DESIGNATION OF PATIENT ADVOCATE
(DURABLE POWER OF ATTORNEY FOR HEALTH CARE)
1. Appointment of patient advocate(s) and personal representative. I, ______________, a Michigan resident, appoint __________________, [address and telephone], as my agent and personal representative, hereinafter referred to as my patient advocate.
I appoint the following person(s), in the order listed, as my successor patient advocate if my patient advocate is removed or is unable to serve. My successor patient advocate is to have the same powers and rights as my patient advocate.
____________________________________
[Typed name]
[Address and telephone]
____________________________________
[Typed name]
[Address and telephone]
My patient advocate or successor patient advocate may delegate his or her powers to the next successor patient advocate if he or she is unable to act.
2. Effective date and durability. My patient advocate or successor patient advocate may only act if I am unable to participate in making decisions regarding my medical or mental health treatment. My attending physician and another physician, licensed psychologist, or other mental health practitioner shall determine, after examining me, when I am unable to participate in making my own medical or mental health treatment decisions.
[Optional: My religious beliefs prohibit a medical examination to determine whether I am unable to participate in making medical treatment decisions; therefore, I want this determination to be made by ___________________________.]
This designation is suspended during any period in which I regain the ability to participate in my own medical treatment decisions.
I intend this document to be a durable power of attorney for health care, and it shall survive my disability or incapacity.
3. Patient advocate’s powers. I grant my patient advocate authority to make all health care decisions for me. In making such decisions, [he / she] should follow my expressed wishes, either written or oral, regarding my medical or mental health treatment. If my patient advocate cannot determine the choice I would want based on my written or oral statements, [he / she] shall choose for me based on what [he / she] believes to be in my best interests regardless of whether the specific medical or mental health treatment or circumstance is addressed in this document.
I [waive / do not waive] my right to revoke the patient advocate designation as to the power to make mental health treatment decisions.
Unless specifically limited by &4, my patient advocate is authorized as follows:
a. to consent to, refuse, or withdraw consent from all types of medical or mental health care, treatment, and procedures; provided that, if I have elected to make a gift of my organs and/or body parts, any withdrawal of medical care, treatment, and procedures shall be performed in a such a manner that my organs and/or body parts are kept vital until they are removed
b. to access my medical or mental health records, obtain individually identifiable health information, and act as my personal representative under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); to disclose the contents of my medical and mental health records to others; and to execute releases and any other documents required to carry out the powers set forth herein. This power is meant to be an unlimited, full, and complete authorization for the release of any and all protected medical and mental health information as defined under HIPAA, as amended, and under the rules and regulations thereof, and covers all protected information from primary and secondary providers, health plans, health care clearinghouses, community mental health facilities, emergency services, financial and administrative transactions, psychotherapy treatment, and business associates. It is understood that the patient advocate to whom this power is given has my permission to use and disseminate this information in his or her sole discretion.
c. to authorize my admission to or discharge from (even against medical advice) any hospital, nursing home, or care facility
d. to contract on my behalf for any health care–related or mental health care–related service or facility, without my patient advocate incurring personal financial liability for such contracts
e. to hire and fire medical, mental health, and other personnel responsible for my care
f. on behalf of me and my estate, to release from liability all persons and entities who act in good-faith reliance on instructions given by my patient advocate and to execute any documents, such as a refusal of treatment form or a do-not-resuscitate order, that a physician or a facility may require to carry out my wishes regarding medical or mental health treatment
g. with regard to mental health treatment decisions, to consent or not consent to the forced administration of medication or inpatient hospitalization
4. Life-sustaining treatment. I understand that I do not have to choose any of the instructions regarding life-sustaining treatment listed below. If I choose one, I will place a check mark by the choice and sign below my choice.
If I sign one of the choices listed below, I direct that reasonable measures be taken to keep me comfortable and to relieve pain.
[Choose only one.]
[ ] Choice 1: I do not want life-sustaining treatment (including artificial delivery of food and water) if any of the following medical conditions exist:
a. I am in an irreversible coma or persistent vegetative state.
b. I am terminally ill, and life-sustaining procedures would only serve to artificially delay my death.
c. My medical condition is such that the burdens of treatment outweigh the expected benefits. In making this determination, I want my patient advocate to consider relief of my suffering, the expenses involved, and the quality of my life, if prolonged.
I expressly authorize my patient advocate to make decisions to withhold or withdraw treatment that would allow me to die, and I acknowledge that such decisions could or would allow my death.
/s/_______________________________________
[ ] Choice 2: I want life-sustaining treatment (including artificial delivery of food or water) unless I am in a coma or vegetative state that 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 expressly authorize my patient advocate to make decisions to withhold or withdraw treatment that would allow me to die, and I acknowledge such decisions could or would allow my death.
/s/_______________________________________
[ ] 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 the procedures. I direct life-sustaining treatment to be provided to prolong my life.
/s/_______________________________________
5. Differences of opinion among medical or mental health personnel. I understand that I do not have to choose any of the instructions regarding differences of opinion listed below. If I choose one, I will place a check mark by my choice and sign my name below that choice.
[Choose only one.]
[ ] Choice 1: I grant broad discretion to my patient advocate if there is a difference of opinion among my treating physicians. If there is a difference of opinion about my medical or mental health treatment among the medical or mental health personnel treating me, my patient advocate shall consider the opinions of all the personnel and then choose the treatment to be administered to me.
/s/_______________________________________
[ ] Choice 2: I grant no discretion to my patient advocate if there is a difference of opinion about my medical or mental health treatment among my treating medical or mental health personnel. If there is a difference of opinion about my treatment among the personnel treating me, my patient advocate shall choose the treatment that the majority of the personnel recommends.
/s/_______________________________________
6. Difference of opinion among family members. I understand that I do not have to choose any of the instructions listed below regarding differences of opinion my family members may have concerning my medical or mental health treatment. If I choose one, I will place a check mark by the choice and sign below my choice.
[Choose only one.]
[ ] Choice 1: I grant broad discretion to my patient advocate if there is a difference of opinion among my family members with regard to my medical or mental health treatment. If there is a difference of opinion among my family members regarding my medical or mental health treatment, my patient advocate shall consider the opinion of each family member and then choose the treatment to be administered to me.
/s/_______________________________________
[ ] Choice 2: I grant no discretion to my patient advocate if there is a difference of opinion among my family members with regard to my medical or mental health treatment. If there is a difference of opinion among my family regarding my treatment, my patient advocate shall choose the treatment that the majority of my family members prefers.
/s/_______________________________________
7. Protection of third parties who rely on these instructions and those of my patient advocate. No person or entity that relies in good faith on the instructions of my patient advocate or successor patient advocate pursuant to this document, without actual notice that this power has been revoked or amended, shall incur any liability to me or to my estate. If I am unable to participate in making decisions for my care and there is no patient advocate or successor patient advocate to act for me, I request that the instructions I have given in this document be followed and be considered conclusive evidence of my wishes.
8. Administrative provisions. My patient advocate shall not be entitled to compensation for services performed under this designation, but he or she shall be entitled to reimbursement for actual and necessary expenses incurred as a result of carrying out his or her responsibilities as my patient advocate.
I revoke any prior designation of patient advocate or durable powers of attorney that I have executed to the extent that they grant powers and authority within the scope of the powers granted in this document.
This document shall be governed by Michigan law. However, I intend for this designation of patient advocate to be honored in any jurisdiction where it is presented and for other jurisdictions to refer to Michigan law to interpret and determine the validity and enforceability of this document.
Photocopies or facsimile reproductions of this signed designation of patient advocate shall be treated as original counterparts.
I am providing these instructions voluntarily and have not been required to give them to obtain treatment or to have care withheld or withdrawn. I am at least 18 years old and of sound mind.
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Dated: ______________________ |
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/s/_____________________________ [Typed name] |
WITNESS STATEMENT AND SIGNATURE
I declare that the person who signed this patient advocate designation did so in my presence and appears to be of sound mind and under no duress, fraud, or undue influence. I am not the husband, wife, parent, child, grandchild, brother, or sister of the person who signed this document. Furthermore, I am not [his / her] presumptive heir, and to the best of my knowledge, I am not a beneficiary to [his / her] will at the time of witnessing. I am not the patient advocate, the physician, or an employee of the life or health insurance provider for the person signing this document. I am not an employee of the health care facility or home for the aged where [he / she] resides or is being treated.
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Witness 1 Dated: ______________________ |
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/s/_____________________________ [Typed name] [Address, telephone] |
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Witness 2 Dated: ______________________ |
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/s/_____________________________ [Typed name] [Address, telephone] |
REAFFIRMATION OF PATIENT ADVOCATE DESIGNATION
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Dated: ______________________ |
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/s/_____________________________ [Typed name] |
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Dated: ______________________ |
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/s/_____________________________ [Typed name] |
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Dated: ______________________ |
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/s/_____________________________ [Typed name] |
ACCEPTANCE OF DESIGNATION AS PATIENT ADVOCATE
I accept the designation as the patient advocate for __________________ (patient). I understand and agree to take reasonable steps to follow the instructions, both verbal and written, of the patient regarding his or her medical and mental health care, custody, and treatment.
I also understand and agree to the following:
1. This patient advocate designation is not effective unless the patient is unable to participate in medical or mental health treatment decisions. If this patient advocate designation includes the authority to make an anatomical gift as described in MCL 700.5506, the authority remains exercisable after the patient’s death.
2. 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 on his or her own behalf.
3. This patient advocate 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.
4. A patient advocate may make a decision to withhold or withdraw treatment that 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.
5. A patient advocate shall not receive compensation for the performance of his or her authority, rights, and responsibilities but may be reimbursed for actual and necessary expenses incurred in the performance of his or her authority, rights, and responsibilities.
6. 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 interests.
7. A patient may revoke his or her patient advocate designation at any time and in any manner sufficient to communicate an intent to revoke.
8. A patient may waive his or her right to revoke the designation as to the power to make mental health treatment decisions.
9. A patient advocate may revoke his or her acceptance to the patient advocate designation at any time and in any manner sufficient to communicate an intent to revoke.
10. A patient admitted to a health facility or agency has the rights enumerated in MCL 333.20201.
If I am unavailable to act after reasonable effort to contact me, I delegate my authority to the persons the patient has designated as successor patient advocate in the order designated. The successor patient advocate is authorized to act until I become available.
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Patient advocate Dated: ______________________ |
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/s/_____________________________ [Typed name] [Address, telephone] |
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Successor patient advocate Dated: ______________________ |
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/s/_____________________________ [Typed name] [Address, telephone] |
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Successor patient advocate Dated: ______________________ |
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/s/_____________________________ [Typed name] [Address, telephone] |