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TENNESSEE DURABLE POWER OF ATTORNEY FOR HEALTH CARE I hereby appoint ____________________________(representative designated to make health care decisions) as my attorney-in-fact to make healthcare decisions for me, if, and only if, I am incapacitated or otherwise unable to make such decisions for myself. If for any reason _______________________________(same representative as above) is unable to fulfill this duty, then I hereby appoint ______________________________________ (successor representative if first cannot serve) as the successor attorney-in-fact.My attorney-in-fact has received an executed copy of this document, and has agreed to serve as my attorney-in-fact for healthcare decisions consistent with my directions herein expressed. If, at any time, I should have a terminal condition, or be in an irreversible coma or permanent vegetative state, and my attending physician or other healthcare provider has determined that there can be no recovery from such condition or state, where the application of medical treatment implemented for the purpose of sustaining life, or the life process would serve only artificially to prolong the dying process, my attorney-in-fact is specifically directed to direct that such medical treatment be withheld or withdrawn, and that I be permitted to die naturally, with only the administration of medications or the performance of any medical procedure deemed necessary to provide me with comfortable care, or to alleviate pain.
______ Authorize the withholding or withdrawal of
______ DO NOT authorize the withholding or
withdrawal
______
Desire to donate my organs and/or tissues for ______
Desire to donate my _____________________________ ______ DO
NOT desire to donate my organs or tissues for My attorney-in-fact shall have the right to examine my medical records and to consent to their disclosure. I grant to my attorney-in-fact the power and authority to execute on my behalf any waiver, release or other document which may be necessary in order to implement the healthcare decisions that this instrument authorizes my attorney-in-fact to make on my behalf. This instrument is to be construed and interpreted as a Durable Power of Attorney for health care and is intended to comply in all respects with the provisions of Tennessee Code Annotated, § 34-6-201, et seq.; and all terms used in this instrument shall have the meanings set forth for such terms in the statute, unless otherwise specifically defined herein. This Durable Power of Attorney for health care revokes any prior Durable Powers of Attorney for Health Care executed by me.
Dated this ________ day of __________________, 20___.
We, the undersigned witnesses, declare under penalty of perjury under the laws of Tennessee, that __________________________(name of person granting power of attorney) is personally known to us to be the principal; that the principal signed and acknowledged this Durable Power of Attorney for Health Care in our presence; that the principal appears to be of sound mind and under no duress, fraud, or undue influence; that neither of us is the person appointed as attorney-in-fact by this instrument; and that neither of us is a healthcare provider, an employee of a healthcare provider, the operator of a healthcare institution, or an employee of an operator of a healthcare institution. We further declare under penalty of perjury under the laws of Tennessee that we are not related to the principal by blood, marriage, or adoption; and that, to the best of our knowledge, we are not entitled to any part of the principal's estate upon the death of the principal under any will or codicil of the principal existing as of the date of this instrument, or by operation of any existing law.
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STATE OF TENNESSEE COUNTY OF SHELBY On this _____ day of ________________, 20______, before the undersigned Notary Public, personally appeared _____________________(witness) and ______________________(witness), personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed it. I declare under penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud or undue influence.
My Commission Expires:
WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document. Before executing this document, you should know these important facts. This document gives the person you designate as your agent (the attorney-in-fact) the power to make healthcare decisions for you. Your agent must act consistently with your desires as stated in this document. Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive. Notwithstanding this document, you have the right to make medical and other healthcare decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objections, and health care necessary to keep you alive may not be stopped or withheld if you object at the time. This document gives your agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose or treat a physical or mental condition. This power is subject to any limitations that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a Court can take away the power of your agent to make healthcare decisions for you if your agent: (1) authorizes anything that is illegal, or (2) acts contrary to your desires as stated in this document. You have the right to revoke the authority of your agent by notifying your agent or your treating physician, hospital or other healthcare provider orally or in writing of the revocation. Your agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document. Unless you otherwise specify in this document, this document gives your agent the power after you die to: (1) authorize an autopsy; (2) donate your body or parts thereof for transplant or therapeutic, educational or scientific purposes; and, (3) direct the disposition of your remains. If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. |