Ohio Durable Power Of Attorney For Health Care Will To Live Form (Page 4 of 7) in pdf

IF I AM PREGNANT

D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and

health care attorney in fact(s) to use all lifesaving procedures for myself with none of the above

special conditions applying if there is a chance that prolonging my life might allow my child to

be born alive. I also direct that lifesaving procedures be used even if I am legally determined to

be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I

specify by writing my signature in the box below, no one is authorized to consent to any

procedure for me that would result in the death of my unborn child.

If I am pregnant, and I am not in the final stage of a terminal condition as defined above,

medical procedures required to prevent my death are authorized even if they may result in the

death of my unborn child provided every possible effort is made to preserve both my life and the

life of my unborn child.

____________________________________

Signature of Declarant

I understand that under Ohio law as outlined in the “notice to Adult Executing This Document”

accompanying this form document, I could execute a durable power of attorney for health care

which would authorize my attorney in fact to refuse to give informed consent to or to withdraw

informed consent to health care necessary to preserve my life in some medical situations in

which this document does not authorize such a refusal or withdrawal. I have chosen to execute

this document because I wish to receive health care necessary to preserve my life in accordance

with the General Presumption of Life stated above, subject only to the written special conditions

I have included above.

ADDITIONAL AUTHORITIES OF ATTORNEY IN FACT

Where necessary or desirable to implement the health care decisions that my attorney in fact is

authorized to make pursuant to this document, my attorney in fact has the power and authority to

do any and all of the following:

(a)

To request, review, and receive any information, verbal or written, regarding my

physical or mental health, including but not limited to, all of my medical and

health care facility records;

(b)

To execute on my behalf any releases or other documents that may be required in

order to obtain this information;

(c)

To consent to the further disclosure of this information if necessary;

(d)

To select, employ and discharge health care personnel, such as physicians, nurses,

therapists, and other medical professionals, including individuals and services

providing home health care, as my attorney in fact shall determine to be

appropriate;

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Ohio Durable Power Of Attorney For Health Care Will To Live Form Page 4