Personal Care Power of Attorney
I, [Your Name], residing at [Your Address], hereby appoint [Agent's Name], residing at [Agent's Address], as my attorney-in-fact (hereinafter referred to as "Agent") to make decisions about my medical treatment and personal care, including but not limited to the following roles and responsibilities:
I. Refusal of Specific Medical Treatments
The Agent is authorized to refuse specific medical treatments, procedures, surgeries, medications, and interventions on my behalf, if and when the time comes, by my previously expressed preferences, values, and directives. This includes but is not limited to decisions regarding resuscitation, life support measures, organ donation, and any other medical interventions necessary for the preservation or improvement of my health and well-being. The Agent shall consider the recommendations of healthcare professionals involved in my care but ultimately make decisions that align with my wishes and best interests.
II. Access to Medical Information
The Agent shall have the authority to access my medical records, consult with healthcare providers, and obtain information relevant to my medical condition to make informed decisions regarding my medical treatment and personal care.
III. Healthcare Facility Selection
The Agent is empowered to choose healthcare facilities, including hospitals, clinics, or long-term care facilities, for my treatment and care, taking into account factors such as quality of care, proximity, and specialized services available.
IV. End-of-Life Decisions
If I am unable to communicate my wishes regarding end-of-life care, the Agent shall have the authority to make decisions about life-sustaining treatments, palliative care, and other interventions, by my values, beliefs, and preferences as known to the Agent.
V. Communication with Healthcare Providers
The Agent shall serve as my spokesperson in all interactions with healthcare providers, conveying my preferences, concerns, and instructions regarding medical treatment and personal care, and advocating for the highest standard of care.
VI. Duration and Revocation
This Personal Care Power of Attorney shall remain in effect unless revoked by me in writing or upon my death. The Agent shall exercise the powers granted herein diligently and in good faith, always acting in my best interests and accordance with applicable laws and ethical standards.
Principal:
[Your Name]
Agent:
[Agent's Name]
WITNESS ACKNOWLEDGEMENT
We, the undersigned witnesses, certify that the Principal, [Your Name], signed this Personal Care Power of Attorney in our presence and that to the best of our knowledge, the Principal is of sound mind and under no duress to execute this document.
Witness 1:
[Witness 1 full name]
[Date]
Witness 2:
[Witness 2 full name]
[Date]
NOTARY ACKNOWLEDGEMENT
On this day of in the year , before me, a Notary Public in and for said County and State, personally appeared [Your Name], known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged that they executed the same for the purposes therein contained.
Witness my hand and official seal.
[Notary Public's Name]
My Commission Expires:
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