2005 Idaho Code - 39-4510 — LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE

                                  TITLE  39
                              HEALTH AND SAFETY
                                  CHAPTER 45
                  THE MEDICAL CONSENT AND NATURAL DEATH ACT
    39-4510.  LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE. (1)
Any competent person may execute a document known as a "Living Will and
Durable Power of Attorney for Health Care." Such document shall be in
substantially the following form, or in another form that contains the
elements set forth in this chapter. A "Living Will and Durable Power of
Attorney for Health Care" executed prior to the effective date of this act,
but which was in the "Living Will" and/or "Durable Power of Attorney for
Health Care" form pursuant to prior Idaho law at the time of execution, or in
another form that contained the elements set forth in this chapter at the time
of execution, shall be deemed to be in compliance with this chapter. A "Living
Will and Durable Power of Attorney for Health Care" or similar document(s)
executed in another state which substantially complies with this chapter shall
be deemed to be in compliance with this chapter. In this chapter, a "Living
Will and Durable Power of Attorney for Health Care" may be referred to as a
"directive." Any portions of the "Living Will and Durable Power of Attorney
for Health Care" which are left blank by the person executing the document
shall be deemed to be intentional and shall not invalidate the document.

          LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE

Date of Directive:....................

Name of person executing Directive:...........................................
Address of person executing Directive:........................................

                                A LIVING WILL
               A Directive to Withhold or to Provide Treatment

1.  Being of sound mind, I willfully and voluntarily make known my desire that
my life shall not be prolonged artificially under the circumstances set forth
below. This Directive shall only be effective if I am unable to communicate my
instructions and:
    a.  I have an incurable injury, disease, illness or condition and two (2)
    medical doctors who have examined me have certified:
         1.  That such injury, disease, illness or condition is terminal; and
         2.  That the application of artificial life-sustaining procedures
         would serve only to prolong artificially my life; and
         3.  That my death is imminent, whether or not artificial
         life-sustaining procedures are utilized; or
    b.  I have been diagnosed as being in a persistent vegetative state.
In such event, I direct that the following marked expression of my intent be
followed, and that I receive any medical treatment or care that may be
required to keep me free of pain or distress.

Check one box and initial the line after such box:

    ........  I direct that all medical treatment, care and procedures
necessary to restore my health, sustain my life, and to abolish or alleviate
pain or distress be provided to me. Nutrition and hydration, whether
artificial or nonartificial, shall not be withheld or withdrawn from me if I
would likely die primarily from malnutrition or dehydration rather than from
my injury, disease, illness or condition.

OR

    ........  I direct that all medical treatment, care and procedures,
including artificial life-sustaining procedures, be withheld or withdrawn,
except that nutrition and hydration, whether artificial or nonartificial shall
not be withheld or withdrawn from me if, as a result, I would likely die
primarily from malnutrition or dehydration rather than from my injury,
disease, illness or condition, as follows: (If none of the following boxes are
checked and initialed, then both nutrition and hydration, of any nature,
whether artificial or nonartificial, shall be administered.)

Check one box and initial the line after such box:

    A.        ........  Only hydration of any nature, whether artificial or
                   nonartificial, shall be administered;
    B.        ........  Only nutrition, of any nature, whether artificial or
                   nonartificial, shall be administered;
    C.        ........  Both nutrition and hydration, of any nature, whether
                   artificial or nonartificial shall be administered.

OR

    ........  I direct that all medical treatment, care and procedures be
withheld or withdrawn, including withdrawal of the administration of
artificial nutrition and hydration.

2.  This Directive shall be the final expression of my legal right to refuse
or accept medical and surgical treatment, and I accept the consequences of
such refusal or acceptance.

3.  If I have been diagnosed as pregnant, this Directive shall have no force
during the course of my pregnancy.

4.  I understand the full importance of this Directive and am mentally
competent to make this Directive. No participant in the making of this
Directive or in its being carried into effect shall be held responsible in any
way for complying with my directions.

                 A DURABLE POWER OF ATTORNEY FOR HEALTH CARE

1.  DESIGNATION OF HEALTH CARE AGENT. None of the following may be designated
as your agent: (1) your treating health care provider; (2) a nonrelative
employee of your treating health care provider; (3) an operator of a community
care facility; or (4) a nonrelative employee of an operator of a community
care facility. If the agent or an alternate agent designated in this Directive
is my spouse, and our marriage is thereafter dissolved, such designation shall
be thereupon revoked.

I do hereby designate and appoint the following individual as my attorney in
fact (agent) to make health care decisions for me as authorized in this
Directive. (Insert name, address and telephone number of one individual only
as your agent to make health care decisions for you.)

Name of Health Care Agent: ...................................................
Address of Health Care Agent: ................................................
Telephone Number of Health Care Agent: .......................................

For the purposes of this Directive, "health care decision" means consent,
refusal of consent, or withdrawal of consent to any care, treatment, service
or procedure to maintain, diagnose or treat an individual's physical
condition.

2.  CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this portion of
this Directive, I create a durable power of attorney for health care. This
power of attorney shall not be affected by my subsequent incapacity. This
power shall be effective only when I am unable to communicate rationally.

3.  GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this
Directive, including as set forth in paragraph 2 immediately above, I hereby
grant to my agent full power and authority to make health care decisions for
me to the same extent that I could make such decisions for myself if I had the
capacity to do so. In exercising this authority, my agent shall make health
care decisions that are consistent with my desires as stated in this Directive
or otherwise made known to my agent including, but not limited to, my desires
concerning obtaining or refusing or withdrawing life-prolonging care,
treatment, services and procedures, including such desires set forth in a
living will or similar document executed by me, if any. (If you want to limit
the authority of your agent to make health care decisions for you, you can
state the limitations in paragraph 4 ("Statement of Desires, Special
Provisions, and Limitations") below. You can indicate your desires by
including a statement of your desires in the same paragraph.)

4.  STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. (Your agent
must make health care decisions that are consistent with your known desires.
You can, but are not required to, state your desires in the space provided
below. You should consider whether you want to include a statement of your
desires concerning life-prolonging care, treatment, services and procedures.
You can also include a statement of your desires concerning other matters
relating to your health care, including a list of one or more persons whom you
designate to be able to receive medical information about you and/or to be
allowed to visit you in a medical institution. You can also make your desires
known to your agent by discussing your desires with your agent or by some
other means. If there are any types of treatment that you do not want to be
used, you should state them in the space below. If you want to limit in any
other way the authority given your agent by this Directive, you should state
the limits in the space below. If you do not state any limits, your agent will
have broad powers to make health care decisions for you, except to the extent
that there are limits provided by law.) In exercising the authority under this
durable power of attorney for health care, my agent shall act consistently
with my desires as stated below and is subject to the special provisions and
limitations stated in a living will or similar document executed by me, if
any. Additional statement of desires, special provisions, and limitations:....
..............................................................................
..............................................................................
(You may attach additional pages or documents if you need more space to
complete your statement.)

5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL
HEALTH.

A.  General Grant of Power and Authority. Subject to any limitations in this
Directive, my agent has the power and authority to do all of the following:
(1) Request, review and receive any information, verbal or written, regarding
my physical or mental health including, but not limited to, medical and
hospital records; (2) Execute on my behalf any releases or other documents
that may be required in order to obtain this information; (3) Consent to the
disclosure of this information; and (4) Consent to the donation of any of my
organs for medical purposes. (If you want to limit the authority of your agent
to receive and disclose information relating to your health, you must state
the limitations in paragraph 4 ("Statement of Desires, Special Provisions, and
Limitations") above.)

B.  HIPAA Release Authority. My agent shall be treated as I would be with
respect to my rights regarding the use and disclosure of my individually
identifiable health information or other medical records. This release
authority applies to any information governed by the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR
160 through 164. I authorize any physician, health care professional, dentist,
health plan, hospital, clinic, laboratory, pharmacy, or other covered health
care provider, any insurance company, and the Medical Information Bureau, Inc.
or other health care clearinghouse that has provided treatment or services to
me, or that has paid for or is seeking payment from me for such services, to
give, disclose and release to my agent, without restriction, all of my
individually identifiable health information and medical records regarding any
past, present or future medical or mental health condition, including all
information relating to the diagnosis of HIV/AIDS, sexually transmitted
diseases, mental illness, and drug or alcohol abuse. The authority given my
agent shall supersede any other agreement that I may have made with my health
care providers to restrict access to or disclosure of my individually
identifiable health information. The authority given my agent has no
expiration date and shall expire only in the event that I revoke the authority
in writing and deliver it to my health care provider.

6.  SIGNING DOCUMENTS, WAIVERS AND RELEASES. Where necessary to implement the
health care decisions that my agent is authorized by this Directive to make,
my agent has the power and authority to execute on my behalf all of the
following: (a) Documents titled, or purporting to be, a "Refusal to Permit
Treatment" and/or a "Leaving Hospital Against Medical Advice"; and (b) Any
necessary waiver or release from liability required by a hospital or
physician.

7.  DESIGNATION OF ALTERNATE AGENTS. (You are not required to designate any
alternate agents but you may do so. Any alternate agent you designate will be
able to make the same health care decisions as the agent you designated in
paragraph 1 above, in the event that agent is unable or ineligible to act as
your agent. If an alternate agent you designate is your spouse, he or she
becomes ineligible to act as your agent if your marriage is thereafter
dissolved.) If the person designated as my agent in paragraph 1 is not
available or becomes ineligible to act as my agent to make a health care
decision for me or loses the mental capacity to make health care decisions for
me, or if I revoke that person's appointment or authority to act as my agent
to make health care decisions for me, then I designate and appoint the
following persons to serve as my agent to make health care decisions for me as
authorized in this Directive, such persons to serve in the order listed below:

A.  First Alternate Agent:
Name..........................................................................
Address.......................................................................
Telephone Number..............................................................

B.  Second Alternate Agent:
Name..........................................................................
Address.......................................................................
Telephone Number..............................................................

C.  Third Alternate Agent:
Name..........................................................................
Address.......................................................................
Telephone Number..............................................................

8.  PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney
for health care.
DATE AND SIGNATURE OF PRINCIPAL. (You must date and sign this Living Will and
Durable Power of Attorney for Health Care.)

I sign my name to this Statutory Form Living Will and Durable Power of
Attorney for Health Care on the date set forth at the beginning of this Form
at ............... (City, State)....................

..............................
Signature

    (2)  A health care directive meeting the requirements of subsection (1) of
this section may be registered with the secretary of state pursuant to the
provisions of section 39-4515, Idaho Code. Failure to register the health care
directive shall not affect the validity of the health care directive.