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Medical Power of Attorney for Health Care

What You Need to Know

By completing the attached form for Medical Power of Attorney, you can appoint someone you know and trust to be your agent. Your agent can make health care decisions for you if you are unable to make them for yourself. This form is an important legal document. Before signing it, be sure you understand the following facts:

Agent

Anyone can be your agent except:

  • A person under 18 years of age, unless emancipated
  • Your health care provider
  • An employee of your heath care provider, unless that employee is related to you
  • Your residential care provider (for example, nursing home or hospice)
  • An employee of your residential care provider, unless that employee is related to you

Tell the person you appoint that you want him/her to be your health care agent. Give him/her a signed copy of the Medical Power of Attorney form.

Authority of Agent

Your agent makes decisions only when you are not able to make them. Unless you state otherwise, he/she has the same authority to make health care decisions as you have now. Your agent may consent, refuse to consent, or withdraw consent to medical treatment. He/she may make decisions about continuing or stopping life support treatment.

A section on the Medical Power of Attorney form is called Limitations On The Decision-Making Authority Of My Agent Are As Follows. You can leave this section blank. However, your agent must follow any instructions you leave for him/her. Examples of limitations you might choose include:

  • Provide comfortable, pain-free care
  • Do not keep me alive if I am going to remain in a coma
  • Use (or do not use) a feeding tube

Even after you have signed the Medical Power of Attorney form, you have the right to make health care decisions for yourself as long as you are able to do so. Treatment cannot be given to you or stopped over your objection. You have the right to take back the authority granted to your agent, at any time, either orally or in writing. To do so, tell your agent or your health care provider that you choose to take back the agent's power. You can do this regardless of your mental capacity or competence.

Witnesses

Your Medical Power of Attorney form is valid only when you sign it in the presence of at least two qualified witnesses. The following persons may NOT act as witnesses:

  • The person you have designated as your agent
  • A person related to you by blood or marriage
  • A person entitled to any part of your estated after your death under a will or codicil executed by you or by the operation of law
  • Your attending physician
  • An employee of your attending physician
  • An employee of a health care facility in which you are a patient if the employee is providing direct patient care to you or is an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility
  • A person who, at the same time this Power of Attorney is executed, has a claim against any part of your estate after your death

Disclosure Statement

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, psycho-surgery, or abortion. A physician must comply with your agent's instructions to 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 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; however, 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.

You should inform the person you appoint that you want him or her 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 or your health or residential care provider orally or in writing, or by your execution of a subsequent Medical power of Attorney. 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.


© 2014 The University of Texas MD Anderson Cancer Center