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Will to Live ( for Nebraska ) |
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Will to Live ( for Nebraska ) |
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Suggestions and Requirements: 1. This document allows you to appoint an "attorney in fact" for health care -- someone, who does NOT have to be a lawyer, who will make health care decisions for you whenever you are unable to make them for yourself. It also allows you to give instructions about medical treatment decisions that the attorney in fact for health care must follow. Any competent person who is at least 19 years old or who is or has been married may appoint an attorney in fact for health care through this document. 2. There are two paragraphs at the end of this document (just above the signature line and following the box relating to pregnancy), each followed by several blank lines. The paragraphs and blank lines are required to be on the form under Nebraska law. The issues they raise, however, are covered by the "Will to Live" language placed immediately above them. IF you wish to avoid confusion and possible inconsistency with the Will to Live language, you may wish NOT to write anything under these two paragraphs and instead to cross off the blank lines under them. To make clear the applicability of the "Will to Live" language, "See above instructions and limitations" has been inserted on the lines beneath each of the two paragraphs. 3. Your attorney in fact for health care CANNOT be: -- your attending physician; -- an employee of your attending physician who is not related to you by blood, marriage, or adoption; -- an owner, operator, or employee of a health care provider, in or of which you are a patient or resident, if the person is not related to you by blood, marriage or adoption; or -- a person who, at the time of the proposed designation, is presently serving as an attorney in fact for ten or more individuals and is not related to you by blood, marriage, or adoption. 4. It is helpful to appoint a successor attorney in fact for health care, to take over if your first choice is unable to serve. There is space on the form for you to appoint such a successor attorney in fact for health care. 5. To properly appoint an attorney in fact for health care through this document, you must: (1) sign and date this document and (2) have it witnessed by two adults who are each personally known to you and who are present when you sign and date the document or acknowledge your signature and date to them (tell them that you wrote the signature and date). 6. A witness CANNOT be: -- your spouse, parent, child, grandchild, or sibling; -- someone who would be entitled to inherit anything from you under state law if you died without a will (normally this means a relative); -- someone known to be entitled to inherit anything under your will at the time of witnessing; -- your attending physician; -- your attorney in fact; or -- an employee of your life or health insurance company. Not more than one witness may be an administrator or employee of your health care provider. 7. The authority of your attorney in fact for health care takes effect only when your attending physician determines that you no longer have the capacity to make your own health care decisions. The doctor must notify the person this document appoints as attorney in fact. Unless you direct otherwise, your attorney in fact must then notify your closest next of kin. Your spouse is considered your closest next of kin, followed in order by an adult child, either of your parents, an adult brother or sister, then the next closest kin. A court may decide any dispute about whether you are in fact incapable of making your own health care decisions. 8. The document will remain in effect until you revoke (cancel) it. You may revoke this document at any time and in any manner by which you are able to communicate your intent to revoke. The revocation becomes effective when communicated to your attending physician, health care provider, or attorney in fact. If you sign a new power of attorney for health care, that will revoke this one. If you name your spouse as your attorney in fact and are later divorced or legally separated, that will revoke your spouse's appointment as your attorney in fact for health care, unless the court decree of divorce or separation states otherwise. 9. You should tell your doctor about this document. You should also ask your doctor to keep a copy of this document as a part of your medical health record. 10. This type of document has been authorized by Nebraska state law. 11. If you have any questions about this document or want assistance filling it out, please consult an attorney. For additional copies of the Will to Live, send a self-addressed, stamped business envelope to:
Form prepared 1998 Nebraska Power of Attorney for Health Care with Will to Live Language POWER OF ATTORNEY FOR HEALTH CARE I, appoint , whose address is , and whose telephone number is ,as my attorney in fact for health care. I appoint , whose address is , and whose telephone number is , as my successor attorney in fact for health care. I authorize my attorney in fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions. I have read the warning which accompanies this document and understand the consequences of executing a power of attorney for health care. I direct that my attorney in fact comply with the following instructions or limitations: GENERAL PRESUMPTION FOR LIFE I direct my health care provider(s) and attorney in fact to make health care decisions consistent with my general desire for the use of medical treatment that would preserve my life, as well as for the use of medical treatment that can cure, improve, or reduce or prevent deterioration in, any physical or mental condition. Food and water are not medical treatment, but basic necessities. I direct my health care provider(s) and attorney in fact to provide me with food and fluids orally, intravenously, by tube, or by other means to the full extent necessary both to preserve my life and to assure me the optimal health possible. I direct that medication to alleviate my pain be provided, as long as the medication is not used in order to cause my death. I direct that the following be provided: * the administration of medication; * cardiopulmonary resuscitation (CPR); and
-- all to the full extent necessary to correct, reverse, or alleviate life-threatening or health-impairing conditions, or complications arising from those conditions. I also direct that I be provided basic nursing care and procedures to provide comfort care. I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of an unborn or newborn child, who has been subject to an induced abortion. This rejection does not apply to the use of tissues or organs obtained in the course of the removal of an ectopic pregnancy. I also reject any treatments that use an organ or tissue of another person obtained in a manner that causes, contributes to, or hastens that person's death. The instructions in this document are intended to be followed even if suicide is alleged to be attempted at some point after it is signed. I request and direct that medical treatment and care be provided to me to preserve my life without discrimination based on my age or physical or mental disability or the "quality" of my life. I reject any action or omission that is intended to cause or hasten my death. I direct my health care provider(s) and attorney in fact to follow the above policy, even if I am judged to be incompetent. During the time I am incompetent, my agent, as named above or below, is authorized to make medical decisions on my behalf, consistent with the above policy, after consultation with my health care provider(s), utilizing the most current diagnoses and/or prognosis of my medical condition, in the following situations with the written special conditions. WHEN MY DEATH IS IMMINENT 1. If I have an incurable terminal illness or injury, and I will die imminently--meaning that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only a week or less even if lifesaving treatment or care is provided to me--the following may be withheld or withdrawn: (Be as specific as possible; SEE SUGGESTIONS.): (Cross off any remaining blank lines.) WHEN I AM TERMINALLY ILL 2. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even though death is not imminent I am in the final stage of that terminal condition--meaning that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only three months or less, even if lifesaving treatment or care is provided to me--the following may be withheld or withdrawn: (Be as specific as possible; SEE SUGGESTIONS.): (Cross off any remaining blank lines.) 3. OTHER SPECIAL CONDITIONS: (Be as specific as possible; SEE SUGGESTIONS.): (Cross off any remaining blank lines.) IF I AM PREGNANT 4. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and attorney in fact(s) to use all lifesaving procedures for myself, with none of the above special conditions applying, if there is a chance that prolonging my life might allow my child to be born alive. I also direct that lifesaving procedures be used even if I am legally determined to be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I specify by writing my signature in the box below, no one is authorized to consent to any procedure for me that would result in the death of my unborn child. I direct that my attorney in fact comply with the following instructions on life-sustaining treatment: (optional) See above instructions and limitations. I direct that my attorney in fact comply with the following instructions on artificially administered nutrition and hydration: (optional) See above instructions and limitations. I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY ATTORNEY IN FACT, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN. (Signature of person making designation/date) DECLARATION OF WITNESSES We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care in our presence, that the principal appears to be of sound mind and not under duress or under influence, and that neither of us nor the principal's attending physician is the person appointed as attorney in fact by this document. Witnessed By: (Signature of Witness/Date) (Printed Name of Witness) (Signature of Witness/Date) (Printed Name of Witness) Form Prepared 1998 |
