specify particular types of treatment I do not want in such circumstances; or I may state no wishes at all. If I have chosen to give my patient advocate power concerning mental health treatment, I may also include specific wishes about mental health treatment such as a preferred mental health professional, hospital, or medication.

My specific wishes concerning health care and/or medical care are the following:

____________________________________________________________________

I choose not to express any wishes in this document. This choice shall not be interpreted as limiting the power of my patient advocate to make any particular decision in any particular circumstance.

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 no one involved in my care shall be liable for honoring my wishes as expressed in this designation or for following the directions of my patient advocate.

Photocopies of this document can be relied upon as though they were originals.

____________________________________________________________________

SPECIFIC INSTRUCTIONS REGARDING LIFE-SUSTAINING TREATMENT

I understand that I do not have to choose one of the instructions regarding life sustaining treatment listed below. If I choose one, I will sign below my choice.

Choice 1. I do not want my life to be prolonged by providing or continuing life-sustaining treatment if any of the following medical conditions exist:

I am in an irreversible coma or persistent vegetative state,

I am terminally ill and life-sustaining procedures would serve only to artificially delay my death,

Under any circumstances where my medical condition is such that the burdens of treatment outweigh the expected benefits. In weighing the burdens and benefits, I want my patient advocate to consider the relief of suffering and the quality of my life as well as the extent of possibility of prolonging my life.

I understand that this decision could or would allow me to die.

____________________Sign here if this statement reflects your desires.

Choice 2. I want my life to be prolonged by life-sustaining treatment unless I am in a coma or vegetative state which my doctor reasonably believes to be irreversible. Once my doctor has reasonably concluded that I will remain unconscious for the rest of my life, I do not want life-sustaining treatment to be provided or continued.

I understand that this decision could or would allow me to die.

____________________Sign here if this statement reflects your desires.

Choice 3. I want my life to be prolonged to the greatest extent possible consistent with sound medical practice without regard to my condition, the chances I have for recovery, or the cost of my care, and I direct life-sustaining treatment be provided in order to prolong my life.

____________________Sign here if this statement reflects your desires.

SIGNATURE

I sign this document voluntarily, and I understand its purpose.

Dated: __________

Signed: ____________________________

Address: ___________________________

___________________________

____________________________________________________________________

NOTICE REGARDING WITNESSES

You must have two adult witnesses who should be disinterested individuals, and must not be your spouse, parent, child, grandchild, sibling, presumptive heir, physician, patient advocate, an employee of your life or health insurance provider, an employee of a health facility that is treating your, or an employee of a home for the aged where you reside.

STATEMENT AND SIGNATURE OF WITNESSES

We sign below as witnesses. This declaration was voluntarily signed in our presence. The declarant appears to be of sound mind, and to be making this designation voluntarily, and under no duress, fraud, or undue influence.

______________________________, ______________________________

(Signature) ______________________________

(Address)

______________________________

(Print Name)

Dated: ________________________

______________________________, ______________________________

More on this topic

(Signature) ______________________________

(Address)

______________________________

(Print Name)

Dated: ________________________

ACCEPTANCE BY PATIENT ADVOCATE

This designation shall not become effective unless the patient is unable to participate in decisions regarding the patient's medical or mental health, as applicable. If this patient advocate designation includes the authority to make an anatomical gift as described in section 5506, the authority remains exercisable after the patient's death.

A patient advocate shall not exercise powers concerning the patient's care, custody, and medical or mental health treatment that the patient, if the patient were able to participate in the decision, could not have exercised in his or her own behalf.

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 I the pregnant patient's death.

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.

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.

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 or mental health treatment decisions are presumed to be in the patient's best interest.

A patient may revoke his or her designation at any time or in any manner sufficient to communicate an intent to revoke.

A patient may waive his or her right to revoke the patient advocate designation as to the power to make mental health treatment decisions, and if such waiver is made, his or her ability to revoke as to certain treatment will be delayed for 30 days after the patient communicates his or her intent to revoke.

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.

A patient admitted to a health facility 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

(Name of patient advocate)

designation as patient advocate or successor patient advocate for _________________,

(Name of patient)

who signed a durable power of attorney for health care on the following date: ________.

Dated: __________

Signed: ________________________________________________

(Signature of patient advocate or successor patient advocate)

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