(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.

 

 

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.

 

A. Name: _______________________ Home Telephone: _______________

Home Address: _______________________ Work Telephone: _______________

____________________________________ Cellular Telephone: _______________

 

B. Name: _______________________ Home Telephone: _______________

Home Address: _______________________ Work Telephone: _______________

____________________________________ Cellular Telephone: _______________

 

C. Name: _______________________ Home Telephone: _______________

Home Address: _______________________ 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. Requesting, reviewing, and receiving any information, verbal or written, regarding my physical or mental health, including, but not limited to, 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 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. 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
(Initial) (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
(Initial) (such as through tubes) OR may exercise that authority only
in accordance with the following special provisions:

__________________________________________________

__________________________________________________

 

______________ B. Limitations Concerning Health Care Decisions. In exercising
(Initial) 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.)

__________________________________________________

__________________________________________________

 

______________ C. Limitations Concerning Mental Health Decisions. In
(Initial) 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
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.)

__________________________________________________

__________________________________________________

 

______________ D. Advance Instruction for Mental Health Treatment. (Notice:
(Initial) 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 N.C. Gen. Stat., 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):

__________________________________________________

__________________________________________________

 

______________ E. Autopsy and Disposition of Remains. In exercising the
(Initial) 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):

__________________________________________________

__________________________________________________

 

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:

 

______________ donate any needed organs or parts; or

(Initial)

______________ donate only the following organs or parts:

(Initial)

__________________________________________________

 

______________ donate my body for anatomical study if needed.

(Initial)

______________ In exercising the authority to make donations, my health care
(Initial) 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 N.C. Gen. Stat. § 35A-1201(a)(5).

 

8. Reliance of Third Parties on Health Care Agent.

 

A. 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.

B. 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. 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 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 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).)