LOUISIANA HEALTH CARE POWER OF ATTORNEY

(Durable Health-Care Mandate with HIPAA Authorization)

[// GUIDANCE: This template is drafted for use under Louisiana law. Customize all bracketed items, confirm statutory compliance at the time of execution, and ensure proper witnessing/notarization in accordance with La. Civ. Code arts. 2985 et seq. and applicable health-care decisions statutes.]

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

1. Title and Parties
   1.1 This Louisiana Health Care Power of Attorney (the “Mandate” or “Power of Attorney”) is made and entered into as of [EFFECTIVE DATE] (the “Effective Date”) by [FULL LEGAL NAME OF PRINCIPAL], residing at [ADDRESS] (“Principal”), in favor of [FULL LEGAL NAME OF AGENT], residing at [ADDRESS] (“Agent”).
   1.2 Alternate Agent(s): [NAME(S) / “None”] (“Alternate Agent”).
2. Recitals
   A. Principal desires to authorize Agent to make health-care decisions on Principal’s behalf in the event Principal is unable to make or communicate such decisions.
   B. This Mandate is intended to be durable and to comply with all applicable provisions of Louisiana law governing mandates and health-care decisions, including end-of-life directives and HIPAA privacy regulations.
3. Governing Jurisdiction
   This Mandate shall be governed by and construed in accordance with the laws of the State of Louisiana (“Governing Law”).

II. DEFINITIONS

For purposes of this Mandate, the following capitalized terms shall have the meanings set forth below. All references to Sections are to sections of this Mandate unless otherwise specified.

“Advance Directive” – A written declaration by Principal concerning medical or surgical treatment and the withholding or withdrawal of life-sustaining procedures.

“Agent” – The individual appointed in Section III.1 with authority granted under this Mandate; includes any duly acting Alternate Agent.

“Competent” – Possessing the ability to understand and appreciate the nature and consequences of one’s decisions and to communicate those decisions.

“End-of-Life Decision” – Any decision to withhold, withdraw, or continue life-sustaining procedures when, in the opinion of the attending physician and a second physician, Principal has a terminal and irreversible condition.

“Good Faith” – Honesty in fact and the observance of reasonable health-care standards applicable to the Agent at the time of a decision.

“Health Care Provider” – Any physician, nurse, hospital, clinic, or other person or entity duly licensed or authorized to render medical or health-care services.

“HIPAA” – The Health Insurance Portability and Accountability Act of 1996, and its implementing regulations (45 C.F.R. Parts 160 & 164).

“Life-Sustaining Procedure” – Any medical intervention that serves only to prolong the process of dying and where, in reasonable medical judgment, death is imminent if such intervention is withheld or withdrawn.

“Principal” – The individual executing this Mandate, identified in Section I.

“State Probate Court” – The district court of proper venue in Louisiana exercising probate jurisdiction.

III. OPERATIVE PROVISIONS

1. Appointment of Agent
   Principal hereby constitutes and appoints Agent as Principal’s true and lawful mandatary (“Agent”) with full power to make any and all health-care decisions for Principal as set forth herein.

2. Scope of Authority
   Subject to the limitations expressly stated in this Mandate, Agent is authorized to:
   a. Consent, refuse, or withdraw consent to any medical or surgical procedure, treatment, or intervention, including, without limitation, diagnostic tests, medication, hospitalization, and surgery.
   b. Choose and discharge physicians, nurses, hospitals, clinics, rehabilitation facilities, or hospice programs.
   c. Approve or deny placement in or discharge from any nursing home, assisted-living facility, or similar institution.
   d. Execute documents required to obtain or transfer medical or health-care benefits.
   e. Access, review, receive, and disclose Principal’s protected health information (“PHI”) to the extent permitted by HIPAA and Section III.6.
   f. Authorize autopsy, organ donation, and disposition of remains in accordance with Principal’s wishes or, if none, in Agent’s discretion.
   g. Make End-of-Life Decisions as provided in Section III.4.
   [// GUIDANCE: You may add or delete sub-powers to fit the Principal’s wishes.]

3. Durable Nature; Effect Upon Incapacity
   This Mandate is durable and shall not be affected by the subsequent incapacity or incompetence of the Principal.

4. End-of-Life Provisions
   4.1 Statement of Intent. Principal desires that End-of-Life Decisions be made consistent with the following directive (choose ONE):
     (i) ❑ WITHHOLD or WITHDRAW life-sustaining procedures when I am diagnosed with a terminal and irreversible condition.
     (ii) ❑ CONTINUE life-sustaining procedures regardless of condition.
     (iii) ❑ [OTHER INSTRUCTIONS].
   4.2 Express Grant of Authority. Agent is expressly authorized to withhold or withdraw artificial nutrition or hydration if, after consultation with treating physicians, Agent determines such action to be consistent with Principal’s wishes and best interests.

5. Mental Health Treatment
   [OPTIONAL] Agent is authorized to consent to admission to a mental health treatment facility for not more than [DAYS] days and to consent to psychotropic medications.

6. HIPAA Authorization
   Principal expressly authorizes any Health Care Provider to disclose to Agent any of Principal’s PHI, including mental health and substance-abuse records, and authorizes Agent to redisclose such information as necessary to carry out Agent’s duties. This authorization is intended to be valid under 45 C.F.R. §164.502(g)(2) and shall remain effective until revoked in writing.

7. Good Faith Reliance
   Any third party may rely upon the instructions of Agent acting in Good Faith without further inquiry, and such third party shall be held harmless and indemnified by Principal’s estate for so relying.

8. Revocation and Termination
   8.1 Principal may revoke this Mandate at any time by (i) a written, signed, and dated instrument; or (ii) personally informing the attending physician.
   8.2 This Mandate shall terminate automatically upon:
   a. Principal’s death;
   b. Judicial appointment of a curator or tutor with express authority over health-care decisions;
   c. [OPTIONAL] Legal separation or divorce of Principal and Agent, if Agent is Principal’s spouse; or
   d. Written resignation by Agent delivered to Principal (or Alternate Agent if Principal is incapacitated).

IV. REPRESENTATIONS & WARRANTIES

1. Principal represents and warrants that:
   a. Principal is at least eighteen (18) years of age, of sound mind, and under no duress.
   b. No prior health-care power of attorney or advance directive remains in effect except [“None” / describe].
   c. Execution of this Mandate is consistent with any existing living will or Advance Directive.

2. Agent represents and warrants that:
   a. Agent is at least eighteen (18) years of age and willing to serve.
   b. Agent is not the attending physician or an employee of a Health Care Provider currently treating Principal, except as allowed by law.

3. Survival. The representations and warranties in this Section IV shall survive execution and remain in effect for the duration of this Mandate.

V. COVENANTS & RESTRICTIONS

1. Agent Covenants
   a. To act in Good Faith and in accordance with Principal’s known wishes and best interests.
   b. To consult, when practicable, with family members and medical professionals before making major decisions.
   c. To keep reasonable records of decisions and communications with Health Care Providers.

2. Restrictions on Agent
   Unless expressly authorized herein, Agent shall not:
   a. Consent to sterilization procedures, abortion, or psychosurgery.
   b. Delegate authority granted under this Mandate to any third party (other than an Alternate Agent).
   c. Act in a manner that creates a conflict of interest with Principal’s estate or financial interests.

3. Notice Obligations
   Agent shall notify Principal’s immediate family (to the extent contact information is available) within a reasonable time after exercising significant powers under Sections III.2 and III.4.

VI. DEFAULT & REMEDIES

1. Events of Default
   a. Agent’s breach of fiduciary duties of Good Faith, loyalty, or reasonable care.
   b. Misuse or unauthorized disclosure of PHI.
   c. Conviction of Agent for a felony offense involving moral turpitude.

2. Cure & Removal
   Upon an Event of Default, any interested person may petition the State Probate Court for:
   a. Temporary suspension or permanent removal of Agent;
   b. Appointment of Alternate Agent or court-appointed guardian; and/or
   c. Injunctive relief to prevent imminent harm.

3. Attorney Fees
   The prevailing party in any judicial proceeding arising hereunder shall be entitled to reasonable attorney fees and costs.

VII. RISK ALLOCATION

1. Indemnification
   Principal and Principal’s estate shall indemnify and hold harmless Agent from any liability, loss, or expense incurred as a result of actions taken in Good Faith pursuant to this Mandate, except for liability arising from Agent’s gross negligence, willful misconduct, or bad faith.

2. Limitation of Liability
   Agent shall not be liable for any injury, deterioration, or death of Principal resulting from decisions made in Good Faith and in accordance with this Mandate and applicable law.

3. Insurance [OPTIONAL]
   Principal recommends (but does not require) that Agent maintain professional liability insurance covering health-care decision-making activities.

4. Force Majeure
   Agent shall not be deemed in default for failure to act when prevented by circumstances beyond Agent’s reasonable control, including acts of God, war, or interruption of communications.

VIII. DISPUTE RESOLUTION

1. Governing Law
   This Mandate shall be governed by the laws of the State of Louisiana.

2. Forum Selection
   Exclusive jurisdiction and venue for any proceeding arising hereunder shall lie in the State Probate Court of competent venue.

3. Arbitration
   Arbitration is not available for disputes under this Mandate.

4. Jury Waiver
   No jury-trial waiver is provided; parties retain all constitutional rights to a jury trial where applicable.

5. Injunctive Relief
   Nothing herein limits the right of any interested person to seek emergent injunctive or declaratory relief in the State Probate Court to enforce or interpret this Mandate or protect Principal’s health and welfare.

IX. GENERAL PROVISIONS

1. Amendment & Waiver
   This Mandate may be amended only by written instrument signed by Principal (or by a curator acting under court order) and duly witnessed and notarized. No waiver of any provision shall be effective unless in writing and shall not constitute a waiver of any other provision.

2. Assignment & Delegation
   Agent may not assign or delegate any authority under this Mandate, except to an Alternate Agent expressly named herein.

3. Successors & Assigns
   This Mandate shall inure to the benefit of and bind the heirs, executors, administrators, and permitted assigns of the parties.

4. Severability
   If any provision is held invalid or unenforceable, such provision shall be reformed to the minimal extent necessary, and the remainder of the Mandate shall remain in full force and effect.

5. Integration
   This Mandate constitutes the entire agreement with respect to the subject matter and supersedes all prior powers of attorney concerning health-care decisions executed by Principal.

6. Counterparts & Electronic Signatures
   This Mandate may be executed in multiple counterparts, each of which shall be deemed an original, and signatures transmitted by electronic means shall be deemed originals for all purposes.

X. EXECUTION BLOCK

[// GUIDANCE: Louisiana best practice is TWO witnesses plus a notary. Witnesses should be competent adults who are not Agent, Alternate Agent, or Health Care Providers involved in Principal’s treatment.]

IN WITNESS WHEREOF, Principal has executed this Louisiana Health Care Power of Attorney on the date first written above.

A. Principal

[PRINCIPAL NAME] (“Principal”)
Date: ________

B. Agent Acknowledgment

I, [AGENT NAME], have read the foregoing Mandate and accept the appointment as Agent. I understand and will act in accordance with my duties under Louisiana law.

[AGENT NAME] (“Agent”)
Date: ________

C. Alternate Agent Acknowledgment (if any)

[ALTERNATE AGENT NAME] (“Alternate Agent”)
Date: ________

D. Witness Attestation

We declare that the Principal appears to be of sound mind and free from duress, that the Principal signed or acknowledged this Mandate in our presence, and we are not persons prohibited from acting as witnesses.

1. _______ Date: _____
   [PRINT NAME & ADDRESS]

2. _______ Date: _____
   [PRINT NAME & ADDRESS]

E. NOTARY PUBLIC

STATE OF LOUISIANA )
PARISH OF ____)

On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], personally known to me or satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed the same for the purposes herein contained.

IN WITNESS WHEREOF, I hereunto set my hand and official seal.

Notary Public
Printed Name: ___
Notary I.D. or Bar Roll No.: _
My Commission Expires: ___

[// GUIDANCE: After execution, provide copies to the Agent, Alternate Agent, primary physician, and any relevant Health Care Provider. Consider filing a copy with the parish clerk if local practice so dictates.]