Durable Power Of Attorney For Healthcare (Page 2 of 8) in pdf

DO I HAVE TO APPOINT A PATIENT ADVOCATE?

You have the option to appoint a Patient Advocate but cannot be required to do so. Health and life insurers

cannot discriminate against individuals who complete or do not complete a Designation Form. In addition,

physicians and other health care providers cannot require you to appoint a Patient Advocate as a precondition

to providing health care services.

But, the advantage is to insure your choice is available to make the medical and/or mental health treatment

decisions, including withholding or withdrawing treatments, that you would when you are unable to do so.

Families sometimes find it difficult to withhold or stop treatment even when they know the patients’ wishes,

or families are unable to come to a consensus. These situations can lead to lengthy and sometimes costly

guardianship proceedings. In the interim, the physician may need to initiate aggressive treatment, including

placing a patient on a ventilator and starting tube feedings.

Before McLaren-Bay Region can accept your designation form, it must be reviewed to ensure it has been

prepared and meets criteria set forth by the Michigan legislature. The form in this booklet complies.

NOTE: It is generally recommended to complete this documentation before you are admitted to the hospital

or in a potential “medical crisis” situation.

*Reminder: Hospital employees are prohibited from acting as witnesses by the Michigan legislature.

DESIGNATION OF PATIENT ADVOCATE FORM

To my Family, Doctors and all Concerned with my care:

These instructions express my wishes about my health care. I want my family, doctors and everyone else

concerned with my care to act in accord with them.

1. General Instructions

My Patient Advocate, _____________________________________________________________________

______________________________________________________________________________________ ,

shall have the authority to make all decisions and to take all actions regarding my care, custody and medical

and/or mental health treatment including, but not limited to the following:

a. Have access to, obtain copies of and authorize release of my medical and other

personal information.

b. Employ and discharge physicians, nurses, therapists and any other health care providers, and

arrange to pay them reasonable compensation. Your patient advocate has the right to make

arrangements for your care, but is not required to personally pay for the cost of your care.

c. Consent to refuse or withdraw for me any medical care; diagnostic, surgical or therapeutic

procedure; or other treatment of any type or nature, including life-sustaining treatments. I

understand that life-sustaining treatment includes, but is not limited to, breathing with the use of a

machine and receiving food, water and other liquids through tubes. I also understand that these

decisions could or would allow me to die. I have listed below any specific instructions I have

related to life-sustaining treatments.

NOTE: Current law does not permit your Patient Advocate to make decisions to withhold or

withdraw treatment if you are pregnant if that decision would result in your death, to

engage in homicide or euthanasia, or to force medical and/or mental health treatment you

do not want because of your religious beliefs.

Durable Power Of Attorney For Healthcare Page 2