G.S. 32A-25.1 Page 1 § 32A-25.1. Statutory form health care power

§ 32A-25.1. Statutory form health care power of attorney.
(a)
The use of the following form in the creation of a health care power of attorney is
lawful and, when used, it shall meet the requirements of and be construed in accordance with
the provisions of this Article:
HEALTH CARE POWER OF ATTORNEY
NOTE: YOU SHOULD USE THIS DOCUMENT TO NAME A PERSON AS YOUR
HEALTH CARE AGENT IF YOU ARE COMFORTABLE GIVING THAT PERSON
BROAD AND SWEEPING POWERS TO MAKE HEALTH CARE DECISIONS FOR
YOU. THERE IS NO LEGAL REQUIREMENT THAT ANYONE EXECUTE A
HEALTH CARE POWER OF ATTORNEY.
EXPLANATION: You have the right to name someone to make health care decisions for you
when you cannot make or communicate those decisions. This form may be used to create a
health care power of attorney, and meets the requirements of North Carolina law. However,
you are not required to use this form, and North Carolina law allows the use of other forms
that meet certain requirements. If you prepare your own health care power of attorney, you
should be very careful to make sure it is consistent with North Carolina law.
This document gives the person you designate as your health care agent broad powers to make
health care decisions for you when you cannot make the decision yourself or cannot
communicate your decision to other people. You should discuss your wishes concerning
life-prolonging measures, mental health treatment, and other health care decisions with your
health care agent. Except to the extent that you express specific limitations or restrictions in
this form, your health care agent may make any health care decision you could make yourself.
This form does not impose a duty on your health care agent to exercise granted powers, but
when a power is exercised, your health care agent will be obligated to use due care to act in
your best interests and in accordance with this document.
This Health Care Power of Attorney form is intended to be valid in any jurisdiction in which it
is presented, but places outside North Carolina may impose requirements that this form does
not meet.
If you want to use this form, you must complete it, sign it, and have your signature witnessed by
two qualified witnesses and proved by a notary public. Follow the instructions about which
choices you can initial very carefully. Do not sign this form until two witnesses and a notary
public are present to watch you sign it. You then should give a copy to your health care agent
and to any alternates you name. You should consider filing it with the Advance Health Care
Directive Registry maintained by the North Carolina Secretary of State:
http://www.nclifelinks.org/ahcdr/
1. Designation of Health Care Agent.
I, __________________, being of sound mind, hereby appoint the following person(s) to serve
as my health care agent(s) to act for me and in my name (in any way I could act in person) to
make health care decisions for me as authorized in this document. My designated health care
agent(s) shall serve alone, in the order named.
G.S. 32A-25.1
Page 1
A.
Name: _______________________
Home Address: _______________________
____________________________________
Home Telephone:
Work Telephone:
Cellular Telephone:
_______________
_______________
_______________
B.
Name: _______________________
Home Address: _______________________
____________________________________
Home Telephone:
Work Telephone:
Cellular Telephone:
_______________
_______________
_______________
C.
Name: _______________________
Home Address: _______________________
____________________________________
Home Telephone:
Work Telephone:
Cellular Telephone:
_______________
_______________
_______________
Any successor health care agent designated shall be vested with the same power and duties as if
originally named as my health care agent, and shall serve any time his or her predecessor is not
reasonably available or is unwilling or unable to serve in that capacity.
2. Effectiveness of Appointment.
My designation of a health care agent expires only when I revoke it. Absent revocation, the
authority granted in this document shall become effective when and if one of the physician(s)
listed below determines that I lack capacity to make or communicate decisions relating to my
health care, and will continue in effect during that incapacity, or until my death, except if I
authorize my health care agent to exercise my rights with respect to anatomical gifts, autopsy,
or disposition of my remains, this authority will continue after my death to the extent necessary
to exercise that authority.
1. _______________________
(Physician)
2. _______________________
(Physician)
If I have not designated a physician, or no physician(s) named above is reasonably available,
the determination that I lack capacity to make or communicate decisions relating to my health
care shall be made by my attending physician.
3. Revocation.
Any time while I am competent, I may revoke this power of attorney in a writing I sign or by
communicating my intent to revoke, in any clear and consistent manner, to my health care
agent or my health care provider.
4. General Statement of Authority Granted.
Subject to any restrictions set forth in Section 5 below, I grant to my health care agent full
power and authority to make and carry out all health care decisions for me. These decisions
include, but are not limited to:
A.
G.S. 32A-25.1
Requesting, reviewing, and receiving any information, verbal or written,
regarding my physical or mental health, including, but not limited to,
Page 2
medical and hospital records, and to consent to the disclosure of this
information.
B.
Employing or discharging my health care providers.
C.
Consenting to and authorizing my admission to and discharge from a
hospital, nursing or convalescent home, hospice, long-term care facility, or
other health care facility.
D.
Consenting to and authorizing my admission to and retention in a facility for
the care or treatment of mental illness.
E.
Consenting to and authorizing the administration of medications for mental
health treatment and electroconvulsive treatment (ECT) commonly referred
to as "shock treatment."
F.
Giving consent for, withdrawing consent for, or withholding consent for,
X-ray, anesthesia, medication, surgery, and all other diagnostic and
treatment procedures ordered by or under the authorization of a licensed
physician, dentist, podiatrist, or other health care provider. This
authorization specifically includes the power to consent to measures for
relief of pain.
G.
Authorizing the withholding or withdrawal of life-prolonging measures.
H.
Providing my medical information at the request of any individual acting as
my attorney-in-fact under a durable power of attorney or as a Trustee or
successor Trustee under any Trust Agreement of which I am a Grantor or
Trustee, or at the request of any other individual whom my health care agent
believes should have such information. I desire that such information be
provided whenever it would expedite the prompt and proper handling of my
affairs or the affairs of any person or entity for which I have some
responsibility. In addition, I authorize my health care agent to take any and
all legal steps necessary to ensure compliance with my instructions
providing access to my protected health information. Such steps shall
include resorting to any and all legal procedures in and out of courts as may
be necessary to enforce my rights under the law and shall include attempting
to recover attorneys' fees against anyone who does not comply with this
health care power of attorney.
I.
To the extent I have not already made valid and enforceable arrangements
during my lifetime that have not been revoked, exercising any right I may
have to authorize an autopsy or direct the disposition of my remains.
J.
Taking any lawful actions that may be necessary to carry out these decisions,
including, but not limited to: (i) signing, executing, delivering, and
acknowledging any agreement, release, authorization, or other document that
may be necessary, desirable, convenient, or proper in order to exercise and
carry out any of these powers; (ii) granting releases of liability to medical
G.S. 32A-25.1
Page 3
providers or others; and (iii) incurring reasonable costs on my behalf related
to exercising these powers, provided that this health care power of attorney
shall not give my health care agent general authority over my property or
financial affairs.
5. Special Provisions and Limitations.
(Notice: The authority granted in this document is intended to be as broad as possible so that
your health care agent will have authority to make any decisions you could make to obtain or
terminate any type of health care treatment or service. If you wish to limit the scope of your
health care agent's powers, you may do so in this section. If none of the following are initialed,
there will be no special limitations on your agent's authority.)
A.
______________
(Initial)
______________
(Initial)
Limitations about Artificial Nutrition or Hydration: In exercising
the authority to make health care decisions on my behalf, my health
care agent:
shall NOT have the authority to withhold artificial nutrition
(such as through tubes) OR may exercise that authority only
in accordance with the following special provisions:
__________________________________________________
__________________________________________________
shall NOT have the authority to withhold artificial hydration
(such as through tubes) OR may exercise that authority only
in accordance with the following special provisions:
__________________________________________________
__________________________________________________
NOTE: If you initial either block but do not insert any special
provisions, your health care agent shall have NO AUTHORITY
to withhold artificial nutrition or hydration.
______________
(Initial)
B.
Limitations Concerning Health Care Decisions. In exercising
the authority to make health care decisions on my behalf, the
authority of my health care agent is subject to the following
special provisions: (Here you may include any specific
provisions you deem appropriate such as: your own definition
of when life-prolonging measures should be withheld or
discontinued, or instructions to refuse any specific types of
treatment that are inconsistent with your religious beliefs, or
are unacceptable to you for any other reason.)
__________________________________________________
__________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
______________
(Initial)
C.
Limitations Concerning Mental Health Decisions. In
exercising the authority to make mental health decisions on
my behalf, the authority of my health care agent is subject to
the following special provisions: (Here you may include any
specific provisions you deem appropriate such as: limiting
G.S. 32A-25.1
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the grant of authority to make only mental health treatment
decisions, your own instructions regarding the administration
or
withholding
of
psychotropic
medications
and
electroconvulsive treatment (ECT), instructions regarding
your admission to and retention in a health care facility for
mental health treatment, or instructions to refuse any specific
types of treatment that are unacceptable to you.)
__________________________________________________
__________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
______________
(Initial)
D.
Advance Instruction for Mental Health Treatment. (Notice:
This health care power of attorney may incorporate or be
combined with an advance instruction for mental health
treatment, executed in accordance with Part 2 of Article 3 of
Chapter 122C of the General Statutes, which you may use to
state your instructions regarding mental health treatment in
the event you lack capacity to make or communicate mental
health treatment decisions. Because your health care agent's
decisions must be consistent with any statements you have
expressed in an advance instruction, you should indicate here
whether you have executed an advance instruction for mental
health treatment):
__________________________________________________
__________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
______________
(Initial)
E.
Autopsy and Disposition of Remains. In exercising the
authority to make decisions regarding autopsy and disposition
of remains on my behalf, the authority of my health care agent
is subject to the following special provisions and limitations.
(Here you may include any specific limitations you deem
appropriate such as: limiting the grant of authority and the
scope of authority, or instructions regarding burial or
cremation):
__________________________________________________
__________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
6. Organ Donation.
To the extent I have not already made valid and enforceable arrangements during my lifetime
that have not been revoked, my health care agent may exercise any right I may have to:
______________
(Initial)
______________
(Initial)
donate any needed organs or parts; or
donate only the following organs or parts:
__________________________________________________
G.S. 32A-25.1
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NOTE: DO NOT INITIAL BOTH BLOCKS ABOVE.
______________
(Initial)
______________
(Initial)
donate my body for anatomical study if needed.
In exercising the authority to make donations, my health care
agent is subject to the following special provisions and
limitations: (Here you may include any specific limitations
you deem appropriate such as: limiting the grant of authority
and the scope of authority, or instructions regarding gifts of
the body or body parts.)
__________________________________________________
__________________________________________________
__________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
NOTE: NO AUTHORITY FOR ORGAN DONATION IS GRANTED IN
THIS INSTRUMENT WITHOUT YOUR INITIALS.
7. Guardianship Provision.
If it becomes necessary for a court to appoint a guardian of my person, I nominate the persons
designated in Section 1, in the order named, to be the guardian of my person, to serve without
bond or security. The guardian shall act consistently with G.S. 35A-1201(a)(5).
8. Reliance of Third Parties on Health Care Agent.
A.
B.
No person who relies in good faith upon the authority of or any
representations by my health care agent shall be liable to me, my estate, my
heirs, successors, assigns, or personal representatives, for actions or
omissions in reliance on that authority or those representations.
The powers conferred on my health care agent by this document may be
exercised by my health care agent alone, and my health care agent's
signature or action taken under the authority granted in this document may
be accepted by persons as fully authorized by me and with the same force
and effect as if I were personally present, competent, and acting on my own
behalf. All acts performed in good faith by my health care agent pursuant to
this power of attorney are done with my consent and shall have the same
validity and effect as if I were present and exercised the powers myself, and
shall inure to the benefit of and bind me, my estate, my heirs, successors,
assigns, and personal representatives. The authority of my health care agent
pursuant to this power of attorney shall be superior to and binding upon my
family, relatives, friends, and others.
9. Miscellaneous Provisions.
A.
G.S. 32A-25.1
Revocation of Prior Powers of Attorney. I revoke any prior health care
power of attorney. The preceding sentence is not intended to revoke any
general powers of attorney, some of the provisions of which may relate to
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health care; however, this power of attorney shall take precedence over any
health care provisions in any valid general power of attorney I have not
revoked.
B.
Jurisdiction, Severability, and Durability. This Health Care Power of
Attorney is intended to be valid in any jurisdiction in which it is presented.
The powers delegated under this power of attorney are severable, so that the
invalidity of one or more powers shall not affect any others. This power of
attorney shall not be affected or revoked by my incapacity or mental
incompetence.
C.
Health Care Agent Not Liable. My health care agent and my health care
agent's estate, heirs, successors, and assigns are hereby released and forever
discharged by me, my estate, my heirs, successors, assigns, and personal
representatives from all liability and from all claims or demands of all kinds
arising out of my health care agent's acts or omissions, except for my health
care agent's willful misconduct or gross negligence.
D.
No Civil or Criminal Liability. No act or omission of my health care agent,
or of any other person, entity, institution, or facility acting in good faith in
reliance on the authority of my health care agent pursuant to this Health Care
Power of Attorney shall be considered suicide, nor the cause of my death for
any civil or criminal purposes, nor shall it be considered unprofessional
conduct or as lack of professional competence. Any person, entity,
institution, or facility against whom criminal or civil liability is asserted
because of conduct authorized by this Health Care Power of Attorney may
interpose this document as a defense.
E.
Reimbursement. My health care agent shall be entitled to reimbursement for
all reasonable expenses incurred as a result of carrying out any provision of
this directive.
By signing here, I indicate that I am mentally alert and competent, fully informed as to the
contents of this document, and understand the full import of this grant of powers to my health
care agent.
This the _____ day of ______________, 20____.
________________________(SEAL)
I hereby state that the principal, _______________, being of sound mind, signed (or directed
another to sign on the principal's behalf) the foregoing health care power of attorney in my
presence, and that I am not related to the principal by blood or marriage, and I would not be
entitled to any portion of the estate of the principal under any existing will or codicil of the
principal or as an heir under the Intestate Succession Act, if the principal died on this date
without a will. I also state that I am not the principal's attending physician, nor a licensed health
care provider or mental health treatment provider who is (1) an employee of the principal's
attending physician or mental health treatment provider, (2) an employee of the health facility
in which the principal is a patient, or (3) an employee of a nursing home or any adult care home
G.S. 32A-25.1
Page 7
where the principal resides. I further state that I do not have any claim against the principal or
the estate of the principal.
Date: _____________________________
Witness: ___________________________
Date: _____________________________
Witness: ___________________________
________________COUNTY, _________________STATE
Sworn to (or affirmed) and subscribed before me this day by _____________________
(type/print name of signer)
______________________
(type/print name of witness)
______________________
(type/print name of witness)
Date: ___________________________
(Official Seal)
______________________________
Signature of Notary Public
__________________, Notary Public
Printed or typed name
My commission expires: __________
(b)
Use of the statutory form prescribed in this section is an optional and nonexclusive
method for creating a health care power of attorney and does not affect the use of other forms
of health care powers of attorney, including previous statutory forms. (1991, c. 639, s. 1; 1993,
c. 523, s. 3; 1998-198, s. 1; 1998-217, s. 53; 2005-351, s. 3; 2006-226, s. 32; 2007-502, s. 6(b);
2008-187, s. 37(a).)
G.S. 32A-25.1
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