Michigan Medical Power of Attorney Form

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The Michigan medical power of attorney form is used when someone would like to transfer all health care decisions to someone else on your behalf. The person you select will be acting in your best interests and will be able to act if you become in a situation where you can no longer think for yourself.

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DURAblE POWER OF ATTORNEY
FOR HEAlTH CARE
(Please print or type required information)
I. Appointment of Patient Advocate
I, ___________________________________________________________
of ___________________________________________________________
hereby appoint _________________________________________________
residing at ____________________________________________________
as my agent in fact (herein called advocate) with the following power to be
exercised in my name and for my benefit, for the purpose of making decisions regarding my care, custody, medical, or mental health treatment. This
Durable Power of Attorney shall not be affected by my disability or incapacity,
and is governed by Section 700.496 of the Michigan Compiled Laws.
In the event that the above-named advocate is unable, or expresses
an intent not to serve as my advocate, I then appoint
___________________________________ residing at _________________
________________________________to serve as my successor advocate.
This Durable Power of Attorney shall be exercisable only when I am
unable to participate in medical treatment decisions. The determination of
my ability to participate in treatment decisions shall be made by my attending
physician and at least one other physician or licensed psychologist.
before the powers granted in this Durable Power of Attorney are exercisable, a copy of it shall be placed in my medical records along with the
written determination of my incompetence.
your name
full legal address
name of your designated patient advocate
full legal address
name of your successor advocate full legal address2 of 5
II. Revocation
I retain the right to revoke this designation at any time, and by any means
whereby I may communicate an intent to revoke it.
As to mental health treatment (initial one)
__________ I retain the right to revoke this designation at any time, and by any means
whereby I may communicate an intent to revoke it.
__________ I waive the right to revoke the powers granted in this Patient Advocate
Designation regarding mental health treatment decisions. This waiver
does not affect the rights afforded to me to terminate formal voluntary
hospitalization under section 330.1419 of the Michigan Compiled Laws.
Furthermore, if I communicate at a later time that I wish to revoke this
Patient Advocate Designation for mental health treatment while I am
deemed unable to participate in decisions regarding mental health
treatment, and I am receiving mental health treatment at that time, mental
health treatment shall not continue for more than thirty (30) days.
III. Grants of Authority and Responsibility
With respect to my physical care and medical treatment, I am granting to my
advocate the authorities and responsibilities indicated below (initial those you are
authorizing):
__________ Access to and control over my medical records and information.
__________ Power to employ and discharge physicians, nurses, therapists, and any
other care providers, and to pay them reasonable compensation.
__________ Power to give informed consent to receiving any medical treatment, or
diagnostic, surgical, or therapeutic procedure.
__________ Power to authorize an anatomical gift (organ donation) of part of my body
for transplant or therapeutic purposes that would occur after my death.3 of 5
__________ Arrange and consent to mental health treatment, which may include
inpatient psychiatric hospitalization and treatment as a formal voluntary
patient, pursuant to section 330.1415 of the Michigan Compiled Laws,
if it is in my best interest and is the least restrictive treatment to protect
my safety and/or the safety of others. However, if I am hospitalized as
a formal voluntary patient under an application executed by my patient
advocate, I retain the right to terminate the hospitalization in accordance
with section 330.1419 of the Michigan Compiled Laws.
__________ Power to refuse, or to authorize the discontinuance of, any medical
treatment, or diagnostic, surgical, or therapeutic procedure, for the
purpose of maintaining my comfort or allowing my imminent death to
occur naturally.
In granting this power, I recognize that my advocate will have authority to
refuse, or direct the discontinuation of, treatment which could allow for my
death. I further acknowledge that before this authority can be legally recognized
I must instruct my advocate in a clear and convincing manner as to my desires
regarding refusal or discontinuance of treatment.
Signature _________________________________________________
__________ Power to execute waivers, medical authorizations and such other approval
as may be required to permit or authorize care which I may need, or to
discontinue care that I am receiving.
IV. Desires and Preferences for Treatment (Optional Section)
I understand that my inability to participate in medical treatment decisions may
encompass a wide range of circumstances, from being conscious, but mentally
incompetent, to being unconscious and unaware.
Option A. My desires and preferences for treatment include: (you may add additional
pages if needed.)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
____________________________________________________________________________________
______________________________________________________________________4 of 5
Option b. by providing my signature here, I adopt the following statement as my
desires and preferences for treatment.
_____________________________________
Because it is impossible to foresee specific circumstances under which someone else
may have to make health care decisions for me, and since it is not possible for me to
know what specific decisions I might make in those circumstances, I have seriously and
carefully considered the principles and beliefs on which I base decisions I make for myself. The following paragraphs are intended to direct those who must make decisions for
me should I become unable to do so.
I direct my patient advocate and all those involved in my medical care to follow these
instructions:
I wish to receive ordinary nursing and medical care that will preserve my life, and to
receive medical treatment which may cure or improve a physical or mental condition.
The medical treatment and procedures which I receive should offer a reasonable probability of effectiveness which is not outweighed by any pain, complication or side effect
imposed by the treatment or procedure.
I direct that care and treatment, particularly food and fluids, be provided to me unless
death is imminent so that the effort to sustain my life is futile, or if my body is unable to
assimilate food or fluids. Pain relief should be provided at the lowest level necessary
to consistently maintain my physical comfort and maintain mental clarity to the greatest
extent possible.
No action should be taken with my death being the intended result, nor should care or
treatment be omitted when such omission, which of itself or by intent, results in death.
Neither euthanasia, nor ‘terminal sedation’ where the proximate cause of death would
be dehydration or starvation, are permitted.
These instructions are binding not only on my patient advocate but on any health care
personnel or institution which shall have responsibility for my health and life.
signature5 of 5
V. Signature and Witnessing
I have discussed this designation with my above-named advocate, who intends to sign
the attached acceptance to this designation (check one):
__________ Concurrently with the execution of this document.
__________ At a future date.
I freely and voluntarily sign this document, in the presence of the below-named
witnesses, and it shall become effective on the date indicated below.
_________________________________________ ___________________________
your Signature Date
STATEMENT OF WITNESS
As a witness to the execution of the Durable Power of Attorney, I attest that the person
who has signed this document in my presence appears to be of sound mind and under
no duress, fraud, or undue influence. I further attest that I am not the person’s spouse,
parent, child, grandchild, sibling, presumptive heir, known devisee, physician, the
named advocate, an employee of life or health insurance provider for the person, or an
employee of a health facility or home for the aged that is treating the person.
_________________________________________ ____________________________
Witness Signature Address
________________________________ ________________ _________ ___________
Type or Print Name City State Zip
_________________________________________ ____________________________
Witness Signature Address
________________________________ ________________ _________ ___________
Type or Print Name City State Zip1 of 2
VI. Acceptance of Power of Attorney
I, _______________________________________________ hereby accept the responsibilities
conferred upon me by ________________________________________________________ to
serve as a patient advocate in the document executed on ______________________________

I maintain the right to revoke this acceptance at any time, and by any means whereby I may
communicate a desire to revoke it. by providing my signature below I acknowledge that I have
read and understand the following requirements of Michigan law pertinent to the execution of a
Durable Power of Attorney for Health Care.
A. This designation shall not become effective unless the patient is unable to participate in
medical treatment decisions.
b. A patient advocate shall not exercise powers concerning a patient’s care, custody, and medical treatment that the patient, if the patient were able to participate in the decision, could not
have exercised on his or her own behalf.
C. This designation cannot be used to make a medical treatment decision to withhold or withdraw treatment from a patient who is pregnant that would result in the pregnant patient’s death.
D. A patient advocate may make a decision to withhold or withdraw treatment which would allow a patient to die only if the patient has expressed in a clear and convincing manner that the
patient advocate is authorized to make such a decision, and that the patient acknowledges that
such a decision could or would allow the patient to die.
E. A patient advocate shall not receive compensation for the performance of his or her authority,
rights, and responsibilities, but a patient advocate may be reimbursed for actual and necessary
expenses incurred in the performance of his or her authority, rights, and responsibilities.
F. A patient advocate shall act in accordance with the standards of care applicable to fiduciaries
when acting for the patient and shall act consistent with the patient’s best interests. The known
desires of the patient expressed or evidenced while the patient is able to participate in medical
treatment decisions are presumed to be in the patient’s best interests.
G. A patient may revoke his or her designation at any time and in any manner sufficient to communicate an intent to revoke.
H. A patient advocate may revoke his or her acceptance to the designation at any time and in
any manner sufficient to communicate an intent to revoke.
type or print name of advocate
type or print name of principal
date2 of 2
I. A patient admitted to a health facility or agency has the rights enumerated in section 20201 of
the public health code, Act No. 368 of 1978, being section 333.20201 of the Michigan Compiled
Laws. Some, but not all, of the rights enumerated in Sec. 20201 include: A patient or resident
in a health facility, or a nursing home shall not be denied appropriate care on the basis of race,
religion, color, national origin, sex, age, handicap, marital status, sexual preference, or source of
payment.
Patients and residents are also entitled to:
• inspect their medical record, and to have the confidentiality of that record maintained.
• receive adequate and appropriate care, and receive information in terms which the patient or
resident can understand about one’s medical condition, proposed course of treatment, and prospects for recovery.
• refuse treatment to the extent provided by law and to be informed of the consequences of that
refusal. When a refusal of treatment prevents a health facility or its staff from providing appropriate
care according to ethical and professional standards, the relationship with the patient or resident
may be terminated upon reasonable notice.
• information about the health facility’s rules and regulations affecting the patient or resident care
and conduct; and information about the facility’s policies and procedures for initiation, review, and
resolution of patient complaints.
• receive and examine an explanation of his or her bill regardless of the source of payment and to
receive, upon request, information relating to financial assistance available through the facility.
• associate and have private communications with a physician, attorney, or any other person, and
to send and receive personal mail unopened.
• be free from mental and physical abuse and from physical and mental restraint except in circumstances necessary to protect the patient or others from injury.
___________________________________________ __________________________
Advocate’s Signature Date
________________________________ _______________ _________ ___________
Address City State Zip Code