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HomeMy WebLinkAbout11-04-11~ / - ll 9C~ ti, _ +) v ~ ,.. i. ~ ~, ~ ii~rn- - ~ - - .`~f~~ ~ <„~~ =- MEDICAL AND HEALTHCARE ~'~?~~ ` - ~~~_,, ~ POWER OF ATTORNEY AND LIVING WILL -' ~ ~ ~ _=. ~'' (DURABLE) n - ~ -: ;__ --r, PREPARED AND EXECUTED IN CONFORMI7C Y ~' T' WITH THE PROVISION OF ACT 169 REGARDING PERSONAL HEATHCARE DECISION ~VIAKING. KNOW ALL PERSONS BY THESE PRESENTS, that 1, TF,RESA SHANK, single woman, currently of 340 Fulton Street, Enola, Cumberland County, Pennsylvania, have made, constituted and appointed, and by these presents do make, constitute and appoint my mother, GRACE E. HOUSE, currently of 419 Diehl Road, Mechanicsburg, Upper Allen Township, Cumberland County, Pennsylvania, currently having a phone number of (717) 766-4054 and cell phone number of (717) 724-7387, as my true and lawful healthcare agent to rrnake health care, personal care and medical treatment decisions on my behalf for me and in my' name and on my behalf generally, to do and perform all matters and things, transact all business; related to my said care, make, execute and acknowledge all contracts, orders, writings, disclosures, consents, acknowledgements, permissions, assurances, and instruments, and the like which may be requisite or proper to effectuate any matter or thing appertaining to or belongiu~g to me with regard to such decisions and powers. In the event that my mother, GRACE FG. HOUSE, is unable or unwilling to act as such agent, I appoint my sister, LAURIE S. RAINES, currently of 36701 Blue Water Run West, Keenwick Sound, Selbyville, Sussex County, Iaelaware, currently having a phone number of (302) 321-6446 and cell phone number of (302) 85'3-0472, as my true and lawful healthcare agent in her place and stead. In the event my sister, LAIURIE S. RAINES, is unable or unwilling to act as such agent, I appoint my Aunt, MAIRY KATHLEEN SNYDER, currently of 18 East Maplewood Avenue, Mechanicsburg, Cumberland County, Pennsylvania, currently having a phone number of (717) 697-6329 and cell phone number of (717) 979-0146, as my true and lawful healthcare agent in her place and stead'. Being of sound and disposing mind, memory and understanding, I hereby make, publish and declare this my Medical and Healthcare Power of Attorney, hereby revoking and making void any and all prior Medical and Healthcare Powers of Attorney by me at any time heretofore made. For Purposes Of Reliance By Third Parties: The presentation of this power by the successor agent shall be deemed conclusive proof that the previous agent has wiled to act or ceased to serve. i. NOTICE OF ACCESS TO MEDICAL RECORDS -Effective immediately and continuously until my death or revocation by a writing signed by me or someone authorized to make healthcare treatment decisions for me, I authorize all healthcare providers or other covered entities to disclose to my healthcare agent, upon my agent's request, any information, oral or written, regarding my physical or mental health, including, but not limited to, medical and hospital records and what is otherwise private, privileged, protected or personal health information, such as health information as defined and described in the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat. 1936) more commonly referred to as "HIPAA," the regulations promulgated thereunder and any other Federal, State or local laws and rules. Information disclosed by a healthcare provider or other covered entity may be re-disclosed and may no longer be subject to the privacy rules provided by 45 C.F.R. Pt. 164. This power shall be full and absolute and shall include the power to grant releases for the dissemination of such information to others. This power shall be exercisable despite anything to the contrary in any current privacy acts or similar acts or regulations or such as may be passed or adopted from time to time in the future. The remainder of this document will take effect when and only when I lack the ability to understand, make or communicate a choice regarding a health or personal care decision as verified by my attending physician. My health care agent may not delegate the authority to make decisions. ~~ Ii. SPECIFIC POWERS INCLUDED IN GENERAL POWER -Without limiting the general powers hereby already conferred, my healthcare agent shall have all those specific powers which are included in the foregoing general powers and such as are more fully delineated in Section III below. III. HEALTH CARE POWERS - In addition, my healthcare agent(s) appointed by this Power of Attorney is hereby and shall be authorized to make health care and rniedical treatment decisions for me which shall include, but not be limited to the following: 1. To authorize, modify, withhold or withdraw medical care and surgical procedures. 2. To authorize, withhold or withdraw nutrition (food) or hydration (water) medically supplied by tube through my nose, stomach, intestines, arteries or veins or in some similar fashion. 3. To authorize my admission to or discharge from a medical, nursing, residential or similar facility and to make agreements for my care and for health insurance for my care, including hospice and/or palliative care. This power shall include the power to enter into agreements for my care at the expense of my Estate in conjunction witih my business Power of Attorney or the Guardian of my Estate, as the case may be; to execute any consent or admission forms required by such facility which are consistent with this paragraph, and enter into agreements for my care by such facility or elsewhere during my lifetime or for such lesser period of time as my healthcare agent may designate. This power shall also include the power to retain nurses for me. 4. To authorize the administration of pain relieving drugs or other medical or surgical procedures calculated to relieve my pain even though their use may lead to permanent physical damage, addiction or even hasten the moment of (but not intentionally cause) my death and to authorize unconventional pain relief therapies which my healthcare agent believes may be helpful to me even if the same m,ay prolong my life. 5. To grant, in conjunction with any instructions given under this,power, releases to hospital staff, physicians, nurses and other medical and hospital administration personnel who act in reliance on instructions given by my healthcare agent or who render written opinions to my healthcare agent in connection with any matter described in this power from all liability for damages suffered or to be suffered by me; to sign documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advice," as well as any necessary waivers of or releases from liability required by any hospital or physician to implement my wishes regarding medical treatment or non- treatment. 6. To hire and fire medical, social service and other support personnel responsible for my care. 7. To take any legal action necessary to do what I have directed. 8. To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order, including anout-of-hospital DNR order, and sign any required documents and consents. IV. GUIDANCE FOR HEALTHCARE AGENT - I PROVIDE THE FOLLOWING POINTS OF CLARIFICATION TO PROVIDE AID IN THE INTERPRETATION AND CARRYING OUT OF MY GOALS AND DESIRES: END STAGE MEDICAL CONDITION 2 If I have an end-stage medical condition or other extreme irreversible medical condition, my goals in making medical decisions are as follows: I wish to eliminate the unnecessary and, futile prolonging of my life if it is diagnosed that thex'e is no reasonable prospect or hope of my recovery from such condition. However, I am willing to have pain killers and similar types of medication and palliative care provided to me even though such treatment could conceivably prolong my life as I see no merit in being permitted to die in agony. SEVERE BRAIN DAMAGE OR BRAIN DISEASE If I should suffer from severe and irreversible brain damage orbrain disease with no realistic hope of significant recovery, I would consider such a condition intolerable and the application of aggressive medical care to be burdensome. I therefore request that my health care agent respond to any intervening (other and separate) life-threatening conditions in the same manner as directed for a primary end-stage medical condition or state of permanent unconsciousness as I have indicated below for re-emphasis in the LIVING WILL portion of this Power of Attorney. HEALTH CARE TREATMENT INSTRUCTIONS IN THE EVENT OF END-STAGE MEDICAL CONDITION OR PERMANENT UNCONSCIOUSNESS (LIVING WILL) The following health care treatment instructions exercise my right to rilake my own health care decisions. These instructions are intended to provide clear and convincing evidence of my wishes to be followed when I lack the capacity to understand, make or communicate my treatment decisions: IF I HAVE AN END-STAGE MEDICAL CONDITION (WHICH', WILL RESULT IN MY DEATH, DESPITE THE INTRODUCTION OR CONTINUATI(bN OF MEDICAL TREATMENT) OR AM PERMANENTLY UNCONSCIOUS SUCH AS AN IRREVERSIBLE COMA OR AN IRREVERSIBLE VEGETATIVE STATE AND THERE IS NO REALISTIC HOPE OF SIGNIFICANT RECOVERY, ALL OF 'I7HE FOLLOWING APPLY: I . I direct that I be given health care treatment to relieve pain or provide comfort even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit forming or, in the alternative, even if such treatment might prolong my life, it being my intention to not die in agony if preventable. 2. T direct that all other life prolonging procedures be withheld or withdrawn. 3. I specifically make no specific checklist herein as to specific treatments to be accepted or refused, preferring instead to rely upon the good faith performance of my wishes herein specified by my doctors and healthcare agents as they may deem best and most proper under the circumstances as they then exist or develop. V. DURABILITY -.This Power of Attorney shall not be affected by any disability on my behalf, including the event that I become incapacitated and/or incompetent to handle my affairs. VL PROCEEDINGS FOR APPOINTMENT OF A GUARDIAN - In the event that legal proceedings concerning my incapacity, within the meaning of P.E.F. Code Chapter 54, or for the appointment of a guardian of my person are commenced, I nominate my healthcare agent appointed by this Power of Attorney for consideration by the court having jurisdiction of those proceedings for appointment as the guardian of my person, and I request the court to make its appointment in accordance with this nomination, except for good cause or disqualification. 3 VII. LEGAL PROTECTION -- TO WHOM IT MAY CONCERN -Pennsylvania law protects my healthcare agent and healthcare providers from any legal liability for their good faith actions in following my wishes as expressed in this form or in complying with my healthcare agent's direction. On behalf of myself, my Executors and heirs, I further hold'' my healthcare agent and my healthcare providers harmless and indemnify them against any Claim for their good faith actions in recognizing my health care agent's authority or in following my treatment instructions. VIII. REGARDING ORGAN DONATION - I have signed hereinbelow my preference as to Organ Donation: I consent to donate my organs and tissues at the time of my death for the purpose of transplant, medical study or education. I do not consent to donate my organs and tissues at the time of my death. w ( I leave the decision as to organ donation to my healthcare agent to be determined in view of the circumstances as they may dwelop. Having carefully read this document, I have hereunto set my hand and seal this day of __~2~_. , 2011, revoking all pr6vious healthcare Powers of Attorney and healthcare treatment instructions. _-~ i ~~~ EAL) TERESA HANK Each of the individual signatures hereinbelow as a witness verifies ind'pvidually on behalf of each witness: 1) that he/she is at least eighteen (18) years of age as required by Pennsylvania Law; 2) he/she is not an heir or a creditor; 3) he/she is not an employee of any current healthcare provider to the principal herein; and 4) that he/she has signed in the presence of the other witness. WITNESSES: ~~~~~~ ~ k%!`~t~ Signature Signature 4 COMMONWEALTH OF PENNSYLVANIA ) SS COUNTY OF CUMBERLAND ) On this, the 1 D ~ day of ~~~~ , 2011, before me, the undersigned officer, personally appeared TERESA SHANK, who being duly sworn according to law, deposes and says that the foregoing Medical and Healthcare Power of Attorney and Living Will is her act and deed and that she desires the same to be recorded as such. IN WITNESS WHEREOF, I have hereunto set my hand and notariali seal the day and year aforesaid. Notary Public My commission expires: (SEAL) COMMONWEALTH :JF PEN SYLVANIA Notarial Seal Charles E. 5hieltls 111, No?ary PuDllc Monroe Twp_, Cumberlantl Couhty My Commission Expires June 80,_2012 Member, Pennsylvani9 A999f319E1 h A NOtaEfaa 5 ACKNOWLEDGMENT (OF ACCEPTANCE OF APPOINTMENT) 1, GRACE E. HOUSE, have read the attached Medical and Healthcare Power of Attorney and Living Will and am the person identified as the healthcare agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the Power of Attorney or in 20 Pa. C.S. when I act as such healthcare agent: I shall exercise the powers for the benefit of the principal. 2. I shall exercise reasonable caution and prudence. 3. I shall do my best to carry out in good faith the duties and instructions given to me in the said Power of Attorney and Living Will. _ ~ DATE: ~ c ~ ~~ / ~' ~ e' I ~ ~~-'~~~'~~-~ ~ (SEAL) BRACE E. HOUSE 6 ACKNOWLEDGMENT (OF ACCEPTANCE OF APPOINTMENT) I, LAURIE S. RAINES, have read the attached Medical and Healthcare Power of Attorney and Living Will and am the person identified as the healthcare agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the Power of Attorney or in 20 Pa. C.S. when I act as such healthcare agent: I shall exercise the powers for the benefit of the principal. 2. I shall exercise reasonable caution and prudence. 3. I shall do my best to carry out in good faith the duties and instructions given to me in the said Power of Attorney and hiving Will. ~_ DA"TE: ~ (~ ~ a~--~~ ~ (SEAL) AURIE S. RAINES 7 ACKNOWLEDGMENT (OF ACCEPTANCE OF APPOINTMENT) 1, MARY KATHLEEN SNYDER, have read the attached Medical and Healthcare Power of Attorney and Living Will and am the person identified as the healthcare agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the Power of Attorney or in 20 Pa. C.S. when I act as such healthcare agent: I shall exercise the powers for the benefit of the principal. 2. I shall exercise reasonable caution and prudence. 3. I shall do my best to carry out in good faith the duties and instructions given to me in the said Power of Attorney and Living Will. _~ ~~ ' DATE: ! ~~ ,' i ~ l ~ 1 v ~"~-~ ,, (SEAL) MARY KATHLE + N S DER 8