This information is approved and/or reviewed by U-M Health System providers but it is not a tool for self-diagnosis or a substitute for medical treatment. You should speak to your physician or make an appointment to be seen if you have questions or concerns about this information or your medical condition.
Exención de responsabilidad en Español | Complete disclaimer
DURABLE POWER OF ATTORNEY
FOR HEALTH CARE
(also available in printable PDF format from the State Bar of Michigan)
DURABLE POWER OF ATTORNEY
FOR HEALTH CARE
I, ___________________________________________________,
(Print or type your full name)
am of sound mind, and I voluntarily make this designation.
I designate _________________________________________, (insert name of patient advocate)
my
_________________________________________________ , (Spouse, child, friend ... )
living at __________________________________________________________________________ (Address of patient advocate)
as my patient advocate to make care, custody and medical treatment decisions for me in the event I become unable to participate in medical treatment decisions. If my first choice cannot serve, I designate __________________________________________________________________________ (Name of successor)
living at ________________________________________________________________ (Address of successor)
to serve as patient advocate.
The determination of when I am unable to participate in medical treatment decisions shall be made by my attending physician and another physician or licensed psychologist.
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 designation.
My patient advocate has authority to consent to or refuse treatment on my behalf, to arrange medical services for me, including admission to a 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.
| OPTIONAL I expressly authorize my patient advocate to make decisions to withhold or withdraw treatment which would allow me to die and I acknowledge such decisions could or would allow my death. ______________________________________________ (Sign your name here if you wish to give your patient advocate this authority.) |
My specific wishes concerning health care are the following: (if none, write "none")
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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 my family, the medical facility, and any doctors, nurses and other medical personnel involved in my care shall have no civil or criminal liability for honoring my wishes as expressed in this designation or for implementing the decisions of my patient advocate.
Photostatic copies of this document, after it is signed and witnessed, shall have the same legal force as the original document.
I sign this document after careful consideration. I understand its meaning and I accept its consequences.
Signed: _______________________________ Date: _____________
Address: ______________________________
_____________________________________
NOTICE REGARDING WITNESSES
You must have two adult witnesses who will not receive your assets when you die (whether you die with or without a will), and who are not your spouse, child, grandchild, brother or sister, an employee of a company through which you have life or health insurance, or an employee at the health care facility where you are a patient.
STATEMENT OF WITNESSES
We sign below as witnesses. This declaration was signed in our presence. The declarant appears to be of sound mind, and to be making this designation voluntarily, without duress, fraud or undue influence.
Signed by witness: ______________________________________
_____________________________________
(Print or type full name)
Address: _____________________________________________
__________________________________________
Signed by witness:______________________________________
_____________________________________
(Print or type full name)
Address: _____________________________________________
__________________________________________
ACCEPTANCE BY PATIENT ADVOCATE
(A) This designation shall not become effective unless the patient is unable to participate in treatment decisions.
(B) A patient advocate shall not exercise powers concerning the patient's care, custody and medical treatment that the patient, if the patient were able to participate in the decision, could not have exercised in his or her own behalf.
(C) 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 in the pregnant patient's death.
(D) 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.
(E) 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.
(F) 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 treatment decisions are presumed to be in the patient's best interests.
(G) A patient may revoke his or her designation at any time or in any manner sufficient to communicate an intent to revoke.
(H) 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.
(I) A patient admitted to a health facility or agency 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 designation as
patient advocate for ______________________________________
Dated: __________ Signed: ________________________________
