Durable Power of Attorney for Healthcare

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Rhode Island Durable Power Of Attorney For Health Care AN ADVANCE CARE DIRECTIVE “A GIFT OF PREPAREDNESS” INTRODUCTION YOUR RIGHTS Adults have the fundamental right to control the decisions relating to their health care. You have the right to make medical and other health care decisions for yourself so long as you can give informed consent for those decisions. No treatment may be given to you over your objection at the time of treatment. You may decide whether you want life sustaining procedu
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   Rhode Island Durable Power Of Attorney For Health Care AN ADVANCE CARE DIRECTIVE “A GIFT OF PREPAREDNESS”   i INTRODUCTIONYOUR RIGHTS Adults have the fundamental right to control the decisions relating to their health care. You havethe right to make medical and other health care decisions for yourself so long as you can giveinformed consent for those decisions. No treatment may be given to you over your objection atthe time of treatment. You may decide whether you want life sustaining procedures withheld or withdrawn in instances of a terminal condition. What is a Durable   Power of Attorney for Health Care? This Durable Power of Attorney for Health Care lets you appoint someone to make health caredecisions for you when you cannot actively participate in health care decision making. The person you appoint to make health care decisions for you when you cannot actively participate inhealth care decision making is called your agent. The agent must act consistent with your desiresas stated in this document or otherwise known. Your agent must act in your best interest. Your agent stands in your place and can make any health care decision that you have the right to make.You should read this Durable Power of Attorney for Health Care carefully. Follow thewitnessing section as required. To have your wishes honored, this Durable Power of Attorneyfor Health Care must be valid. REMEMBER  i You must be at least eighteen (18) years old. i You must be a Rhode Island resident. i You should follow the instructions on this Durable Power of Attorney for Health Care. i You must voluntarily sign this Durable Power of Attorney for Health Care. i You must have this Durable Power of Attorney for Health Care witnessed properly. i No special form must be used but if you use this form it will be recognized by health care providers. i Make copies of your Durable Power of Attorney for Health Care for your agent, alternativeagent, physicians, hospital, and family. i Do not put your Durable Power of Attorney for Health Care in a safe deposit box . i Although you are not required to update your Durable Power of Attorney for Health Care,you may want to review it periodically. Commonly Used Life-Support Measures Are Listed on the Back Inside Page   1 DURABLE POWER OF ATTORNEY FOR HEALTH CARE(RHODE ISLAND HEALTH CARE ADVANCE DIRECTIVE)   I, ________________________________________________________________________, (Insert your name and address) am at least eighteen (18) years old, a resident of the State of Rhode Island, and understand thisdocument allows me to name another person (called the health care agent) to make health caredecisions for me if I can no longer make decisions for myself and I cannot inform my health care providers and agent about my wishes for medical treatment. P ART I: A PPOINTMENT OF H EALTH C ARE A GENT  T HIS I S W HO I W ANT T O M AKE H EALTH C ARE D ECISIONS  F OR  M E I F I CAN NO LONGER MAKE DECISIONS    Note:   You may not appoint the following individuals as an agent: (1) your treating health care provider, such as a doctor, nurse, hospital, or nursing home,(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 . When I am no longer able to make decisions for myself, I name and appointto make health care decisionsfor me. This person is called my health care agent.Telephone number of my health care agent:Address of my health care agent: You should discuss this health care directive with your agent and give your agent a copy. (O PTIONAL )A PPOINTMENT OF A LTERNATE H EALTH C ARE A GENTS : You are not required to name alternative health care agents. An alternative health care agent will be able to make the same health care decisions as the health care agent named above, if thehealth care agent is unable or ineligible to make health care decisions for you. For example, if  you name your spouse as your health care agent and your marriage is dissolved, then your  former spouse is ineligible to be your health care agent. When I am no longer able to make decisions for myself and my health care agent is notavailable, not able, loses the mental capacity to make health care decisions for me, becomesineligible to act as my agent, is not willing to make health care decisions for me, or I revoke the person appointed as my agent to make health care decisions for me, I name and appointthe following persons as my agent to make health care decision for me as authorized by thisdocument, in the order listed below:  _____ My Initials   2 My First Alternative Health Care Agent : __________________________________________ Telephone number of my first alternative health care agent:Address of my first alternative health care agent:My Second Alternative Health Care Agent : ________________________________________ Telephone number of my second alternative health care agent:Address of my second alternative health care agent:  My health care agent is automatically given the powers I would have to make health caredecisions for me if I were able to make such decisions. Some typical powers for a health careagent are listed below   in (A) through (H). My health care agent must convey my wishes for medical treatment contained in this document or any other instructions I have given to my agent. If I have not given health care instructions, then my agent must act in my best interest. A court can take away the power of an agent to make health care decisions for you if your agent:(1) Authorizes anything illegal,(2) Acts contrary to your known wishes, or (3) Where your desires are not known, does anything that is clearly contrary to your best interest. Whenever I can no longer make decisions about my medical treatment, my health care agent hasthe power to:(A) Make any health care decision for me. This includes the power to give, refuse, or withdraw consent to any care, treatments, services, tests, or procedures. Thisincludes deciding whether to stop or not start health care that is keeping me or mightkeep me alive, and deciding about mental health treatment.(B) Advocate for pain management for me.(C) Choose my health care providers, including hospitals, physicians, and hospice.(D) Choose where I live and receive health care which may include residential care,assisted living, a nursing home, a hospice, and a hospital.(E) Review my medical records and disclose my health care information, as needed.(F) Sign releases or other documents concerning my medical treatment.(G) Sign waivers or releases from liability for hospitals or physicians.(H) Make decisions concerning participation in research.If I DO NOT want my health care agent to have a power listed above in (A) through (H) OR if Iwant to LIMIT an power in (A) through (H), I must say that here:  _____ My Initials
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