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Ohio und mind and not under or subject to duress, fraud or undue influence. My Commission Expires:____________________ _________________________________________ (Notary) -9- the above Durable Power of Attorney 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 so, before me, the undersigned Notary Public, personally appeared ______________________________________, who is known to me or who has satisfactorily proven to be the person whose name is subscribed to____________________________________________________ -8- OR ACKNOWLEDGEMENT State of Ohio County of _____________________________, s.s.: On this the _________ day of _________________________, 20___ess Signature: _____________________________________________ Print Name: ___________________________________________________ Residence Address: _____________________________________________ Date: _______ Print Name: ___________________________________________________ Residence Address: _____________________________________________ Date: ________________________________________________________ Witnnursing home in which the principal is receiving care, and that I am an adult not related to the principal by blood, marriage or adoption. Witness Signature: __________________________________________r subject to duress, fraud or undue influence. 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 BEFORE A NOTARY PUBLIC. I attest that the 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 oOF ATTORNEY FOR HEALTH CARE WILL NOT BE VALID 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 ttorney for Health Care after careful deliberation on _________________________ (date) at ____________________________, (city) Ohio. ___________________________________ (Principal) THIS DURABLE POWER s I sign it in the presence of either a notary 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 Ahis one. Ohio law requires that I be given the 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 unles (or the physician's staff) by me or by a witness -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 trbally or in writing. If I have given a copy 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 of the Ohio Revised Code. 9. REVOCATION OF THIS 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 vesion or the appointment of my agent to make health care decisions. 8. PRIOR DESIGNATIONS REVOKED. I hereby revoke any prior Durable Powers of Attorney for Health Care executed by me under Chapter 1337orney for Health Care shall have no expiration date. 7. SEVERABILITY. Any invalid or unenforceable power, authority or provision of this instrument shall not affect any other power, authority or proviercise all of the authority conferred above. 6. 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 Attnship) presently residing at ____________________________________________ (address) _________________ (home telephone number) _________________ (work telephone number) Each alternate shall have and ex______________________ (address) _________________ (home telephone number) _________________ (work telephone number) Second Alternate Agent___________________________________________,(name and relatioable or is unwilling or unable to serve or to continue to serve: First Alternate Agent: ___________________________________________,(name and relationship) presently residing at ______________________f the following individuals to succeed to such authorities 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 avail ME OR ALLEVIATE MY PAIN. 5. DESIGNATION OF ALTERNATE AGENT. -6- Because I wish that an agent shall be available to exercise the authorities granted hereunder at all times, I further designate each o ME DETERMINES, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT SUCH NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TOPROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIED NUTRITION AND HYDRATION IF I AM IN A PERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINEDTATE. IF I HAVE MARKED THE FOREGOING BOX AND HAVE PLACED 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 nt necessary or desirable to implement health care decisions that my agent is authorized to make pursuant to this document. 4. WITHDRAWAL OF NUTRITION AND HYDRATION WHEN IN A PERMANENTLY UNCONSCIOUS Sto medical treatment or written requests that I be transferred to another facility; (2) Documents that are Do Not Resuscitate Orders, Discharge Orders or other similar orders; and (3) Any other documeluding, but not limited to, hospitals, nursing homes, assisted residence facilities, and the like; and (h) To execute on my behalf any or all of the following: (1) Documents that are written consents als, including individuals and services providing home health care, as my agent shall determine to be appropriate; (g) To select and contract with any medical or health care facility on my behalf, inc To consent to the further disclosure of this information if necessary; (f ) To select, employ, and discharge health care personnel, such as physicians, nurses, therapists and other medical professionuding, but not limited to, all of my medical and health care facility records; (d) To execute on my behalf any releases or other documents that may be required in order to obtain this information; (e)on unless I have specifically authorized such refusal or withdrawal in Paragraph 4; (c) To request, review, and receive any information, verbal or written, regarding my physical or mental health, incle informed consent to life-sustaining treatment; provided, however, my agent is not authorized to refuse or direct the withdrawal of -5- artificially or technologically supplied nutrition or hydratirtificially or technologically supplied nutrition or hydration; (b) If I am in a permanently unconscious state, to give informed consent to life-sustaining treatment or to withdraw or to refuse to givauthority to do any and all of the following: (a) If I am in a terminal condition, to give, to withdraw or to refuse to give informed consent to life-sustaining treatment, including the provision of aests. 3. ADDITIONAL AUTHORITIES OF AGENT. Where necessary 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 hat are consistent with my desires as stated in this document 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 interrsing procedure, treatment, intervention or other measure used to maintain, diagnose or treat my physical or mental condition. In exercising this authority, my agent shall make health care decisions tot have the capacity to make or communicate informed health 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 nuy agent full power and authority to make all health care decisions 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 nns for me consistent with my wishes as authorized in this document or, if not expressed here, as otherwise made known to my agent by me.. 2. GENERAL STATEMENT OF AUTHORITY GRANTED. I hereby grant to m_____________________________ (address) _________________ (home telephone number) _________________ (work telephone number) as my attorney in fact who shall act as my agent to make health care decisior Chapter 1337 of the Ohio Revised Code, I hereby designate and appoint: ________________________________________________________________ (name of agent) presently residing at ________________________________________________________________, (address) Ohio, am an adult of sound mind. After careful consideration, I knowingly and voluntarily create this Durable Power of Attorney for Health Care undein it to you. -4- Power of Attorney for Health Care 1. DESIGNATION OF attorney in fact. I, _____________________________________________________________, (name) presently residing at _______________nistrator of any nursing home in which you are receiving care also are ineligible to be witnesses. If there is anything in this document that you do not understand, you should ask your lawyer to expla are present when you sign or acknowledge your signature. No person who is related to you by blood, marriage, or adoption may be a witness. The attorney in fact, your attending physician, and the admi otherwise in this document. This document is not valid as 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 whocute this document and create a valid durable power of attorney for health care with it, it will revoke any prior, valid durable power of attorney for health care that you created, unless you indicate attending physician, or when a witness to the revocation or other health care personnel to whom the revocation is communicated by such a witness communicate it to your attending physician. If you exewhen you express your intention to make the revocation. However, if you made your attending physician aware of this document, any such revocation will be effective only when you communicate it to yourrself. You have the right to revoke the designation of the 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 decisions for yourself on that date, the document and the power it grants to your attorney in fact will continue in effect until you regain the capacity to make informed health care decisions for youse to specify a date upon which your durable power of attorney for health care generally will expire. However, if you specify an expiration date and then lack the capacity to make informed health cares either type of employee or agent is a competent adult and you and the employee or agent are members of the same religious order. This document has no expiration date under Ohio law, but you may chooy at which you are being treated, as the attorney in fact under this document, unless either type of employee or agent is a competent adult and related to you by blood, marriage, or adoption, or unlesou are receiving care as the attorney in fact under this document. Additionally, you CANNOT designate an employee or agent of your attending physician, or an employee or agent of a health care facilitGenerally, you may designate any competent adult as the attorney in fact under this document. However, you CANNOT designate your attending physician or the administrator of any nursing home in which yceive information about proposed health care, to review health 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- in this document or by making them known to the attorney in fact in another manner. When acting pursuant to this document, the attorney in fact GENERALLY will have the same rights that you have to ree attorney in fact will have to act consistently with your desires or, if your desires are unknown, to act in your best interest. You may express your desires to the attorney in fact by including themth care is not, or is no longer, significantly effective in achieving the purposes for which you consented to its use. Additionally, when exercising authority to make health care decisions for you, thinformed consent to any health care to which you previously consented, unless a change in your physical condition has significantly decreased the benefit of that health care to you, or unless the heal WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR 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 NATURE UNDERNEATH OR ADJACENT TO THE STATEMENT, CHECK, OR OTHER MARK PREVIOUSLY DESCRIBED. (D) YOUR ATTENDING PHYSICIAN DETERMINES, IN GOOD FAITH, THAT YOU AUTHORIZED THE ATTORNEY IN FACT TO REFUSE OROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN IS MADE, OR CHECKING OR OTHERWISE MARKING A BOX OR LINE (IF ANY) THAT IS ADJACENT TO A SIMILAR STATEMENT ON THIS DOCUMENT; (II) PLACING YOUR INITIALS OR SIGRMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION TO YOU IF YOU ARE IN A PERMANENTLY UNCONSCIOUS STATE AND IF THE DETERMINATION THAT NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PRNCLUDING A STATEMENT IN CAPITAL LETTERS OR OTHER CONSPICUOUS TYPE, INCLUDING, BUT NOT LIMITED TO, A DIFFERENT FONT, BIGGER TYPE, OR BOLDFACE TYPE, THAT THE ATTORNEY IN FACT MAY REFUSE OR WITHDRAW INFOLY UNCONSCIOUS STATE, YOU AUTHORIZE THE ATTORNEY IN FACT 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) IANCE WITH REASONABLE MEDICAL STANDARDS, THAT NUTRITION OR HYDRATION 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 PERMANENTCONDITION OR IN A PERMANENTLY UNCONSCIOUS STATE. (B) YOUR ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED YOU DETERMINE, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDalive); (4) REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY ADMINISTERED SUSTENANCE (NUTRITION) OR FLUIDS (HYDRATION) TO YOU, UNLESS: (A) YOU ARE IN A TERMINAL hysician and at least one other physician who examines you determine, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that the fetus would not be born e for you if you are pregnant and if the refusal or withdrawal would terminate the pregnancy (unless the pregnancy or health care would pose a substantial risk to your life, or unless your attending pW, YOUR ATTORNEY IN FACT WOULD BE AUTHORIZED TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE.); (3) Refuse or withdraw informed consent to health carREVIOUSLY DESCRIBED MEDICAL OR NURSING PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN, THEN, SUBJECT TO (4) BELOURE, TREATMENT, INTERVENTION, OR OTHER MEASURE THAT WOULD BE TAKEN TO DIMINISH YOUR PAIN OR DISCOMFORT, NOT TO POSTPONE YOUR DEATH. CONSEQUENTLY, IF YOUR ATTENDING PHYSICIAN WERE TO DETERMINE THAT A P OR TECHNOLOGICALLY ADMINISTERED SUSTENANCE (NUTRITION) OR FLUIDS (HYDRATION) WHEN ADMINISTERED TO DIMINISH YOUR PAIN OR DISCOMFORT, NOT TO POSTPONE YOUR DEATH, AND ANY OTHER MEDICAL OR NURSING PROCEDefuse or withdraw informed consent to the provision of nutrition or hydration to you as described under (4) below). (YOU SHOULD UNDERSTAND THAT COMFORT CARE IS DEFINED IN OHIO LAW TO MEAN ARTIFICIALLY withdraw informed consent to health care necessary to provide 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 rainty and 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); (2) Refuse orloss of cerebral cortical functioning, resulting in you having no capacity to experience pain or suffering, and your attending physician additionally determines, to a reasonable degree of medical certd health care decisions for yourself. -1- (b) You are in a state of permanent unconsciousness that is characterized by you being irreversibly unaware of yourself and your environment and by a total y determines, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that there is no reasonable possibility that you will regain the capacity to make informefrom which (i) there can be no recovery and (ii) your death is likely to occur within a relatively short time if life-sustaining treatment is not administered, and your attending physician additionallordance with reasonable medical standards, that either of the following applies: (a) You are suffering from an irreversible, incurable, and untreatable condition caused by disease, illness, or injury se or withdraw informed consent to life-sustaining treatment (unless your attending physician and one other physician who examines you determine, to a reasonable degree of medical certainty and in accOWEVER, even if the attorney in fact has general authority to make health care decisions for you under this document, the attorney in fact NEVER will be authorized to do any of the following: (1) Refuve informed consent, to refuse to give informed consent, or to withdraw informed consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. Hent as you could make those decisions yourself, if you had the capacity to do so. The authority of the attorney in fact to make health care decisions for you GENERALLY will include the authority to giou have lost the capacity to make an informed decision on a health care matter, the attorney in fact GENERALLY will be authorized by this document to make health care decisions for you to the same extdocument on the authority of the attorney in fact to make health care decisions for you. Subject to any specific limitations you include in this document, if your attending physician determines that ye the capacity to make informed health care decisions for yourself, you retain the right to make all medical and other health care decisions for yourself. You may include specific limitations in this er is effective only when your attending physician determines that you have lost the capacity to make informed health care decisions for yourself and, notwithstanding this document, as long as you havcument gives the person you designate (the attorney in fact) the power to make MOST health care decisions for you if you lose the capacity to make informed health care decisions for yourself. This powttorney for Health Care NOTICE TO ADULT EXECUTING THIS DOCUMENT (Pursuant to R.C. Sec.1337.17) This is an important legal document. Before executing this document, you should know these facts: This dof this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -6- Durable Power of Aattorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out oand from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an eir 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 vary from time to time type, including, but not limited to, a different font, bigger type, or boldface type. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to thords, and the two sentences in the second set of parentheses in paragraph (2), followed by an asterisk and all of paragraph (4) shall appear in the printed form in capital letters or other conspicuousstributed in this state for the purpose described in this section shall include the following notice (see notice below at the beginning of the Power of Attorney): In the preceding notice, the single we health care decisions on the principal's behalf, but the printed form shall not be used as an instrument for granting authority for any other decisions. Any printed form that is sold or otherwise dihealth care may be sold or otherwise distributed in this state for 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 makpower of attorney for health care revokes a prior, valid durable 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 personnel acting under the direction of the attending physician shall make the fact a part of the principal's medical record. (C) Unless the instrument provides otherwise, a valid durable s described in division (A) of this section to the attending physician of a principal of the fact that his durable power of attorney for health care has been revoked, the attending physician or other nformed of the revocation of a durable power of attorney for health care by an alleged witness may rely on the information and act in accordance with the revocation. -5- (B) Upon the communication alth care personnel to whom the revocation is communicated by such a witness. Absent actual knowledge to the contrary, the attending physician of the principal and other health care personnel who are if the durable power of attorney for health care, the revocation shall be effective upon its communication to the attending physician by the principal himself, a witness to the revocation, or other heay so revoke at any time and in any manner. The revocation shall be effective when the principal expresses his intention to so revoke, except that, if the principal made his attending physician aware o7.14 Revocation of power. (A) A principal who creates a valid durable power of attorney for health care may revoke that instrument or the designation of the attorney in fact under it. The principal mased the benefit of that health care to the principal. (2) The health care is not, or is no longer, significantly effective in achieving the purposes for which the principal consented to its use. § 133d consent to any health care to which the principal previously consented, unless at least one of the following applies: (1) A change in the physical condition of the principal has significantly decreaby complying with the requirements of divisions (E)(2)(a) and (b) of this section. (F) An attorney in fact under a durable power of attorney for health care does not have authority to withdraw informee principal authorized the attorney in fact to refuse or withdraw informed consent to the provision of nutrition or hydration to the principal when the principal is in a permanently unconscious state check, or other mark described in division (E)(2)(a) of this section. (3) If the principal is in a permanently unconscious state, the principal's attending physician determines, in good faith, that thne that is adjacent to a similar statement on a printed form of a durable power of attorney for health care; (b) Placing the principal's initials or signature underneath or adjacent to the statement, tion to the principal if the principal is in a permanently unconscious state and if the determination described in division (E)(1) of this section is made, or checking or otherwise marking a box or linspicuous 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 hydracipal when the principal is in a permanently unconscious state by doing both of the following in the durable power of attorney for health care: (a) Including a statement in capital letters or other coe principal is in a permanently unconscious state, the principal has authorized the attorney in fact to refuse or withdraw informed consent to the provision of nutrition or -4- hydration to the prinedical certainty and in accordance with reasonable medical standards, that nutrition or hydration will not or no longer will serve to provide comfort to, or alleviate pain of, the principal. (2) If thanently unconscious state and unless the following apply: (1) The principal's attending physician and at least one other physician who has examined the principal determine, to a reasonable degree of mfor health care does not have authority to refuse or withdraw informed consent to the provision of nutrition or hydration to the principal, unless the principal is in a terminal condition or in a permine, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that the fetus would not be born alive. (E) An attorney in fact under a durable power of attorney ancy or the health care would pose a substantial risk to the life of the principal, or unless the principal's attending physician and at least one other physician who has examined the principal determnot have authority to refuse or withdraw informed consent to health care for a principal who is pregnant if the refusal or withdrawal of the health care would terminate the pregnancy, unless the pregnbe prohibited from refusing or withdrawing informed consent to the provision of nutrition or hydration to the principal. (D) An attorney in fact under a durable power of attorney for health care does using or withdrawing informed consent to the provision of nutrition or hydration to the principal if, under the circumstances described in division (E) of this section, the attorney in fact would not health care necessary to provide comfort care. This division does not preclude, and shall not be construed as precluding, an attorney in fact under a durable power of attorney for health care from refherwise provided in this division, 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 rdance with reasonable medical standards, that there is no reasonable possibility that the principal will regain the capacity to make informed health care decisions for the principal. (C) Except as ot who is in a terminal condition or in a permanently unconscious state, the attending physician of the principal shall determine, in good faith, to a reasonable degree of medical certainty, and in accoified to determine whether the principal is in a permanently unconscious state. (3) In order for an attorney in fact to refuse or withdraw informed consent to life-sustaining treatment for a principalialist in a particular branch of medicine or surgery or osteopathic medicine and surgery, or of experience acquired in the practice of medicine and surgery or osteopathic medicine and surgery, is qualeducation or training, of a practice limited to particular diseases, illnesses, injuries, therapies, or branches of medicine and surgery or osteopathic medicine and surgery, of certification as a specmanently unconscious state, the consulting physician associated with the determination that the principal is in the permanently -3- unconscious state shall be a physician who, by virtue of advanced ents of divisions (B)(2) and (3) of this section are satisfied. (2) In order for an attorney in fact to refuse or withdraw informed consent to life-sustaining treatment for a principal who is in a per principal, to refuse or withdraw informed consent to lifesustaining treatment, unless the principal is in a terminal condition or in a permanently unconscious state and unless the applicable requiremew health care records, and to consent to the disclosure of health care records. (B) (1) An attorney in fact under a durable power of attorney for health care does not have authority, on behalf of thea durable power of attorney for health care, when acting pursuant to the instrument, the attorney in fact has the same right as the principal to receive information about proposed health care, to revible power of attorney for health care may have, apart from the instrument, to make or participate in the making of health care decisions on behalf of the principal. (3) Unless the right is limited in unknown, shall act in the best interest of the principal. (2) This section does not affect, and shall not be construed as affecting, any right that the person designated as attorney in fact in a durase provided in divisions (B) to (F) of this section, in exercising that authority, the attorney in fact shall act consistently with the desires of the principal or, if the desires of the principal are in fact may make health care decisions for the principal to the same extent as the principal could make those decisions for the principal if the principal had the capacity to do so. Except as otherwiy to make informed health care decisions for the principal. Except as otherwise provided in divisions (B) to (F) of this section and subject to any specific limitations in the instrument, the attorneynd specifically authorizes the attorney in fact to make health care decisions for the principal, and only if the attending physician of the principal determines that the principal has lost the capacitey in fact under a durable power of attorney for health care shall make health care decisions for the principal only if the instrument substantially complies with section 1337.12 of the Revised Code af the Revised Code. (b) "Do-not-resuscitate order" and "DNR identification" have the same meanings as in section 2133.21 of the Revised Code. § 1337.13 Authority of attorney in fact. (A) (1) An attornth care or a valid decision by the attorney in fact under a durable power of attorney. (2) As used in division (D) of this section: -2- (a) "Declaration" has the same meaning as in section 2133.01 o health care supersedes any DNR identification that is based upon a do-not-resuscitate order that a physician issued for the principal which is inconsistent with the durable power of attorney for healection 2133.03 of the Revised Code, the DNR identification supersedes the durable power of attorney for health care to the extent of any conflict between the two. A valid durable power of attorney forower of attorney for health care and a DNR identification that is based upon a valid declaration and if the declaration supersedes the durable power of attorney for health care under division (B) of sf a principal has both a valid durable power of attorney for health care and a valid declaration, division (B) of section 2133.03 of the Revised Code applies. If a principal has both a valid durable ptification described in section 147.53 of the Revised Code and also shall attest that the principal appears to be of sound mind and not under or subject to duress, fraud, or undue influence. (D) (1) Ithe instrument. (C) If acknowledged for purposes of division (A)(1)(b) of this section, a durable power of attorney for health care shall be acknowledged before a notary public, who shall make the certo be of sound mind and not under or subject to duress, fraud, or undue influence. The signatures of the principal and the witnesses under this division are not required to appear on the same page of e presence of each witness. Then, each witness shall subscribe the witness's signature after the signature of the principal and, by doing so, attest to the witness's belief that the principal appears gible to be witnesses. The witnessing of a durable power of attorney for health care shall involve the principal signing, or acknowledging the principal's signature, at the end of the instrument in thrson who is designated as the attorney in fact in the instrument, the attending physician of the principal, and the administrator of any nursing home in which the principal is receiving care are ineli witnessed by at least two individuals who are adults and who are not ineligible to be witnesses under this division. Any person who is related to the principal by blood, marriage, or adoption, any peregains the capacity to make informed health care decisions for the principal. (B) If witnessed for purposes of division (A)(1)(b) of this section, a durable power of attorney for health care shall bens an expiration date, if the principal lacks the capacity to make informed health care decisions for the principal on the expiration date, the instrument shall continue in effect until the principal religious order. (3) A durable power of attorney for health care shall not expire, unless the principal specifies an expiration date in the instrument. However, when a durable power of attorney contaiividual is a competent adult and related to the principal by blood, marriage, or adoption, or if the -1- individual is a competent adult and the principal and the individual are members of the same a durable power of attorney for health care, except that these limitations do not preclude a principal from designating either type of employee or agent as the principal's attorney in fact if the indthe principal and an employee or agent of any health care facility in 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,ving care 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. An employee or agent of the attending physician of of attorney for health care may designate any competent adult as the attorney in fact. The attending physician of the principal and an administrator of any nursing home in which the principal is receiin accordance with division (B) of this section or be acknowledged by the principal in accordance with division (C) of this section. (2) Except as otherwise provided in this division, a durable power attorney for health care shall satisfy both of the following: (a) It 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 rmed consent, to refuse to give informed consent, or to withdraw informed consent to any health care that is being or could be provided to the principal. Additionally, to be valid, a durable power of make informed health care decisions for the principal. Except as otherwise provided in divisions (B) to (F) of section 1337.13 of the Revised Code, the authorization may include the right to give infobed in division (A)(2) of this section to make health care decisions for the principal at any time that the attending physician of the principal determines that the principal has lost the capacity to urable power of attorney for health care by executing a durable power of attorney, in accordance with division (B) of section 1337.09 of the Revised Code, that authorizes an attorney in fact as descri the Ohio Power of Attorney for Health Care Form. § 1337.12 Durable power of attorney for health care; witnesses; acknowledgment. (A) (1) An adult who is of sound mind voluntarily may create a valid dlth Care Form. This Ohio Power of Attorney for Health Care is based on Ohio Statutes Title 13 Chapter 1337 Section 1337.11 et. Seq. The following are useful excerpts from the Ohio Statutes relating toInformation and Instructions Ohio Power of Attorney for Health Care This package contains (1) Information and Instruction for Ohio Power of Attorney for Health Care; (2) Ohio Power of Attorney for Hea Ohio