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Rhode Island __________________ Address: ______________________________________ nature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: _________________________ Zip Code: ___________________________ The declarant is personally known to me and voluntarily signed this document in my presence. _____________________________________________ (Witness Sig_____, __________________ __________________________________________ (Declarant's Signature) Address: __________________________________________________________________ ______________________________eviate pain. This authorization includes [__] does not include [__] the withholding or withdrawal of artificial feeding (check only one box above). Signed this __________________ day of _____________o make decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort, or to allng shall not be artificially prolonged under the circumstances set forth below, do hereby declare: If I should have an incurable or irreversible condition that will cause my death and if I am unable tse found at findlegalforms.com Living Will DECLARATION I, ______________________________________________________________ being of sound mind willfully and voluntarily make known my desire that my dying matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Uand should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate plannieteness. [_]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 starting point for you vocation. [_] 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 effect or compl provider or emergency medical services personnel upon communication to that physician health care provider or emergenc y medical services personnel by the declarant or by another who witnessed the reel, absence of reliable documentation as defined in § 23-4.11-2(6) shall constitute a revocation of the declaration. (b) A revocation is only effective as to the attending physician or any health carechapter 4.10 of this title, both of which have been executed by the same person, the latter executed document shall control as to any inconsistent provision. (4) For emergency medical services personnion a part of the declarant's medical record. (3) If there is an inconsistency between a declaration executed pursuant to this chapter and a durable health care power of attorney executed pursuant to der upon communication to that physician or health care provider by the declarant or by another who witnessed the revocation. (2) The attending physician or health care provider shall make the revocatby which the declarant is able to communicate an intent to revoke, without regard to mental or physical condition. A revocation is only effective as to the attending physician or any health care proviatment decisions. (d) A declaration may, but need not, be in the following form: (see form below) § 23-4.11-4 Revocation of declaration (a) A declaration may be revoked at any time and in any manner nding physician; Living Will Information & Instructions ­ Page 3 (2) The declarant is determined by the attending physician to be in a terminal condition; and (3) The declarant is unable to make treider who is provided a copy of the declaration shall make it a part of the declarant's medical record. (c) A declaration has operative effect only when: (1) The declaration is communicated to the attedeclarant, or another at the declarant's direction in the presence of two (2) subscribing witnesses who are not related to the declarant by blood or marriage. (b) A physician or other health care provetent individual eighteen (18) years of age or older may at any time execute a declaration governing the withholding or withdrawal of life sustaining procedures. The declaration must be signed by the t the administration of life sustaining procedures, will, in the opinion of the attending physician, result in death. § 23-4.11-3 Declaration relating to use of life sustaining procedures. (a) A compnifies and certifies that a valid and current declaration is on file and that the individual is a qualified patient. (13) "Terminal condition" means an incurable or irreversible condition that, withouor bracelet of uniform design, adopted by the director of health, with consultation from the local community emergency medical services agencies and licensed hospice and home health agencies, that sig has been determined by the attending physician to be in a terminal condition. (12) "Reliable documentation" means a standardized, state-wide form of identification such as a nontransferable necklace ntity. (10) "Physician" means an individual licensed to practice medicine in this state. (11) "Qualified patient" means a patient who has executed a declaration in accordance with this chapter and whoand care or alleviate pain. (9) "Person" means an individual, corporation, business trust, estate, trust, partnership, association, government, governmental subdivision or agency, or any other legal et, will serve only to prolong the dying process. "Life sustaining procedure" shall not include any medical procedure or intervention considered necessary by the attending physician to provide comfort er health care in the ordinary course of business or practice of a profession. (8) "Life sustaining procedure" means any medical procedure or intervention that, when administered to a qualified patiences personnel acting within the ordinary course of their professions. (7) "Health care provider" means a person who is licensed, certified, or otherwise authorized by the law of this state to administtructions ­ Page 2 (6) "Emergency medical services personnel" means paid or volunteer firefighters, law enforcement officers, first responders, emergency medical technicians, or other emergency servire of the patient. (4) "Declaration" means a witnessed document executed in accordance with the requirements of § 23-4.11-3. (5) "Director" means the director of health. Living Will Information & Insby parenteral, nasogastric, gastric or any means other than through per oral voluntary sustenance. (3) "Attending physician" means the physician who has primary responsibility for the treatment and cace service advisory board, of providing palliative care to, and withholding lifesustaining procedures from, a qualified patient. (2) "Artificial feeding" means the provision of nutrition or hydration ion of this chapter: (1) "Advance directive protocol" means a standardized, state-wide method developed for emergency medical services personnel by the department of health and approved by the ambulanation instructing his or her physician to withhold or withdraw life sustaining procedures in the event of a terminal condition. § 23-4.11-2 Definitions. The following definitions govern the constructthey are no longer able to participate actively in decisions about themselves, the legislature declares that the laws of the state shall recognize the right of an adult person to make a written declaredical care, including the decision to have life sustaining procedures withheld or withdrawn in instances of a terminal condition. (b) In order that the rights of patients may be respected even after 23-4.11 Rights of the Terminally Ill Act § 23-4.11-1 Purpose. (a) The legislature finds that adult persons have the fundamental right to control the decisions relating to the rendering of their own mitle 23 Chapter 23-4.11 section 23-4.11-1 et. Seq. of the Rhode Island Statutes For your convenience, we have included useful excerpts from the Rhode Island Statutes relating to Living Wills. CHAPTER and Instructions Rhode Island Living Will This package contains (1) Information and Instruction for Rhode Island Living Will; (2) Rhode Island Living Will. This Rhode Island Living Will is based on T___________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ -6- Informationncipal under a will now existing or by operation of law. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ___________________perjury that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the pri____________________________________ Date: ________________________________________ (AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.) I further declare under penalty of __________________________ Date: ________________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: __ty, nor an employee of an operator of a community care facility. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ____________uence, that I am not the person appointed as attorney in fact by this document, and that I am not a health care provider, an employee of a health care provider, the operator of a community care facilie to be the principal, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue infle the additional declaration set out following the place where the witnesses sign.) I declare under penalty of perjury that the person who signed or acknowledged this document is personally known to mloyee of an operator of a community care facility. You are not required to have this document witnessed by a notary public. -5- (At least one of the qualified witnesses or the notary public must maka witness: (1) A person you designate as your agent or alternate agent, (2) A health care provider, (3) An employee of a health care provider, (4) The operator of a community care facility, (5) An empED TO HAVE THIS POWER OF ATTORNEY NOTARIZED STATEMENT OF WITNESSES (This document must be witnessed by two (2) qualified adult witnesses or one (1) notary public. None of the following may be used as UR SIGNATURE. IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS POWER OF ATTORNEY.) YOU ARE NOT REQUIR___________________________________________ (You sign here) (THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED BY TWO (2) QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YO) I sign my name to this Statutory Form Durable Power of Attorney for Health Care on ____________________________ (Date) at ____________________________ (C ity) ____________________________ (State) _ second alternate agent.) (9) PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney for health care. DATE AND SIGNATURE OF PRINCIPAL (YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY first alternate agent.) -4- (B) Second Alternate Age nt: __________________________________ __________________________________________________________ (Insert name, address, and telephone number oferve in the order listed below: (A) First Alternate Agent: ____________________________________ _________________________________________________________ (Insert name, address, and telephone number ofent to make health care decisions for me, then I designate and appoint the following persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to sigible to act as my agent to make a health care decision for me or loses the mental capacity to make health care decisions for me, or if I revoke that person's appointment or authority to act as my ag you designated is your spouse, he or she becomes ineligible to act as your agent if your marriage is dissolved.) If the person designated as my agent in paragraph (1) is not available or becomes inelou designate will be able to make the same health care decisions as the agent you designated in paragraph (1), above, in the event that agent is unable or ineligible to act as your agent. If the agent you want the authority of your agent to end on a specific date.) (8) DESIGNATION OF ALTERNATE AGENTS. (You are not required to designate any alternate agents but you may do so. Any alternate agent y shorter period in the space below, this power of attorney will exist until it is revoked.) This durable power of attorney for health care expires on ______________________ (Fill in this space ONLY ifRefusal to Permit Treatment" and "Leaving Hospital Against Medical Advice." (b) Any necessary waiver or release from liability required by a hospital or physician. (7) DURATION. (Unless you specify alth care decisions that my agent is authorized by this document to make, my agent has the power and authority to execute on my behalf all of the following: (a) Documents titled or purporting to be a "ou must state the limitations in paragraph (4) ("Statement of desires, special provisions, and limitations") above.) (6) SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary to implement the heaer to obtain this information. (c) Consent to the disclosure of this information. -3- (If you want to limit the authority of your agent to receive and disclose information relating to your health, yal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records. (b) Execute on my behalf any releases or other documents that may be required in ordNG TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my agent has the power and authority to do all of the following: (a) Request, review, and receive any information, verbr statement. If you attach additional pages, you must date and sign EACH of the additional pages at the same time you date and sign this document.) (5) INSPECTION AND DISCLOSURE OF INFORMATION RELATIent of my death, I request that my agent inform my family/next of kin of my desire to be an organ and tissue donor, if possible. (You may attach additional pages if you need more space to complete youitional statement of desires, special provisions, and limitations regarding health care decisions: (c) Statement of desire regarding organ and tissue donation: Initial if applicable: [_____] In the evmy desires as stated below and is subject to the special provisions and limitations stated below: (a) Statement of desires concerning life-prolonging care, treatment, services, and procedures: (b) Add decisions for you, except to the extent that there are limits provided by law.) In exercising the authority under this durable power of attorney for health care, my agent shall act consistently with in any other way the authority given your agent by this document, you should state the limits in the space below. If you do not state any limits, your agent will have broad powers to make health caret by discussing your desires with your agent or by some other means. If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limiting care, treatment, services, and procedures. You can also include a statement of your desires concerning other matters relating to your health care. You can also make your desires known to your agenour known desires. You can, but are not required to, state your desires in the space provided below. You should consider whether you want to include a statement of your desires concerning life-prolongncluding a statement of your desires in the same paragraph.) -2- (4) STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. (Your agent must make health care decisions that are consistent with yyour agent to make health care decisions for you, you can state the limitations in paragraph (4) ("Statement of Desires, Special Provisions, and Limitations") below. You can indicate your desires by ithdrawing life-prolonging care, treatment, services, and procedures and informing my family or next of kin of my desire, if any, to be an organ or tissue donor. (If you want to limit the authority of alth care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, including, but not limited to, my desires concerning obtaining or refusing or wir and authority to make 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. In exercising this authority, my agent shall make he document I intend to create a durable power of attorney for health care. (3) GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I hereby grant to my agent full powe consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition. (2) CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By thisorney in fact (agent) to make health care decisions for me as authorized in this document. For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal ofr, (2) a nonrelative employee of your treating health care provider, (3) an operator of a community care facility, or (4) a nonrelative employee of an operator of a community care facility.) as my att, address, and telephone number of one individual only as your agent to make health care decisions for you. None of the following may be designated as your agent: (1) your treating health care provideNATION OF HEALTH CARE AGENT. I, ________________________________________________ (insert your name and address) do hereby designate and appoint: __________________________________________ (insert name is immediately available to your agent and alternate agents or give each of them an executed copy of this document. You may also want to give your doctor an executed copy of this document. (1) DESIGshould ask a lawyer to explain it to you. Your agent may need this document immediately in case of an emergency that requires a decision concerning your health care. Either keep this document where iting procedure described at the end of this form. This document will not be valid unless you comply with the witnessing procedure. If there is anything in this document that you do not understand, you nsent to their disclosure unless you limit this right in this document. This document revokes any prior durable power of attorney for health care. -1- You should carefully read and follow the witnessgent by notifying your agent or your treating doctor, hospital, or other health care provider orally or in writing of the revocation. Your agent has the right to examine your medical records and to cot's power and authority ceases upon your death except to inform your family or next of kin of your desire, if any, to be an organ and tissue owner. You have the right to revoke the authority of your aires, or (3) Where your desires are not known, does anything that is clearly contrary to your best interests. Unless you specify a specific period, this power will exist until you revoke it. Your agennot desire. In addition, a court can take away the power of your agent to make health care decisions for you if your agent: (1) Authorizes anything that is illegal, (2) Acts contrary to your known descal or mental condition. This power is subject to any statement of your desires and any limitation that you include in this document. You may state in this document any types of treatment that you do ect at the time. This document gives your agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physirespect to the particular decision. In addition, no treatment may be given to you over your objection at the time, and health care necessary to keep you alive may not be stopped or withheld if you objing treatment necessary to keep you alive. Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with s as stated in this document or otherwise made known. Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopp valid and binding. This document gives the person you designate as your agent (the attorney in fact) the power to make health care decisions for you. Your agent must act consistently with your desirel laws of this state. Before executing this document, you should know these important facts: You must be at least eighteen (18) years of age and a resident of the state for this document to be legallyund at findlegalforms.com -2- Statutory Form Durable Power Of Attorney For Health Care WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document which is authorized by the generaparty. Any possible tax consequences arising out of 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 fousing or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another al and/or tax advice. Laws vary from time to time and 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 warranties have been made or are 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 leg§ 23-4.10-2 Statutory form of durable power of attorney The statutory form of durable power of attorney is as follows (see form below): [_] These forms are provided "as is" and no implied or express revocation a part of the declarant's medical record. (c) For emergency medical services personnel, the absence of reliable documentation shall constitute a revocation of a durable power of attorney. ysician or health care provider or emergency medical services personnel by the declarant or by another who witnessed the revocation. (b) The attending physician or health care provider shall make the t regard to mental or physical condition. A revocation is only effective as to the attending physician or any health care provider or emergency medical services personnel upon communication to that physician, result in death. § 23-4.10-3 Revocation (a) A durable power of attorney may be revoked at any time and in any manner by which the declarant is able to communicate an intent to revoke, withou medicine in this state. (11) "Terminal condition" means an incurable or irreversible condition that, without the administration of life-sustaining procedures, will, in the opinion of the attending phiness trust, estate, trust, partnership, association, government, governmental subdivision or agency, or any other legal entity. (10) "Physician and/or doctor" means an individual licensed to practiceure or intervention considered necessary by the attending physician or emergency service personnel to provide comfort, care, or alleviate pain. -1- (9) "Person" means an individual, corporation, buscedure" means any medical procedure or intervention that, when administered to a patient, will serve only to prolong the dying process. "Life-sustaining procedure" shall not include any medical proceda person who is licensed, certified, or otherwise authorized by the law of this state to administer health care in the ordinary course of business or practice of a profession. (8) "Life-sustaining prow enforcement officers, first responders, emergency medical technicians, or other emergency services personnel acting within the ordinary course of their professions. (7) "Health-care provider" means "Durable power of attorney" means a witnessed document executed in accordance with the requirements of § 23-4.10-2. (6) "Emergency medical services personnel" means paid or volunteer firefighters, la per oral voluntary sustenance. (3) "Attending physician" means the physician who has primary responsibility for the treatment and care of the patient. (4) "Director" means the director of health. (5)olding life-sustaining procedures from, a qualified patient. (2) "Artificial feeding" means the provision of nutrition or hydration by parenteral, nasogastric, gastric, or any means other than througha standardized, state-wide method developed for emergency service personnel by the department of health and approved by the ambulance service advisory board, of providing palliative care to, and withhlating to the Rhode Island Power of Attorney for Health Care Form. § 23-4.10-1.1 Definitions The following definitions govern the construction of this chapter: (1) "Advance directive protocol" means hode Island Power of Attorney for Health Care is based on Title 23 Chapter 23-4.10 Section 23-4.10-1.1 of the Rhode Island Statutes. The following are useful excerpts from the Rhode Island Statutes reer of Attorney for Health Care This package contains (1) Information and Instruction for Rhode Island Power of Attorney for Health Care; (2) Rhode Island Power of Attorney for Health Care Form. This R 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 Information and Instructions Rhode Island Pow sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document shouldd/or tax advice. Laws vary 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 cons ulting an attorney first to makenties have been made or are 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 an an Advance Health Care Directive. 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 warraRhode Island Advance Health Care Directive This package contains both a Rhode Island Power of Attorney for Health Care and a Rhode Island Living Will. Together these forms are also sometimes known as Rhode Island