A Medical Power of Attorney, formerly known as a Durable Power of Attorney
for Health Care, is a document giving another person the power to make
health-care decisions for you in the event you are unable to do so.
The Texas Legislature in 1999 changed the name of the old "Durable Power
of Attorney for Health Care" to the new "Medical Power of
Attorney" and prescribed a new, mandatory form. We have included a copy of
this new form, which must be used after September 1, 1999.
Here is the Disclosure Statement and the wording of the mandatory form from
the Legislature:
INFORMATION CONCERNING
THE MEDICAL POWER OF ATTORNEY
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS
DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
Except to the extent you state otherwise, this document gives
the person you name as your agent the authority to make any and all health care
decisions for you in accordance with your wishes, including your religious and
moral beliefs, when you are no longer capable of making them yourself. Because
"health care" means any treatment, service, or procedure to maintain,
diagnose, or treat your physical or mental condition, your agent has the power
to make a broad range of health care decisions for you. Your agent may consent,
refuse to consent, or withdraw consent to medical treatment and may make
decisions about withdrawing or withholding life-sustaining treatment. Your agent
may not consent to voluntary inpatient mental health services, convulsive
treatment, psychosurgery, or abortion. A physician must comply with your agent's
instructions or allow you to be transferred to another physician.
Your agent's authority begins when your doctor certifies that
you lack the competence to make health care decisions.
Your agent is obligated to follow your instructions when making
decisions on your behalf. Unless you state otherwise, your agent has the same
authority to make decisions about your health care as you would have had.
It is important that you discuss this document with your
physician or other health care provider before you sign it to make sure that you
understand the nature and range of decisions that may be made on your behalf. If
you do not have a physician, you should talk with someone else who is
knowledgeable about these issues and can answer your questions. You do not need
a lawyer's assistance to complete this document, but if there is anything in
this document that you do not understand, you should ask a lawyer to explain it
to you.
The person you appoint as agent should be someone you know and
trust. The person must be 18 years of age or older or a person under 18 years of
age who has had the disabilities of minority removed. If you appoint your health
or residential care provider (e.g., your physician or an employee of a home
health agency, hospital, nursing home, or residential care home, other than a
relative), that person has to choose between acting as your agent or as your
health or residential care provider; the law does not permit a person to do both
at the same time.
You should inform the person you appoint that you want the
person to be your health care agent. You should discuss this document with your
agent and your physician and give each a signed copy. You should indicate on the
document itself the people and institutions who have signed copies. Your agent
is not liable for health care decisions made in good faith on your behalf.
Even after you have signed this document, you have the right to
make health care decisions for yourself as long as you are able to do so and
treatment cannot be given to you or stopped over your objection. You have the
right to revoke the authority granted to your agent by informing your agent or
your health or residential care provider orally or in writing or by your
execution of a subsequent medical power of attorney. Unless you state otherwise,
your appointment of a spouse dissolves on divorce.
This document may not be changed or modified. If you want to
make changes in the document, you must make an entirely new one.
You may wish to designate an alternate agent in the event that
your agent is unwilling, unable, or ineligible to act as your agent. Any
alternate agent you designate has the same authority to make health care
decisions for you.
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE
PRESENCE OF TWO COMPETENT ADULT WITNESSES. THE FOLLOWING PERSONS MAY NOT ACT AS
ONE OF THE WITNESSES:
(1) the person you have designated as your agent;
(2) a person related to you by blood or marriage;
(3) a person entitled to any part of your estate
after your death under a will or codicil executed by you or by operation of law;
(4) your attending physician;
(5) an employee of your attending physician;
(6) an employee of a health care facility in which
you are a patient if the employee is providing direct patient care to you or is
an officer, director, partner, or business office employee of the health care
facility or of any parent organization of the health care facility; or
(7) a person who, at the time this power of attorney
is executed, has a claim against any part of your estate after your death.
MEDICAL POWER OF ATTORNEY
DESIGNATION OF HEALTH CARE AGENT
I, ________________________ (insert your name) appoint:
Name:
Address:
Phone:
as my agent to make any and all health care decisions for me,
except to the extent I state otherwise in this document. This medical power of
attorney takes effect if I become unable to make my own health care decisions
and this fact is certified in writing by my physician.
LIMITATIONS ON THE DECISION-MAKING AUTHORITY OF MY AGENT ARE
AS FOLLOWS:
DESIGNATION OF ALTERNATE AGENT.
(You are not required to designate an alternate agent but you
may do so. An alternate agent may make the same health care decisions as the
designated agent if the designated agent is unable or unwilling to act as your
agent. If the agent designated is your spouse, the designation is automatically
revoked by law if your marriage is dissolved.)
If the person designated as my agent is unable or unwilling to
make health care decisions for me, I designate the following persons to serve as
my agent to make health care decisions for me as authorized by this document,
who serve in the following order:
First Alternate Agent
Name:
Address:
Phone:
Second Alternate Agent
Name:
Address:
Phone:
The original of this document is kept at:
The following individuals or institutions have signed copies:
Name:
Address:
Name:
Address:
DURATION:
I understand that this power of attorney exists indefinitely
from the date I execute this document unless I establish a shorter time or
revoke the power of attorney. If I am unable to make health care decisions for
myself when this power of attorney expires, the authority I have granted my
agent continues to exist until the time I become able to make health care
decisions for myself.
(IF APPLICABLE) This power of attorney ends on the
following date: __________________
PRIOR DESIGNATIONS REVOKED.
I revoke any prior medical power of attorney.
ACKNOWLEDGMENT OF DISCLOSURE STATEMENT.
I have been provided with a disclosure statement explaining the
effect of this document. I have read and understand that information contained
in the disclosure statement.
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY.)
I sign my name to this medical power of attorney on the
___________ day of ______________ (month, year)
at ___________________________ (City and State).
(Signature)
(Print Name)
STATEMENT OF FIRST WITNESS.
I am not the person appointed as agent by this document. I am
not related to the principal by blood or marriage. I would not be entitled to
any portion of the principal's estate on the principal's death. I am not the
attending physician of the principal or an employee of the attending physician.
I have no claim against any portion of the principal's estate on the principal's
death. Furthermore, if I am an employee of a health care facility in which the
principal is a patient, I am not involved in providing direct patient care to
the principal and am not an officer, director, partner, or business office
employee of the health care facility or of any parent organization of the health
care facility.
Signature:
Print Name:
Date:
Address:
SIGNATURE OF SECOND WITNESS.
Signature:
Print Name:
Date:
Address:
