HEALTH CARE POWER OF ATTORNEY
With a HEALTH CARE POWER OF ATTORNEY the principal [the person giving the powers] will designate to an AGENT [the person receiving the powers] those powers that the PRINCIPAL chooses to consent to give relating to health care. This power can include, without limitation, full power to give or refuse consent to all medical, surgical, hospital and related health care. This power of attorney may be effective immediately or only when the PRINCIPAL is unable to make or communicate health care decisions. The choice of the PRINCIPAL as to when the powers will become effective must be narrated [contained in the document]. There should always be language that indicates that when the AGENT makes decisions or takes any action under the power that those actions and decisions will have the same effect on heirs, devisees and personal representative as if the person were alive, competent to act or acting for himself..
It is recommended that when and if the current AGENT is unwilling or unable to serve or continue to serve that the name of an alternate AGENT be appointed to serve.
The document should narrative whether or not the PRINCIPAL has completed and attached a living will for purposes of providing specific direction to the AGENT in situations that may occur during any period that the PRINCIPAL is unable to make or communicate health care decisions or after the PRINCIPAL’S death.
All choices of the PRINCIPAL should be enumerated and initialed.
The document should contain information as to whether the PRNCIPAL has or has not completed a prehospital medical care directive pursuant to §36-3251, Arizona Revised Statutes.
The document should contain information as to how long the health care power of attorney continues in effect.
The document should contain information concerning revocation.
It needs to be signed by the PRINCIPAL and signed by a witness and an address shown for the witness.
The document may be notarized instead of being witnessed.
Choices of the PRINCIPAL concerning autopsy should be expressed although under Arizona law an autopsy may be required.
The PRINCIPAL may elect to donate organs and such donation is optional.
(Under Arizona law, you may make a gift of all or part of your body to a bank or storage facility or a hospital, physician or medical or dental school for transplantation, therapy, medical or dental evaluation or research or for the advancement of medical or dental science. You may also authorize your agent to do so or a member of your family may make a gift unless you give them notice that you do not want a gift made. In the space below you may make a gift yourself or state that you do not want to make a gift. If you do not complete this section, your agent will have the authority to make a gift of a part of your body pursuant to law. Note: The donation elections you make in this health care power of attorney survive your death.)
The PRINCIPAL may elect to donate specific organs and under specific conditions. The PRINCIPAL’S choices should be narrated or set forth for initialing. If the PRINCIPAL does not indicate he does not want to donate any portion or all of his body then his AGENT or the PRINCIPAL’S family will have the authority to make a gift of all or part of the PRNCIPAL’S body.
The PRINCIPAL has an option to discuss donation with a physician and the power may contain a statement within the body of the power that the PRINCIPAL has discussed options with a physician and understands probable medical consequences of treatment choices on which the physician may sign indicating such physician is in agreement and will comply with the provisions of the choices of the PRINCPAL
An example of such a statement may read as follows:
I, Dr. ________________________ have reviewed this guidance document and have discussed with _________ any questions regarding the probable medical consequences of the treatment choices provided above. This discussion with the principal occurred on ________________.
I have agreed to comply with the provisions of this directive.
Signature of Physician
This power could also attach a Living Will of the PRINCIPAL but this is optional.