Fillable Durable Health Care Power Of Attorney Form

STATE OF ALABAMA

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COUNTY OF

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DURABLE HEALTH CARE POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS THAT I, _________________, of __________________,

City of _____________, County of ___________, Alabama, hereby make, constitute and appoint

______________________, whose address is ________________________________, to act as my agent

or attorney in fact, to make health care and related personal decisions for me as authorized in this

document. Should ___________________________ for any reason be unable or unwilling to act,

temporarily or permanently, then I appoint __________________, of ____________________________.

as such agent/attorney in fact, with the same authority.

By this document I intend to create a durable power of attorney upon, and only during, any period of

incapacity in which, in the opinion of my health care agent/attorney in fact, after consultation with my

health care providers, I am unable to make or communicate a choice regarding a particular health care

decision. This document is intended to complement and supplement any Advance Health Care Directive

and/or Durable Power of Attorney for financial matters that I may have executed or may execute in the

future. It is my desire to receive appropriate medical treatment so long as there is a reasonable hope of

recovery, but I do not want my life artificially extended beyond any reasonable hope of recovery to a

meaningful quality of life and I do not want to prolong the dying process. I do not intend by this document

to authorize or request euthanasia or assisted suicide but to avoid being unwillingly sustained in a condition

that is only a semblance of life; or to be allowed to endure pain for which there is treatment available,

whether or not recovery is possible.

I grant to my agent full power to make decisions for me regarding my health care. In exercising his/her

authority, my agent shall attempt to communicate with me regarding my wishes if I am able to

communicate in any way. If my agent cannot determine the choice I want made, then (s)he shall make the

choice for me based upon what (s)he believes I would do if I were able, or if unable to so determine, then

based upon what (s)he believes to be my best interests. I intend the power given to be as broad as possible,

except for any limitations in my Advance Directives or set out hereinafter. Accordingly, unless so limited,

my agent is authorized:

To consent to, refuse or withdraw consent to any and all types of medical care, treatment, surgical

procedures, diagnostic procedures, medications and use of mechanical or other procedures affecting bodily

functions; including, without limitation, artificial respiration, nutritional support and hydration, and

cardiopulmonary resuscitation;

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To have access to and have the right to disclose medical reports, records and information to the

extent that I would myself;

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To authorize admission to or discharge from any hospital, residential care or related facility, even

against medical advice;

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To contract for health care or related services, without the agent incurring personal liability

therefore;

To hire and fire medical, social service or related personnel responsible for my care;

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To authorize or refuse to authorize any medication or procedure to relieve pain, even though such

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use may lead to temporary discomfort or addiction, or inadvertently hasten the moment of death;

To make anatomical gifts of part of all of my body for medical purposes,

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To authorize an autopsy and direct disposition of my remains, to the extent permitted by law, and

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To take any other action necessary to effectuate the intent and purpose of this broad grant of

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powers, including, without limitation, granting any waiver of release from liability required by any

health care provider or related agency, and

To sign any document relative to health care in any way whatsoever and pursuing legal action in

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my name at the expense of my estate, should that be necessary to enforce compliance with my

wishes as determined by my agent pursuant to the authority given herein.

Without in any way limiting the broad powers herein granted, I express the hope that, circumstances

permitting, my agent will consult family and friends for their advice and support in arriving at what may be

difficult decisions; but the final decisions shall be that of my agent.

No person who relies in good faith upon any representation of my agent or successor agent shall be liable to

Durable Health Care Power Of Attorney Form - Alabama

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