Patient Education Advance Directives State of Ohio Forms | страница 2

State
 of
 Ohio

Health
 Care
 Power
 of
 Attorney

 [R.C.
 §1337]

__________________________________________________________________

(Print
 Full
 Name)

_____________________________________________

(Birth
 Date)

This
 is
 my
 Health
 Care
 Power
 of
 Attorney.
 I
 revoke
 all
 prior
 Health
 Care
 Powers
 of
 Attorney

signed
 by
 me.
 I
 understand
 the
 nature
 and
 purpose
 of
 this
 document.
 If
 any
 provision
 is
 found
 to
 be

invalid
 or
 unenforceable,
 it
 will
 not
 affect
 the
 rest
 of
 this
 document.

I
 understand
 that
 my
 agent
 can
 make
 health
 care
 decisions
 for
 me
 only
 whenever
 my
 attending

physician
 has
 determined
 that
 I
 have
 lost
 the
 capacity
 to
 make
 informed
 health
 care
 decisions.

However,
 this
 does
 not
 require
 or
 imply
 that
 a
 court
 must
 declare
 me
 incompetent.

Definitions

Adult
  means
 a
 person
 who
 is
 18
 years
 of
 age
 or
 older.

Agent
 or
 attorney-­‐in-­‐fact
 means
 a
 competent
 adult
 who
 a
 person
 (the
 “principal”)
 can
 name
 in
 a

Health
 Care
 Power
 of
 Attorney
 to
 make
 health
 care
 decisions
 for
 the
 principal.

Artificially
 or
 technologically
 supplied
 nutrition
 or
 hydration
  means
 food
 and
 fluids
 provided
 through

intravenous
 or
 tube
 feedings.
  [You
 can
 refuse
 or
 discontinue
 a
 feeding
 tube
 or
 authorize
 your
 Health

Care
 Power
 of
 Attorney
 agent
 to
 refuse
 or
 discontinue
 artificial
 nutrition
 or
 hydration.]

Bond
 means
 an
 insurance
 policy
 issued
 to
 protect
 the
 ward’s
 assets
 from
 theft
 or
 loss
 caused
 by

the
 Guardian
 of
 the
 Estate’s
 failure
 to
 properly
 perform
 his
 or
 her
 duties.

Comfort
 care
  means
 any
 measure,
 medical
 or
 nursing
 procedure,
 treatment
 or
 intervention,

including
 nutrition
 and/or
 hydration,
 that
 is
 taken
 to
 diminish
 a
 patient’s
 pain
 or
 discomfort,

but
 not
 to
 postpone
 death.

CPR
  means
 cardiopulmonary
 resuscitation,
 one
 of
 several
 ways
 to
 start
 a
 person’s
 breathing
 or

heartbeat
 once
 either
 has
 stopped.
 It
 does
 not
 include
 clearing
 a
 person’s
 airway
 for
 a
 reason

other
 than
 resuscitation.

Do
 Not
 Resuscitate
 or
 DNR
 Order
  means
 a
 physician’s
 medical
 order
 that
 is
 written
 into
 a

patient’s
 record
 to
 indicate
 that
 the
 patient
 should
 not
 receive
 cardiopulmonary
 resuscitation.

Ohio
 Health
 Care
 Power
 of
 Attorney

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