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Ohio : ______________________________ (Notary Public) 4 (s)he executed the same for the purposes expressed therein. I attest that the Declarant appears to be of sound mind and not under or subject to duress, fraud or undue influence. My Commission Expires____________________________________, (Name of Declarant) known to me or satisfactorily proven to be the Declarant whose name is subscribed to the above Living Will Declaration, and acknowledged that ENT State of Ohio County of _______________________________, S.S.: On this the ____________ day of _______________________, 20 _______, before me, the undersigned Notary Public, personally appeared _________________ (Witness 2 Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ OR ACKNOWLEDGEM__ (Witness 1 Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ _____________________________ministrator of a nursing home in which the Declarant is receiving care, and that I am an adult not related to the Declarant by blood, marriage, or adoption. ___________________________________________nd that the Declarant appears to be of sound mind and not under or subject to duress, fraud or undue influence. I further attest that I am not the attending physician of the Declarant, I am not the ad________________ (city), Ohio. __________________________________________ (Declarant's Signature) 3 I attest that the Declarant signed or acknowledged this Living Will Declaration in my presence, aience pain or suffering. I understand the purpose and effect of this document and sign my name to this Living Will Declaration after careful deliberation on _______________, (date) at ________________erized by both of the following: (1) I am irreversibly unaware of myself and my Environment, and (2) There is a total loss of cerebral cortical functioning, resulting in my having no capacity to experusness that, to a reasonable Degree of medical certainty as determined in Accordance with reasonable medical standards by My attending physician and one other physician who Has examined me, is charact no recovery, and (2) death is likely to occur within a relatively short time if life-sustaining treatment is not Administered. (c) "permanently unconscious state" means a state of Permanent unconscio of medical certainty as determined in Accordance with reasonable medical standards by my attending physician and one other physician who has examined me, both of the following apply: (1) there can beincipally to prolong the process of dying. (B) "terminal condition" means an irreversible, Incurable, and untreatable condition caused by Disease, illness, or injury from which, to a reasonable Degreening treatment" means any medical procedure, treatment, intervention, or other measure including artificially or technologically supplied nutrition and hydration that, when administered, will serve pr____________________________________________________________ Work Phone: _______________________________________________________________ For purposes of this Living Will Declaration: (A) "Life-sustai_______________________________ Address: __________________________________________________________________ ______________________________________ Zip Code: ___________________________ Home Phone: ___ Work Phone: _______________________________________________________________ Name 2: ____________________________________________________________________ Relationship: __________________________________________________________________________ ______________________________________ Zip Code: ___________________________ Home Phone: _______________________________________________________________ 2 of priority: Name 1: ____________________________________________________________________ Relationship: ______________________________________________________________ Address: _______________________es that life-sustaining treatment should be withheld or withdrawn, he or she shall make a good faith effort and use reasonable diligence to notify one of the persons named below in the following order ____________________________________________________________________________ ____________________________________________________________________________ In the event my attending physician determin______________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ MEDICAL STANDARDS, THAT SUCH NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO ME OR ALLEVIATE MY PAIN. Additional Instructions (optional): ______________________________ERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED ME DETERMINE, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLEE MY ATTENDING PHYSICIAN TO WITHHOLD,OR IN THE EVENT THAT TREATMENT HAS ALREADY COMMENCED, TO WITHDRAW THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIED NUTRITION AND HYDRATION, IF I AM IN A Pake me comfortable and to relieve my pain but not to postpone my death. o __________ IN ADDITION, IF I HAVE MARKED THE FOREGOING BOX AND HAVE PLACED MY INITIALS ON THE LINE ADJACENTTO IT, I AUTHORIZragraph, I have authorized its withholding or withdrawal; · withdraw such treatment if such treatment has commenced; and, · permit me to die naturally and provide me with only that care necessary to mhat my attending physician shall: 1 · administer no life-sustaining treatment, except for the provision of artificially or technologically supplied nutrition or hydration unless, in the following pally and provide me with only the care necessary to make me comfortable and to relieve my pain but not to postpone my death. In the event I am in a permanently unconscious state, I declare and direct tn, I declare and direct that my attending physician shall: · administer no life-sustaining treatment; · withdraw life-sustaining treatment if such treatment has commenced; and, permit me to die naturamedical or surgical treatment. I am a competent adult who understands and accepts the consequences of such refusal and the purpose and effect of this document. In the event I am in a terminal conditional condition or a permanently unconscious state, it is my intention that this Living Will Declaration shall be honored by my family and physicians as the final expression of my legal right to refuse vised Code, do voluntarily make known my desire that my dying shall not be artificially prolonged. If I am unable to give directions regarding the use of life-sustaining treatment when I am in a termi_____________________, (address) Ohio, being of sound mind and not subject to duress, fraud or undue influence, intending to create a Living Will Declaration under Chapter 2133 et. Seq. of the Ohio ReDurable Power of Attorney for Health Care. Declaration I, ___________________________________________________________, (name of Declarant) presently residing at _______________________________________ may be relied on only for individuals in a terminal condition or a permanently unconscious state. If you wish to direct your medical treatment in other circumstances, you should consider preparing a ning treatment, you have the legal right to so choose and you might want to state your medical treatment preferences in writing in another form of Declaration. Under Ohio law a Living Will Declaration withdrawn if the individual is unable to communicate and is in a terminal condition or a permanently unconscious state. If you would choose not to withhold or withdraw any or all forms of life sustaieclaration is designed to serve as evidence of an individual's desire that life-sustaining medical treatment, including artificially or technologically supplied nutrition and hydration, be withheld orofessional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Notice to Declarant This form of a Living Will Dar situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax pr from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particule provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws varyed in this section, "DNR identification" has the same meaning as in section 2133.21 of the Revised Code. [_] These forms are provided "as is" and no implied or express warranties have been made or arny other type of designation, except that the printed form may be used as a DNR identification if the declarant specifies on the form that the declarant wishes to use it as a DNR identification. As us that life-sustaining treatment would be withheld or withdrawn pursuant to the declaration. The printed form shall not be used as an instrument for granting any other type of authority or for making aPage 5 state as described in division (A)(3)(a) of section 2133.02 of the Revised Code, and may designate one or more persons who are to be notified by the declarant's attending physician at any timer a permanently unconscious state, may authorize the withholding or withdrawal of nutrition or hydration should the declarant be in a permanently unconscious Living Will Information & Instructions ­ e use or continuation, or the withholding or withdrawal, of life-sustaining treatment should the declarant be in a terminal condition, a permanently unconscious state, or either a terminal condition oed form of a declaration ma y be sold or otherwise distributed in this state for use by adults who are not advised by an attorney. By use of a printed form of that nature, a declarant may authorize thing physician or other health care personnel acting under the direction of the attending physician shall make the fact a part of the declarant's medical record. § 2133.07 Use of printed form. A printnce with the revocation. (B) Upon the communication as described in division (A) of this section to the attending physician of a declarant of the fact that his declaration has been revoked, the attendontrary, the attending physician of a declarant and other health care personnel who are informed of the revocation of a declaration by an alleged witness may rely on the information and act in accordasician of the declarant by the declarant himself, a witness to the revocation, or other health care personnel to whom the revocation is communicated by such a witness. Absent actual knowledge to the c intention to revoke the declaration, except that, if the declarant made his attending physician aware of the declaration, the revocation shall be effective upon its communication to the attending phy04 of the Revised Code. § 2133.04 Revocation of declaration. (A) A declarant may revoke a declaration at any time and in any manner. The revocation shall be effective when the declarant expresses histhe declarant should be in a terminal condition or in a permanently unconscious state. Division (B)(2) of this section does not apply if the declarant revokes the declaration pursuant to section 2133.ower of attorney for health care and a valid declaration, the declaration supersedes the durable power of attorney for health care to the extent that the provisions of the documents would conflict if ate order, as defined in section 2133.21 of the Revised Code, that a physician has issued for the declarant and that is inconsistent with the declaration. (2) If a declarant has both a valid durable p a DNR identification, as defined in section 2133.21 of the Revised Code, of the declarant that is based upon a prior inconsistent declaration of the declarant or that is based upon a do- not-resuscit(1)(a) of this section does not apply if a declaration is revoked pursuant to section 2133.04 of the Revised Code after the signing of a general consent to treatment form. (b) A declaration supersedesion, or the withholding or withdrawal, of life-sustaining treatment and other medical or nursing procedures, treatments, interventions, or other measures in connection with the declarant. Division (B) extent that the provisions of a declaration and a general consent to treatment form do not conflict, both documents shall govern the use Living Will Information & Instructions ­ Page 4 or continuater the declarant's admission to a health care facility to the extent there is a conflict between the declaration and the form, even if the form is signed after the execution of the declaration. To thesions regarding the administration of life-sustaining treatment. (B)(1)(a) A declaration supersedes any general consent to treatment form signed by or on behalf of the declarant prior to, upon, or afta reasonable degree of medical certainty, and in accordance with reasonable medical standards, that there is no reasonable possibility that the declarant will regain the capacity to make informed decion to become operative in connection with a declarant who is in a terminal condition or in a permanently unconscious state, the attending physician of the declarant shall determine, in good faith, to acquired in the practice of medicine or surgery or osteopathic medicine and surgery, is qualified to determine whether the declarant is in a permanently unconscious state. (3) In order for a declaratianches of medicine or surgery or osteopathic medicine and surgery, of certification as a specialist in a particular branch of medicine or surgery or osteopathic medicine and surgery, or of experience arant is in the permanently unconscious state shall be a physician who, by virtue of advanced education or training, of a practice limited to particular diseases, illnesses, injuries, therapies, or bre. (2) In order for a declaration to become operative in connection with a declarant who is in a permanently unconscious state, the consulting physician associated with the determination that the declen the declaration becomes operative, the attending physician and health care facilities shall act in accordance with its provisions or comply with the provisions of section 2133.10 of the Revised Cod (3) of this section are satisfied, and the attending physician determines that the declarant no longer is able to make informed decisions regarding the administration of life-sustaining treatment. Wh declarant determine that the declarant is in a terminal condition or in a permanently unconscious state, whichever is addressed in the declaration, the applicable requirements of divisions (A)(2) and attorney for health care . (A)(1) A declaration becomes operative when it is communicated to the attending physician of the declarant, the attending physician and one other physician who examines thes the same meaning as in section 2133.21 of the Revised Code. § 2133.03 When declaration becomes operative; declaration supersedes general consent to treatment, DNR identification or durable power ofhas become operative as described in division (A) of section 2133.03 of the Revised Code, shall comply with the provisions of section 2133.10 of the Revised Code. (E) As used in this section, "CPR" haliance with the declarant's declaration, the physician or facility promptly shall so advise the declarant and comply with the provisions of section 2133.10 of the Revised Code, or, if the declaration ing Will Information & Instructions ­ Page 3 (2) If an attending physician of a declarant or a health care facility in which a declarant is confined is not willing or not able to comply or allow compf an attending physician of a declarant or of a health care facility in which a declarant is confined may refuse to comply with the declarant's declaration on the basis of a matter of conscience. Live facility in which a declarant is confined may refuse to comply or allow compliance with the declarant's declaration on the basis of a matter of conscience or on another basis. An employee or agent od, when section 2133.05 of the Revised Code is applicable, also shall comply with that section. (D)(1) Subject to division (D)(2) of this section, an attending physician of a declarant or a health carnding physician, or other health care personnel acting under the direction of an attending physician, who is furnished a copy of a declaration shall make it a part of the declarant's medical record anfication described in section 147.53 of the Revised Code and also shall attest that the declarant appears to be of sound mind and not under or subject to duress, fraud, or undue influence. (C) An atteed to appear on the same page of the declaration. (2) If acknowledged for purposes of division (A) of this section, a declaration shall be acknowledged before a notary public, who shall make the certiud, or undue influence. The signatures of the declarant or other individual at the direction of the declarant under division (A) of this section and of the witnesses under this division are not require declarant or other individual at the direction of the declarant and, by doing so, attest to the witness' belief that the declarant appears to be of sound mind and not under or subject to duress, frahysician of the declarant, and who are not the administrator of any nursing home in which the declarant is receiving care. Each witness shall subscribe the witness' signature after the signature of ththe direction of the declarant, signed the declaration. The witnesses to a declaration shall be adults who are not related to the declarant by blood, marriage, or adoption, who are not the attending pIf witnessed for purposes of divisio n (A) of this section, a declaration shall be witnessed by two individuals as described in this division in whose presence the declarant, or another individual at hen a declarant is in a terminal condition. The provisions of division (E) of section 2133.12 of the Revised Code pertaining to comfort care shall apply to a declarant in a terminal condition. (B)(1) in division (A)(3)(a)(i) of this section. (b) Division (A)(3)(a) of this section does not apply to the extent that a declaration authorizes the withholding or withdrawal of life-sustaining treatment w that is adjacent to a similar statement on a printed form of a declaration; (ii) Placing the declarant's initials or signature underneath or adjacent to the statement, check, or other mark described le medical standards, that nutrition or hydration will not or no longer will serve to provide comfort to the declarant or alleviate the declarant's pain, or checking or otherwise marking a box or line state and if the declarant's attending physician and at least one other physician who has examined the declarant determine, to a reasonable degree of medical certainty and in accordance with reasonabdface type, that the declarant's attending Living Will Information & Instructions ­ Page 2 physician may withhold or withdraw nutrition and hydration if the declarant is in a permanently unconsciousus state by doing both of the following in the declaration: (i) Including a statement in capital letters or other conspicuous type, including, but not limited to, a different font, bigger type, or bolalleviate the declarant's pain, then the declarant shall authorize the declarant's attending physician to withhold or withdraw nutrition or hydration when the declarant is in the permanently unconscior withdraw nutrition or hydration when the declarant is in a permanently unconscious state and when the nutrition and hydration will not or no longer will serve to provide comfort to the declarant or of section 2133.01 of the Revised Code. (3)(a) If a declarant who has authorized the withholding or withdrawal of life-sustaining treatment intends that the declarant's attending physician withhold o either or both of the terms "terminal condition" and "permanently unconscious state" and shall define or otherwise explain those terms in a manner that is substantially consistent with the provisions to apply when the declarant is in a terminal condition, in a permanently unconscious state, or in either a terminal condition or a permanently unconscious state, the declarant's declaration shall usethe withholding or withdrawal of CPR in accordance with sections 2133.01 to 2133.15 or sections 2133.21 to 2133.26 of the Revised Code. (2) Depending upon whether the declarant intends the declarationcific authorization for the use or continuation or the withholding or withdrawal of CPR, but the failure to include a specific authorization for the withholding or withdrawal of CPR does not preclude s who are to be notified by the declarant's attending physician at any time that life-sustaining treatment would be withheld or withdrawn pursuant to the declaration. The declaration may include a spedivision (B)(1) of this section or be acknowledged by the declarant in accordance with division (B)(2) of this section. The declaration may include a designation by the declarant of one or more persontment. The declaration shall be signed at the end by the declarant or by another individual at the direction of the declarant, state the date of its execution, and either be witnessed as described in ; refusal to comply. (A)(1) An adult who is of sound mind voluntarily may execute at any time a declaration governing the use or continuation, or the withholding or withdrawal, of life-sustaining treavenience, we have included useful excerpts from the Ohio Statutes relating to Living Wills. 2133.02 Declaration governing use or continuation, or withholding or withdrawal, of lifesustaining treatmentains (1) Information and Instruction for Ohio Living Will; (2) Ohio Living Will. This Ohio Living Will is based on Title 21 Chapter 2133 Section 2133.01 et. Seq. of the Ohio Revised Code. For your con duress, fraud or undue influence. My Commission Expires:____________________ _________________________________________ (Notary) -9- Information and Instructions Ohio Living Will This package cont for Health Care as the principal, and acknowledged that (s)he executed the same for the purposes expressed therein. I attest that the principal appears to be of sound mind and not under or subject toPublic, personally appeared ______________________________________, who is known to me or who has satisfactorily proven to be the person whose name is subscribed to the above Durable Power of Attorney______________ -8- OR ACKNOWLEDGEMENT State of Ohio County of _____________________________, s.s.: On this the _________ day of _________________________, 20___, before me, the undersigned Notary ______________________ Print Name: ___________________________________________________ Residence Address: _____________________________________________ Date: ______________________________________________________________________ Residence Address: _____________________________________________ Date: ________________________________________________________ Witness Signature: _______________________eceiving care, and that I am an adult not related to the principal by blood, marriage or adoption. Witness Signature: _____________________________________________ Print Name: _______________________uence. I further attest that I am not the agent designated in this document, I am not the attending physician of the principal, I am not the administrator of a nursing home in which the principal is re principal signed or acknowledged this Durable Power of Attorney for Health Care in my presence, that the principal appears to be of sound mind and not under or subject to duress, fraud or undue inflALID UNLESS IT IS EITHER (1) SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC. I attest that theration on _________________________ (date) at ____________________________, (city) Ohio. ___________________________________ (Principal) THIS DURABLE POWER OF ATTORNEY FOR HEALTH CARE WILL NOT BE Vary public or two witnesses who meet the law's requirements. I understand the purpose and effect of this document and sign my name to this Durable Power of Attorney for Health Care after careful delibthe notice printed at the end of this document. I have read this notice before signing this document. I understand that this document will not be valid unless I sign it in the presence of either a nottness -7- to the revocation. I understand that if I execute a new durable power of attorney for health care, the new document will automatically replace this one. Ohio law requires that I be given of this document to a physician, my revocation will not be effective as to that physician until the fact of my revocation is communicated to that physician (or the physician's staff) by me or by a wiTHIS DOCUMENT I understand that I can revoke this document at any time and in any manner merely by expressing my intention to revoke it. This can be done verbally or in writing. If I have given a copyalth care decisions. 8. PRIOR DESIGNATIONS REVOKED. I hereby revoke any prior Durable Powers of Attorney for Health Care executed by me under Chapter 1337 of the Ohio Revised Code. 9. REVOCATION OF date. 7. SEVERABILITY. Any invalid or unenforceable power, authority or provision of this instrument shall not affect any other power, authority or provision or the appointment of my agent to make he NO EXPIRATION DATE. This Durable Power of Attorney for Health Care shall not be affected by my disability or by lapse of time. This Durable Power of Attorney for Health Care shall have no expiration ________________________ (address) _________________ (home telephone number) _________________ (work telephone number) Each alternate shall have and exercise all of the authority conferred above. 6._ (home telephone number) _________________ (work telephone number) Second Alternate Agent___________________________________________,(name and relationship) presently residing at ____________________tinue to serve: First Alternate Agent: ___________________________________________,(name and relationship) presently residing at ____________________________________________ (address) ________________thorities and to serve under this instrument, in the order named, if at any time the agent first named (or any alternate designee) is not readily available or is unwilling or unable to serve or to conATE AGENT. -6- Because I wish that an agent shall be available to exercise the authorities granted hereunder at all times, I further designate each of the following individuals to succeed to such auERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT SUCH NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO ME OR ALLEVIATE MY PAIN. 5. DESIGNATION OF ALTERNED NUTRITION AND HYDRATION IF I AM IN A PERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED ME DETERMINES, TO A REASONABLE DEGREE OF MEDICAL CLACED MY INITIALS ON THE LINE ADJACENT TO IT, MY AGENT MAY REFUSE, OR IN THE EVENT TREATMENT HAS ALREADY COMMENCED, WITHDRAW INFORMED CONSENT TO THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIions that my agent is authorized to make pursuant to this document. 4. WITHDRAWAL OF NUTRITION AND HYDRATION WHEN IN A PERMANENTLY UNCONSCIOUS STATE. ? IF I HAVE MARKED THE FOREGOING BOX AND HAVE Pferred to another facility; (2) Documents that are Do Not Resuscitate Orders, Discharge Orders or other similar orders; and (3) Any other document necessary or desirable to implement health care decissisted residence facilities, and the like; and (h) To execute on my behalf any or all of the following: (1) Documents that are written consents to medical treatment or written requests that I be transealth care, as my agent shall determine to be appropriate; (g) To select and contract with any medical or health care facility on my behalf, including, but not limited to, hospitals, nursing homes, asn if necessary; (f ) To select, employ, and discharge health care personnel, such as physicians, nurses, therapists and other medical professionals, including individuals and services providing home hcare facility records; (d) To execute on my behalf any releases or other documents that may be required in order to obtain this information; (e) To consent to the further disclosure of this informatio withdrawal in Paragraph 4; (c) To request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, all of my medical and health d, however, my agent is not authorized to refuse or direct the withdrawal of -5- artificially or technologically supplied nutrition or hydration unless I have specifically authorized such refusal orration; (b) If I am in a permanently unconscious state, to give informed consent to life-sustaining treatment or to withdraw or to refuse to give informed consent to life-sustaining treatment; providem in a terminal condition, to give, to withdraw or to refuse to give informed consent to life-sustaining treatment, including the provision of artificially or technologically supplied nutrition or hydy or desirable to implement the health care decisions that my agent is authorized to make pursuant to this document, my agent has the power and authority to do any and all of the following: (a) If I ament or otherwise made known to my agent by me or, if I have not made my desires known, that are, in the judgment of my agent, in my best interests. 3. ADDITIONAL AUTHORITIES OF AGENT. Where necessar used to maintain, diagnose or treat my physical or mental condition. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this docuth care decisions for myself. My agent shall have the authority to give, to withdraw or to refuse to give informed consent to any medical or nursing procedure, treatment, intervention or other measuredecisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, at any time during which I do not have the capacity to make or communicate informed healdocument or, if not expressed here, as otherwise made known to my agent by me.. 2. GENERAL STATEMENT OF AUTHORITY GRANTED. I hereby grant to my agent full power and authority to make all health care (home telephone number) _________________ (work telephone number) as my attorney in fact who shall act as my agent to make health care decisions for me consistent with my wishes as authorized in this e and appoint: ________________________________________________________________ (name of agent) presently residing at _____________________________________________________ (address) _________________ am an adult of sound mind. After careful consideration, I knowingly and voluntarily create this Durable Power of Attorney for Health Care under Chapter 1337 of the Ohio Revised Code, I hereby designatESIGNATION OF attorney in fact. I, _____________________________________________________________, (name) presently residing at _______________________________________________________, (address) Ohio, are also are ineligible to be witnesses. If there is anything in this document that you do not understand, you should ask your lawyer to explain it to you. -4- Power of Attorney for Health Care 1. DNo person who is related to you by blood, marriage, or adoption may be a witness. The attorney in fact, your attending physician, and the administrator of any nursing home in which you are receiving c a durable power of attorney for health care unless it is acknowledged before a notary public or is signed by at least two adult witnesses who are present when you sign or acknowledge your signature. orney for health care with it, it will revoke any prior, valid durable power of attorney for health care that you created, unless you indicate otherwise in this document. This document is not valid asor other health care personnel to whom the revocation is communicated by such a witness communicate it to your attending physician. If you execute this document and create a valid durable power of attwever, if you made your attending physician aware of this document, any such revocation will be effective only when you communicate it to your attending physician, or when a witness to the revocation attorney in fact and the right to revoke this entire document at any time and in any manner. Any such revocation generally will be effective when you express your intention to make the revocation. Ho power it grants to your attorney in fact will continue in effect until you regain the capacity to make informed health care decisions for yourself. You have the right to revoke the designation of therney for health care generally will expire. However, if you specify an expiration date and then lack the capacity to make informed health care decisions for yourself on that date, the document and the you and the employee or agent are members of the same religious order. This document has no expiration date under Ohio law, but yo u may choose to specify a date upon which your durable power of attonder this document, unless either type of employee or agent is a competent adult and related to you by blood, marriage, or adoption, or unless either type of employee or agent is a competent adult andcument. Additionally, you CANNOT designate an employee or agent of your attending physician, or an employee or agent of a health care facility at which you are being treated, as the attorney in fact uorney in fact under this document. However, you CANNOT designate your attending physician or the administrator of any nursing home in which you are receiving care as the attorney in fact under this dolth care records, and to consent to the disclosure of health care records. You can limit that right in this document if you so choose. -3- Generally, you may designate any competent adult as the attn fact in another manner. When acting pursuant to this document, the attorney in fact GENERALLY will have the same rights that you have to receive information about proposed health care, to review headesires or, if your desires are unknown, to act in your best interest. You may express your desires to the attorney in fact by including them in this document or by making them known to the attorney i achieving the purposes for which you consented to its use. Additionally, when exercising authority to make health care decisions for you, the attorney in fact will have to act consistently with your consented, unless a change in your physical condition has significantly decreased the benefit of that health care to you, or unless the health care is not, or is no longer, significantly effective in HYDRATION TO YOU IF YOU ARE IN A PERMANENTLY UNCONSCIOUS STATE BY COMPLYING WITH THE REQUIREMENTS OF (4)(C)(I) AND (II) ABOVE. (5) Withdraw informed consent to any health care to which you previouslyTHER MARK PREVIOUSLY DESCRIBED. (D) YOUR ATTENDING PHYSICIAN DETERMINES, IN GOOD FAITH, THAT YOU AUTHORIZED THE ATTORNEY IN FACT TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION ORCKING OR OTHERWISE MARKING A BOX OR LINE (IF ANY) THAT IS ADJACENT TO A SIMILAR STATEMENT ON THIS DOCUMENT; (II) PLACING YOUR INITIALS OR SIGNATURE UNDERNEATH OR ADJACENT TO THE STATEMENT, CHECK, OR OYOU IF YOU ARE IN A PERMANENTLY UNCONSCIOUS STATE AND IF THE DETERMINATION THAT NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN IS MADE, OR CHES TYPE, INCLUDING, BUT NOT LIMITED TO, A DIFFERENT FONT, BIGGER TYPE, OR BOLDFACE TYPE, THAT THE ATTORNEY IN FACT MAY REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION TO YOU BY DOING BOTH OF THE FOLLOWING IN THIS DOCUMENT: (I) INCLUDING A STATEMENT IN CAPITAL LETTERS OR OTHER CONSPICUOUYDRATION WILL NOT OR -2- NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN. (C) IF, BUT ONLY IF, YOU ARE IN A PERMANENTLY UNCONSCIOUS STATE, YOU AUTHORIZE THE ATTORNEY IN FACT TOTTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED YOU DETERMINE, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT NUTRITION OR HISION OF ARTIFICIALLY OR TECHNOLOGICALLY ADMINISTERED SUSTENANCE (NUTRITION) OR FLUIDS (HYDRATION) TO YOU, UNLESS: (A) YOU ARE IN A TERMINAL CONDITION OR IN A PERMANENTLY UNCONSCIOUS STATE. (B) YOUR Adetermine, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that the fetus would not be born alive); (4) REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVwal would terminate the pregnancy (unless the pregnancy or health care would pose a substantial risk to your life, or unless your attending physician and at least one other physician who examines you ITHDRAW INFORMED CONSENT TO THE PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE.); (3) Refuse or withdraw informed consent to health care for you if you are pregnant and if the refusal or withdra, INTERVENTION, OR OTHER MEASURE WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN, THEN, SUBJECT TO (4) BELOW, YOUR ATTORNEY IN FACT WOULD BE AUTHORIZED TO REFUSE OR WE TAKEN TO DIMINISH YOUR PAIN OR DISCOMFORT, NOT TO POSTPONE YOUR DEATH. CONSEQUENTLY, IF YOUR ATTENDING PHYSICIAN WERE TO DETERMINE THAT A PREVIOUSLY DESCRIBED MEDICAL OR NURSING PROCEDURE, TREATMENTLUIDS (HYDRATION) WHEN ADMINISTERED TO DIMINISH YOUR PAIN OR DISCOMFORT, NOT TO POSTPONE YOUR DEATH, AND ANY OTHER MEDICAL OR NURS ING PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE THAT WOULD Bion or hydration to you as described under (4) below). (YOU SHOULD UNDERS TAND THAT COMFORT CARE IS DEFINED IN OHIO LAW TO MEAN ARTIFICIALLY OR TECHNOLOGICALLY ADMINISTERED SUSTENANCE (NUTRITION) OR Fe you with comfort care (except that, if the attorney in fact is not prohibited from doing so under (4) below, the attorney in fact could refuse or withdraw informed consent to the provision of nutritat there is no reasonable possibility that you will regain the capacity to make informed health care decisions for yourself); (2) Refuse or withdraw informed consent to health care necessary to providg no capacity to experience pain or suffering, and your attending physician additionally determines, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, thstate of permanent unconsciousness that is characterized by you being irreversibly unaware of yourself and your environment and by a total loss of cerebral cortical functioning, resulting in you havin in accordance with reasonable medical standards, that there is no reasonable possibility that you will regain the capacity to make informed health care decisions for yourself. -1- (b) You are in a s likely to occur within a relatively short time if life-sustaining treatment is not administered, and your attending physician additionally determines, to a reasonable degree of medical certainty and following applies: (a) You are suffering from an irreversible, incurable, and untreatable condition caused by disease, illness, or injury from which (i) there can be no recovery and (ii) your death i(unless your attending physician and one other physician who examines you determine, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that either of the make health care decisions for you under this document, the attorney in fact NEVER will be authorized to do any of the following: (1) Refuse or withdraw informed consent to life-sustaining treatment o withdraw informed consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. HOWEVER, even if the attorney in fact has general authority toe capacity to do so. The authority of the attorney in fact to make health care decisions for you GENERALLY will include the authority to give informed consent, to refuse to give informed consent, or tealth care matter, the attorney in fact GENERALLY will be authorized by this document to make health care decisions for you to the same extent as you could make those decisions yourself, if you had thlth care decisions for you. Subject to any specific limitations you include in this document, if your attending physician determines that you have lost the capacity to make an informed decision on a hrself, you retain the right to make all medical and other health care decisions for yourself. You may include specific limitations in this document on the authority of the attorney in fact to make hea that you have lost the capacity to make informed health care decisions for yourself and, notwithstanding this document, as long as you have the capacity to make informed health care decisions for youthe power to make MOST health care decisions for you if you lose the capacity to make informed health care decisions for yourself. This power is effective only when your attending physician determinesNT (Pursuant to R.C. Sec.1337.17) This is an important legal document. Before executing this document, you should know these facts: This document gives the person you designate (the attorney in fact) [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -6- Durable Power of Attorney for Health Care NOTICE TO ADULT EXECUTING THIS DOCUMEion. You should also consult an attorne y whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situateffect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a startingtype, or boldface type. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal paragraph (2), followed by an asterisk and all of paragraph (4) shall appear in the printed form in capital letters or other conspicuous type, including, but not limited to, a different font, bigger on shall include the following notice (see notice below at the beginning of the Power of Attorney): In the preceding notice, the single words, and the two sentences in the second set of parentheses inted form shall not be used as an instrument for granting authority for any other decisions. Any printed form that is sold or otherwise distributed in this state for the purpose described in this sectifor use by adults who are not advised by an attorney. By use of such a printed form, a principal may authorize an attorney in fact to make health care decisions on the principal's behalf, but the prin power of attorney for health care. § 1337.17 Use of printed form; notice to principal. A printed form of durable power of attorney for health care may be sold or otherwise distributed in this state g physician shall make the fact a part of the principal's medical record. (C) Unless the instrument provides otherwise, a valid durable power of attorney for health care revokes a prior, valid durablesician of a principal of the fact that his durable power of attorney for health care has been revoked, the attending physician or other health care personnel acting under the direction of the attendinlth care by an alleged witness may rely on the information and act in accordance with the revocation. -5- (B) Upon the communication as described in division (A) of this section to the attending phyh a witness. Absent actual knowledge to the contrary, the attending physician of the principal and other health care personnel who are informed of the revocation of a durable power of attorney for heashall be effective upon its communication to the attending physician by the principal himself, a witness to the revocation, or other health care personnel to whom the revocation is communicated by sucbe effective when the principal expresses his intention to so revoke, except that, if the principal made his attending physician aware of the durable power of attorney for health care, the revocation rable power of attorney for health care may revoke that instrument or the designation of the attorney in fact under it. The principal may so revoke at any time and in any manner. The revocation shall lth care is not, or is no longer, significantly effective in achieving the purposes for which the principal consented to its use. § 1337.14 Revocation of power. (A) A principal who creates a valid dunsented, unless at least one of the following applies: (1) A change in the physical condition of the principal has significantly decreased the benefit of that health care to the principal. (2) The hea of this section. (F) An attorney in fact under a durable power of attorney for health care does not have authority to withdraw informed consent to any health care to which the principal previously co informed consent to the provision of nutrition or hydration to the principal when the principal is in a permanently unconscious state by complying with the requirements of divisions (E)(2)(a) and (b)ion. (3) If the principal is in a permanently unconscious state, the principal's attending physician determines, in good faith, that the principal authorized the attorney in fact to refuse or withdraw durable power of attorney for health care; (b) Placing the principal's initials or signature underneath or adjacent to the statement, check, or other mark described in division (E)(2)(a) of this sectcious state and if the determination described in division (E)(1) of this section is made, or checking or otherwise marking a box or line that is adjacent to a similar statement on a printed form of abigger type, or boldface type, that the attorney in fact may refuse or withdraw informed consent to the provision of nutrition or hydration to the principal if the principal is in a permanently uncons doing both of the following in the durable power of attorney for health care: (a) Including a statement in capital letters or other conspicuous type, including, but not limited to, a different font, has authorized the attorney in fact to refuse or withdraw informed consent to the provision of nutrition or -4- hydration to the principal when the principal is in a permanently unconscious state byrds, that nutrition or hydration will not or no longer will serve to provide comfort to, or alleviate pain of, the principal. (2) If the principal is in a permanently unconscious state, the principal principal's attending physician and at least one other physician who has examined the principal determine, to a reasonable degree of medical certainty and in accordance with reasonable medical standaormed consent to the provision of nutrition or hydration to the principal, unless the principal is in a terminal condition or in a permanently unconscious state and unless the following apply: (1) Thee with reasonable medical standards, that the fetus would not be born alive. (E) An attorney in fact under a durable power of attorney for health care does not have authority to refuse or withdraw inf of the principal, or unless the principal's attending physician and at least one other physician who has examined the principal determine, to a reasonable degree of medical certainty and in accordancth care for a principal who is pregnant if the refusal or withdrawal of the health care would terminate the pregnancy, unless the pregnancy or the health care would pose a substantial risk to the life provision of nutrition or hydration to the principal. (D) An attorney in fact under a durable power of attorney for health care does not have authority to refuse or withdraw informed consent to healn or hydration to the principal if, under the circumstances described in division (E) of this section, the attorney in fact would not be prohibited from refusing or withdrawing informed consent to thenot preclude, and shall not be construed as precluding, an attorney in fact under a durable power of attorney for health care from refusing or withdrawing informed consent to the provision of nutritioable power of attorney for health care does not have authority, on behalf of the principal, to refuse or withdraw informed consent to health care necessary to provide comfort care. This division does ble possibility that the principal will regain the capacity to make informed health care decisions for the principal. (C) Except as otherwise provided in this division, an attorney in fact under a durate, the attending physician of the principal shall determine, in good faith, to a reasonable degree of medical certainty, and in accordance with reasonable medical standards, that there is no reasonascious state. (3) In order for an attorney in fact to refuse or withdraw informed consent to life-sustaining treatment for a principal who is in a terminal condition or in a permanently unconscious stc medicine and surgery, or of experience acquired in the practice of medicine and surgery or osteopathic medicine and surgery, is qualified to determine whether the principal is in a permanently uncons, illnesses, injuries, therapies, or branches of medicine and surgery or osteopathic medicine and surgery, of certification as a specialist in a particular branch of medicine or surgery or osteopathith the determination that the principal is in the permanently -3- unconscious state shall be a physician who, by virtue of advanced education or training, of a practice limited to particular disease) In order for an attorney in fact to refuse or withdraw informed consent to life-sustaining treatment for a principal who is in a permanently unconscious state, the consulting physician associated wing treatment, unless the principal is in a terminal condition or in a permanently unconscious state and unless the applicable requirements of divisions (B)(2) and (3) of this section are satisfied. (2 care records. (B) (1) An attorney in fact under a durable power of attorney for health care does not have authority, on behalf of the principal, to refuse or withdraw informed consent to lifesustainito the instrument, the attorney in fact has the same right as the principal to receive information about proposed health care, to review health care records, and to consent to the disclosure of healthtrument, to make or participate in the making of health care decisions on behalf of the principal. (3) Unless the right is limited in a durable power of attorney for health care, when acting pursuant s section does not affect, and shall not be construed as affecting, any right that the person designated as attorney in fact in a durable power of attorney for health care may have, apart from the ins that authority, the attorney in fact shall act consistently with the desires of the principal or, if the desires of the principal are unknown, shall act in the best interest of the principal. (2) Thiame extent as the principal could make those decisions for the principal if the principal had the capacity to do so. Except as otherwise provided in divisions (B) to (F) of this section, in exercising as otherwise provided in divisions (B) to (F) of this section and subject to any specific limitations in the instrument, the attorney in fact may make health care decisions for the principal to the se decisions for the principal, and only if the attending physician of the principal determines that the principal has lost the capacity to make informed health care decisions for the principal. Except make health care decisions for the principal only if the instrument substantially complies with section 1337.12 of the Revised Code and specifically authorizes the attorney in fact to make health carication" have the same meanings as in section 2133.21 of the Revised Code. § 1337.13 Authority of attorney in fact. (A) (1) An attorney in fact under a durable power of attorney for health care shall power of attorney. (2) As used in division (D) of this section: -2- (a) "Declaration" has the same meaning as in section 2133.01 of the Revised Code. (b) "Do-not-resuscitate order" and "DNR identif do-not-resuscitate order that a physician issued for the principal which is inconsistent with the durable power of attorney for health care or a valid decision by the attorney in fact under a durablees the durable power of attorney for health care to the extent of any conflict between the two. A valid durable power of attorney for health care supersedes any DNR identification that is based upon aased upon a valid declaration and if the declaration supersedes the durable power of attorney for health care under division (B) of section 2133.03 of the Revised Code, the DNR identification supersed care and a valid declaration, division (B) of section 2133.03 of the Revised Code applies. If a principal has both a valid durable power of attorney for health care and a DNR identification that is bshall attest that the principal appears to be of sound mind and not under or sub ject to duress, fraud, or undue influence. (D) (1) If a principal has both a valid durable power of attorney for healthb) of this section, a durable power of attorney for health care shall be acknowledged before a notary public, who shall make the certification described in section 147.53 of the Revised Code and also due influence. The signatures of the principal and the witnesses under this division are not required to appear on the same page of the instrument. (C) If acknowledged for purposes of division (A)(1)(itness's signature after the signature of the principal and, by doing so, attest to the witness's belief that the principal appears to be of sound mind and not under or subject to duress, fraud, or un for health care shall involve the principal signing, or acknowledging the principal's signature, at the end of the instrument in the presence of each witness. Then, each witness shall subscribe the we attending physician of the principal, and the administrator of any nursing home in which the principal is receiving care are ineligible to be witnesses. The witnessing of a durable power of attorneyt ineligible to be witnesses under this division. Any person who is related to the principal by blood, marriage, or adoption, any person who is designated as the attorney in fact in the instrument, thprincipal. (B) If witnessed for purposes of division (A)(1)(b) of this section, a durable power of attorney for health care shall be witnessed by at least two individuals who are adults and who are nonformed health care decisions for the principal on the expiration date, the instrument shall continue in effect until the principal regains the capacity to make informed health care decisions for the ll not expire, unless the principal specifies an expiration date in the instrument. However, when a durable power of attorney contains an expiration date, if the principal lacks the capacity to make imarriage, or adoption, or if the -1- individual is a competent adult and the principal and the individual are members of the same religious order. (3) A durable power of attorney for health care shatations do not preclude a principal from designating either type of employee or agent as the principal's attorney in fact if the individual is a competent adult and related to the principal by blood, n which the principal is being treated shall not be designated as an attorney in fact in, or act as an attorney in fact pursuant to, a durable power of attorney for health care, except that these limias an attorney in fact pursuant to, a durable power of attorney for health care. An employee or agent of the attending physician of the principal and an employee or agent of any health care facility i attorney in fact. The attending physician of the principal and an administrator of any nursing home in which the principal is receiving care shall not be designated as an attorney in fact in, or act y the principal in accordance with division (C) of this section. (2) Except as otherwise provided in this division, a durable power of attorney for health care may designate any competent adult as the shall be signed at the end of the instrument by the principal and shall state the date of its execution. (b) It shall be witnessed in accordance with division (B) of this section or be acknowledged bormed consent to any health care that is being or could be provided to the principal. Additionally, to be valid, a durable power of attorney for health care shall satisfy both of the following: (a) Iterwise provided in divisions (B) to (F) of section 1337.13 of the Revised Code, the authorization may include the right to give informed consent, to refuse to give informed consent, or to withdraw inf for the principal at any time that the attending physician of the principal determines that the principal has lost the capacity to make informed health care decisions for the principal. Except as othr of attorney, in accordance with division (B) of section 1337.09 of the Revised Code, that authorizes an attorney in fact as described in division (A)(2) of this section to make health care decisionspower of attorney for health care; witnesses; acknowledgment. (A) (1) An adult who is of sound mind voluntarily may create a valid durable power of attorney for health care by executing a durable powen Ohio Statutes Title 13 Chapter 1337 Section 1337.11 et. Seq. The following are useful excerpts from the Ohio Statutes relating to the Ohio Power of Attorney for Health Care Form. § 1337.12 Durable is package contains (1) Information and Instruction for Ohio Power of Attorne y for Health Care; (2) Ohio Power of Attorney for Health Care Form. This Ohio Power of Attorney for Health Care is based oprofessional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Ohio Power of Attorney for Health Care Thular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax ry from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particare provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vaDirective. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have been made or Ohio Advance Health Care Directive This package contains both a Ohio Power of Attorney for Health Care and a Ohio Living Will. Together these forms are also sometimes known as an Advance Health Care Ohio