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Health Care Power of Attorney and Advance Directive Regarding a Natural Death (“Living Will”) – North Carolina

Health Care Power of Attorney and Advance Directive Regarding a Natural Death (“Living Will”)

Note:  You should use this document to name a person as your Health Care Agent if you are comfortable giving that person broad and sweeping powers to make health care decisions for you.

This document also gives your health care providers instructions to withhold or withdraw life-prolonging measures in certain situations.

There iis no legal requirement that anyone execute a Health Care Power of Attorney or a living will.

GENERAL INSTRUCTIONS

You have the right to name someone to make health care decisions for you when you cannot make or communicate those decisions.  This form may be used to create a Health Care Power of Attorney, and meets the requirements of North Carolina law.

This document gives the person you designate as your Health Care Agent broad powers to make health care decisions for you when you cannot make the decision yourself or cannot communicate your decision to other people.  You should discuss your wishes concerning life prolonging measures, mental health treatment, and other health care decisions with your Health Care Agent.  Except to the extent that you express specific limitations or restrictions in this form, your Health Care Agent may make any health care decision you could make yourself.

This form does not impose a duty on your Health Care Agent to exercise granted powers, but when a power is exercised, your Health Care Agent will be obligated to use due care to act in your best interests and in accordance with this document.

You can use also use this Advance Directive (“Living Will”) form to give instructions for the future if you want your health care providers to withhold or withdraw life-prolonging measures in certain situations.  You should talk to your doctor about what these terms mean.  The Living Will states what choices you would have made for yourself if you were able to communicate, and will offer guidance to your Health Care Agent where you have given your Agent discretion.  Talk to your family members, friends, and others you trust about your choices.  Also, it is a good idea to talk with professionals such as your doctors, clergypersons, and lawyers before you complete and sign this Living Will

This Health Care Power of Attorney and Living Will form is intended to be valid in any jurisdiction in which it is presented, but places outside North Carolina may impose requirements that this form does not meet.  If you want to use this form, you must complete it, sign it, and have your signature witnessed by two qualified witnesses and proved by a notary public.  Follow the instructions about which choices you can initial very carefully.

Do not sign this form until two witnesses and a notary public are present to watch you sign it.

You then should consider giving a copy to your primary physician, to each Health Care Agent you name, and a trusted relative, and should consider filing it with the Advanced Health Care Directive Registry maintained by the North Carolina Secretary of State.  For more information, see:  http://www.nclifelinks.org/.

This document is authorized by North Carolina General Statutes, chapter 32A, section 25; and chapter 90, sections 320-321.

Health Care Power of Attorney and Advance Directive Regarding a Natural Death (“LivingWill”)

My Desires Regarding Health Care and Natural Death

  1. Designation of Health Care Agent.  I, Declarant Name, being of sound mind, hereby appoint the following person(s) to serve as my Health Care Agent(s) to act for me and in my name (in any way I could act in person) to make health care decisions for me as authorized in this document.  My designated Health Care Agent(s) shall serve alone, in the order named.

A.

Name:

Home Phone:

Address:

Work Phone:

Cell Phone:

B.

Name:

Home Phone:

Address:

Work Phone:

Cell Phone:

C.

Name:

Home Phone:

Address:

Work Phone:

Cell Phone:

Any successor Health Care Agent designated shall be vested with the same power and duties as if originally named as my Health Care Agent, and shall serve any time his or her predecessor is not reasonably available or is unwilling or unable to serve in that capacity.

  1. Effectiveness of Appointment.  My designation of a Health Care Agent expires only when I revoke it.  Absent revocation, the authority granted in this document shall become effective when and if one of the physician(s) listed below determines that I lack capacity to make or communicate decisions relating to my health care, and will continue in effect during that incapacity, or until my death, except that, if I authorize my Health Care Agent to exercise my rights with respect to anatomical gifts, autopsy, or disposition of my remains, this authority will continue after my death to the extent necessary to exercise that authority.

1.

(Physician)

2.

(Physician)

[If I have not designated a physician, or no physician(s) named above is reasonably available, the determination that I lack capacity to make or communicate decisions relating to my health care shall be made by my attending physician.]

  1. Revocation.  Any time while I am competent, I may revoke this power of attorney in a writing I sign or by communicating my intent to revoke, in any clear and consistent manner, to my Health Care Agent or my health care provider.
  2. General Statement of Authority Granted.  Subject to any restrictions set forth in Sections 5, 6, and 10 below, I grant to my Health Care Agent full power and authority to make and carry out all health care decisions for me.  These decisions include, but are not limited to:
  3. Requesting, reviewing, and receiving any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, and to consent to the disclosure of this information.
  4. Employing or discharging my health care providers.
  5. Consenting to and authorizing my admission to and discharge from a hospital; nursing or convalescent home; hospice; long‑term care facility; or other health care facility.
  6. Consenting to and authorizing my admission to and retention in a facility for the care or treatment of mental illness.
  7. Consenting to and authorizing the administration of medications for mental health treatment and electroconvulsive treatment (ECT) commonly referred to as “shock treatment.”
  8. Giving consent for, withdrawing consent for, or withholding consent for, X‑ray, anesthesia, medication, surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a licensed physician, dentist, podiatrist, or other health care provider.  This authorization specifically includes the power to consent to measures for relief of pain.
  9. Authorizing the withholding or withdrawal of life‑prolonging measures, subject to any limitations as specified in Section 10 below.
  10. Providing my medical information at the request of any individual acting as my attorney‑in‑fact under a durable power of attorney or as a Trustee or successor Trustee under any Trust Agreement of which I am a Grantor or Trustee, or at the request of any other individual whom my Health Care Agent believes should have such information.  I desire that such information be provided whenever it would expedite the prompt and proper handling of my affairs or the affairs of any person or entity for which I have some responsibility.  In addition, I authorize my Health Care Agent to take any and all legal steps necessary to ensure compliance with my instructions providing access to my protected health information.  Such steps shall include resorting to any and all legal procedures in and out of courts as may be necessary to enforce my rights under the law and shall include attempting to recover attorneys’ fees against anyone who does not comply with this Health Care Power of Attorney.
  11. To the extent I have not already made valid and enforceable arrangements during my lifetime that have not been revoked, exercising any right I may have to authorize an autopsy or direct the disposition of my remains.
  12. Taking any lawful actions that may be necessary to carry out these decisions, including, but not limited to: (i) signing, executing, delivering, and acknowledging any agreement, release, authorization, or other document that may be necessary, desirable, convenient, or proper in order to exercise and carry out any of these powers; (ii) granting releases of liability to medical providers or others; and (iii) incurring reasonable costs on my behalf related to exercising these powers, provided that this Health Care Power of Attorney shall not give my Health Care Agent general authority over my property or financial affairs.
  13. Special Provisions and Limitations.

(Notice:  The authority granted in this document is intended to be as broad as possible so that your Health Care Agent will have authority to make any decisions you could make to obtain or terminate any type of health care treatment or service.  If you wish to limit the scope of your Health Care Agent’s powers, you may do so in this section.  If none of the following are initialed, there will be no special limitations on your Agent’s authority.)

  1. Limitations Concerning Health Care Decisions.
Note:  Do not initial unless you insert a limitation.
________

In exercising the authority to make health care decisions on my behalf, the authority of my Health Care Agent is subject to the following special provisions:  (You may include any specific provisions you deem appropriate such as:  your own definition of when life‑prolonging measures should be withheld or discontinued, or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs, or are unacceptable to you for any other reason.)
                                                                                                                        
  1. Limitations Concerning Mental Health Decisions.
Note:  Do not initial unless you insert a limitation.
________

In exercising the authority to make mental health decisions on my behalf, the authority of my Health Care Agent is subject to the following special provisions:  (You may include any specific provisions you deem appropriate such as:  limiting the grant of authority to make only mental health treatment decisions, your own instructions regarding the administration or withholding of psychotropic medications and electroconvulsive treatment (ECT), instructions regarding your admission to and retention in a health care facility for mental health treatment, or instructions to refuse any specific types of treatment that are unacceptable to you.)
                                                                                                                        
  1. Advance Instruction for Mental Health Treatment.

(Notice:  This health care power of attorney may incorporate or be combined with an Advance Instruction for Mental Health Treatment, executed in accordance with Part 2 of Article 3 of Chapter 122C of the General Statutes, which you may use to state your instructions regarding mental health treatment in the event you lack capacity to make or communicate mental health treatment decisions.  Because your Health Care Agent’s decisions must be consistent with any statements you have expressed in such an Advance Instruction, you should indicate here whether you have executed an Advance Instruction for Mental Health Treatment.)

______ I have executed an Advance Instruction for Mental Health Treatment.
  1. Autopsy and Disposition of Remains.
DO NOT initial below unless you insert a limitation.
______ In exercising the authority to make decisions regarding autopsy and disposition of remains on my behalf, the authority of my Health Care Agent is subject to the following special provisions and limitations:  (Here you may include any specific limitations you deem appropriate such as:  limiting the grant of authority and the scope of authority, or instructions regarding burial or cremation.)
                                                                                                                        
  1. Organ Donation.

NOTE:  No authority for organ donation is granted in this instrument without your initials in at least one block in this section.

To the extent I have not already made valid and enforceable arrangements during my lifetime that have not been revoked, my Health Care Agent may exercise any right I may have to:

NOTE:  Do not initial both blocks.
______ donate any needed organs or parts; or.
______ donate only the following organs or parts:
                                                                                                                          

 

NOTE:  Do not initial both blocks.
______ donate my body for anatomical study if needed.
______ NOTE:  DO NOT initial below unless you insert a limitation.In exercising the authority to make donations, my Health Care Agent is subject to the following special provisions and limitations: (Here you may include any specific limitations you deem appropriate such as: limiting the grant of authority and the scope of authority, or instructions regarding gifts of the body or body parts.)
                                                                                                                          
  1. Guardianship Provision.  If it becomes necessary for a court to appoint a guardian of my person, I nominate the persons designated in Section 1, in the order named, to be the guardian of my person, to serve without bond or security.  The guardian shall act consistently with G.S. 35A‑1201(a)(5).
  2. Reliance of Third Parties on Health Care Agent.
  3. No person who relies in good faith upon the authority of or any representations by my Health Care Agent shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or omissions in reliance on that authority or those representations.
  4. The powers conferred on my Health Care Agent by this document may be exercised by my Health Care Agent alone, and my Health Care Agent’s signature or action taken under the authority granted in this document may be accepted by persons as fully authorized by me and with the same force and effect as if I were personally present, competent, and acting on my own behalf.  All acts performed in good faith by my Health Care Agent pursuant to this power of attorney are done with my consent and shall have the same validity and effect as if I were present and exercised the powers myself, and shall inure to the benefit of and bind me, my estate, my heirs, successors, assigns, and personal representatives.  The authority of my Health Care Agent pursuant to this power of attorney shall be superior to and binding upon my family, relatives, friends, and others.
  5. 9.      Miscellaneous Provisions. 
  6. Revocation of Prior Powers of Attorney.  I revoke any prior health care power of attorney.  The preceding sentence is not intended to revoke any general powers of attorney, some of the provisions of which may relate to health care; however, this power of attorney shall take precedence over any health care provisions in any valid general power of attorney I have not revoked.
  7. Jurisdiction, Severability, and Durability.  This Health Care Power of Attorney is intended to be valid in any jurisdiction in which it is presented.  The powers delegated under this power of attorney are severable, so that the invalidity of one or more powers shall not affect any others.  This power of attorney shall not be affected or revoked by my incapacity or mental incompetence.
  8. Health Care Agent Not Liable.  My Health Care Agent and my Health Care Agent’s estate, heirs, successors, and assigns are hereby released and forever discharged by me, my estate, my heirs, successors, assigns, and personal representatives from all liability and from all claims or demands of all kinds arising out of my Health Care Agent’s acts or omissions, except for my Health Care Agent’s willful misconduct or gross negligence.
  9. No Civil or Criminal Liability.  No act or omission of my Health Care Agent, or of any other person, entity, institution, or facility acting in good faith in reliance on the authority of my Health Care Agent pursuant to this Health Care Power of Attorney shall be considered suicide, nor the cause of my death for any civil or criminal purposes, nor shall it be considered unprofessional conduct or as lack of professional competence.  Any person, entity, institution, or facility against whom criminal or civil liability is asserted because of conduct authorized by this Health Care Power of Attorney may interpose this document as a defense.
  10. Reimbursement.  My Health Care Agent shall be entitled to reimbursement for all reasonable expenses incurred as a result of carrying out any provision of this directive.
  11. When My Directives Apply:  I, Declarant Name, being of sound mind, desire to specify the extent to which my life may be prolonged by life prolonging measures.  My directions about prolonging my life shall apply IF my attending physician determines that I lack capacity to make or communicate health care decisions and:
  12. IF I have an incurable or irreversible condition that will result in my death within a relatively short period of time.
Note: You may initial only one of these choices.
______ Directive for Maximum Treatment.  I do not authorize my Health Care Agent to withdraw or withhold or discontinue any life-prolonging measures.  I want my life to be prolonged to the greatest extent possible, within the standards of accepted, without regard to my condition, the chances I have for recovery, or the cost of the procedures.
______ Agent Discretion.  I authorize my Health Care Agent to make decisions for me regarding life-prolonging measures.  I do not want my life to be prolonged by life-prolonging means if my Health Care Agent believes that the burdens of such measures outweigh the expected benefits.  I want my Health Care Agent to consider the relief of suffering, my personal beliefs, the expense involved, and the quality of my life as prolonged, when making decisions for me regarding life-prolonging measures.
______ Withhold or Withdraw Life-Prolonging Treatment; Administer Artificial Nutrition.  I do not want my life to be prolonged, and I direct that life-prolonging measures shall be withheld or discontinued, notwithstanding any directions of my Health Care Agent to the contrary.  HOWEVER, I DO want to receive artificial nutrition and hydration.  Therefore, my Health Care Agent shall NOT have the authority to withhold artificial nutrition (such as through tubes) OR may exercise that authority only in accordance with the following special provisions, if any:

 

                                                                                                                        
______ Withhold or Withdraw Life-Prolonging Treatment; Withhold or Withdraw Artificial Nutrition and Hydration.  I do not want my life to be prolonged, and I direct that life-prolonging measures shall be withheld or discontinued, notwithstanding any directions of my Health Care Agent to the contrary.  I do NOT want to receive artificial nutrition or hydration, notwithstanding any directions of my Health Care Agent to the contrary.
  1. IF I become unconscious and my health care providers determine that, to a high degree of medical certainty, I will never regain my consciousness.
Note: You may initial only one of these choices.
______ Directive for Maximum Treatment.  I do not authorize my Health Care Agent to withdraw or withhold or discontinue any life-prolonging measures.  I want my life to be prolonged to the greatest extent possible, within the standards of accepted, without regard to my condition, the chances I have for recovery, or the cost of the procedures.
______ Agent Discretion.  I authorize my Health Care Agent to make decisions for me regarding life-prolonging measures.  I do not want my life to be prolonged by life-prolonging means if my Health Care Agent believes that the burdens of such measures outweigh the expected benefits.  I want my Health Care Agent to consider the relief of suffering, my personal beliefs, the expense involved, and the quality of my life as prolonged, when making decisions for me regarding life-prolonging measures.
______ Withhold or Withdraw Life-Prolonging Treatment; Administer Artificial Nutrition.  I do not want my life to be prolonged, and I direct that life-prolonging measures shall be withheld or discontinued, notwithstanding any directions of my Health Care Agent to the contrary.  HOWEVER, I DO want to receive artificial nutrition and hydration.  Therefore, my Health Care Agent shall NOT have the authority to withhold artificial nutrition (such as through tubes) OR may exercise that authority only in accordance with the following special provisions, if any:

 

                                                                                                                        
______ Withhold or Withdraw Life-Prolonging Treatment; Withhold or Withdraw Artificial Nutrition and Hydration.  I do not want my life to be prolonged, and I direct that life-prolonging measures shall be withheld or discontinued, notwithstanding any directions of my Health Care Agent to the contrary.  I do NOT want to receive artificial nutrition or hydration, notwithstanding any directions of my Health Care Agent to the contrary.
  1. IF I suffer from advanced dementia or any other condition which results in the substantial loss of my cognitive ability and my health care providers determine that, to a high degree of medical certainty, this loss is not reversible.
Note: You may initial only one of these choices.
______ Directive for Maximum Treatment.  I do not authorize my Health Care Agent to withdraw or withhold or discontinue any life-prolonging measures.  I want my life to be prolonged to the greatest extent possible, within the standards of accepted, without regard to my condition, the chances I have for recovery, or the cost of the procedures.
______ Agent Discretion.  I authorize my Health Care Agent to make decisions for me regarding life-prolonging measures.  I do not want my life to be prolonged by life-prolonging means if my Health Care Agent believes that the burdens of such measures outweigh the expected benefits.  I want my Health Care Agent to consider the relief of suffering, my personal beliefs, the expense involved, and the quality of my life as prolonged, when making decisions for me regarding life-prolonging measures.
______ Withhold or Withdraw Life-Prolonging Treatment; Administer Artificial Nutrition.  I do not want my life to be prolonged, and I direct that life-prolonging measures shall be withheld or discontinued, notwithstanding any directions of my Health Care Agent to the contrary.  HOWEVER, I DO want to receive artificial nutrition and hydration.  Therefore, my Health Care Agent shall NOT have the authority to withhold artificial nutrition (such as through tubes) OR may exercise that authority only in accordance with the following special provisions, if any:
                                                                                                                          
______ Withhold or Withdraw Life-Prolonging Treatment; Withhold or Withdraw Artificial Nutrition and Hydration.  I do not want my life to be prolonged, and I direct that life-prolonging measures shall be withheld or discontinued, notwithstanding any directions of my Health Care Agent to the contrary.  I do NOT want to receive artificial nutrition or hydration, notwithstanding any directions of my Health Care Agent to the contrary.
  1. I wish to be made as comfortable as possible.  I direct that my health care providers take reasonable steps to keep me as clean, comfortable, and free of pain as possible so that my dignity is maintained, even though this care may hasten my death.
  2. I understand my Advance Directive.  I am aware and understand that this document directs certain life‑prolonging measures to be withheld or discontinued in accordance with my advance instructions.
  3. My health care providers may rely on this Directive.  My health care providers shall not be liable to me or to my family, my estate, my heirs, or my personal representative for following the instructions I give in this instrument.  Following my directions shall not be considered suicide, or the cause of my death, or malpractice or unprofessional conduct.  If I have revoked this  instrument but my health care providers do not know that I have done so, and they follow the instructions in this instrument in good faith, they shall be entitled to the same protections to which they would have been entitled if the instrument  had not been revoked.
  4. I want this Directive to be effective anywhere.  I intend that this Advance Directive be followed by any health care provider in any place.
  5. I have the right to revoke this Directive.  I understand that at any time I may revoke this Directive in a writing I sign or by communicating in any clear and consistent manner my intent to revoke it to my attending physician.  I understand that if I revoke this instrument I should try to destroy all copies of it.

By signing here, I indicate that I am mentally alert and competent, fully informed as to the contents of this document, and understand the full import of this grant of powers to my Health Care Agent.

This the          day of August 2013.

Declarant Name       _____________________________________________________________

I hereby state that the declarant, Declarant Name, being of sound mind, signed (or directed another to sign on declarant’s behalf) the foregoing Health Care Power of Attorney and Advance Directive Regarding a Natural Death in my presence, and that I am not related to the declarant by blood or marriage, and I would not be entitled to any portion of the estate of the declarant under any existing will or codicil of the declarant or as an heir under the Intestate Succession Act, if the declarant died on this date without a will.  I also state that I am not the declarant’s attending physician, nor a licensed health care provider who is (1) an employee of the declarant’s attending physician, (2) nor an employee of the health facility in which the declarant is a patient, or (3) an employee of a nursing home or any adult care home where the declarant resides.  I further state that I do not have any claim against the declarant or the estate of the declarant.

                                                                                                                                               

Witness Signature                                                                                                                             

Date                                                         

Witness Signature          __________________________________________________________

Date

 

STATE OF NORTH CAROLINA

FORSYTH COUNTY

I, Richard J. Rutledge, a Notary Public for Forsyth County North Carolina, hereby certify that Declarant Name appeared before me and swore to me and to the witnesses in my presence that this instrument is a Health Care Power of Attorney and his/her Declaration of A Desire for A Natural Death, and that he/she willingly and voluntarily made and executed it as his/her free act and deed for the purposes expressed in it.

I further certify that ____________________ and ____________________, witnesses, appeared before me and swore that they witnessed Declarant Name sign the attached Health Care Power of Attorney and Declaration of A Desire for A Natural Death, believing him/her to be of sound mind; and also swore that at the time they witnessed the signing (1) they were not related within the third degree to him/her or his/her spouse, and (2) they did not know nor have a reasonable expectation that they would be entitled to any portion of his/her estate upon his/her death under any will or codicil thereto then existing or under the Intestate Succession Act as it provided at that time, and (3) they were not a physician attending him/her, nor an employee of an attending physician, nor an employee of a health facility in which he/she was a patient, nor an employee of a nursing home or any group-care home in which he/she resided, and (4) they did not have a claim against him/her.  I further certify that I am satisfied as to the genuineness and due execution of the instrument.

This the         day of August 2013.

Richard J. Rutledge, Notary Public

My Commission Expires:    February 11, 2014.   

(seal)

 

Rick Rutledge (http://www.rickrutledgelaw.com/) practices law in Winston-Salem, North Carolina, focusing on how the law affects people—individuals, families, and the small businesses that make up the backbone of the American economy. His general practice concentrates on estate planning, life planning, property, small business, contracts, civil litigation, employment law, elder law, family law, and minor criminal matters.

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