Healthcare Power of Attorney - Louisiana

Louisiana Health-Care Mandate

With Special End-of-Life Representative Designation

Louisiana calls this agency relationship a mandate and the agent a mandatary. This document specifically authorizes health-care decisions under R.S. 40:1159.4 and also designates the mandatary under R.S. 40:1151.4(A)(2)(b) to make an end-of-life declaration if the statutory conditions are met.

1. Principal

Full legal name: [________________________________]

Date of birth: [__/__/____]

Address: [________________________________]

Telephone / email: [________________________________]

2. Primary Mandatary

I appoint the following person as my mandatary for the health-care affairs stated in this document:

Name: [________________________________]

Address: [________________________________]

Telephone / email: [________________________________]

3. Alternate Mandataries

I separately confer the same contingent health-care authority on these alternates. An alternate may act only if every person listed earlier has died, resigned, is unavailable, is unwilling to act, or lacks authority:

4. Effective Time and Continuing Authority

My mandatary may exercise health-care authority only when a physician documents that I cannot make or communicate the decision at issue. While I can make and communicate a decision, my own decision controls.

Under Louisiana Civil Code article 3026, my incapacity, disability, or another condition making express revocation impossible or impractical does not terminate this mandate or the mandatary's authority.

5. Health-Care Authority

Subject to my instructions and applicable law, I specifically authorize my mandatary to:

• Consent to, refuse, or withdraw consent from surgical or medical treatment or procedures recommended, prescribed, or directed by a licensed physician;
• Consent to an autopsy;
• Select and communicate with physicians, hospitals, hospices, nursing facilities, and other health-care providers;
• Arrange admission, transfer, or discharge;
• Sign consents and other documents needed to implement an authorized health-care decision; and
• Request and receive information needed for a decision to the extent the holder may lawfully disclose it.

This document grants no authority over my property, banking, taxes, gifts, contracts unrelated to health care, or disposition of my remains.

6. Principal's Instructions

My health-care wishes, values, religious beliefs, treatment preferences, comfort-care goals, and limitations on authority are:

[____________________________________________________________]

[____________________________________________________________]

My mandatary shall follow these instructions and any separate valid living-will declaration that I have made.

Separate living-will declaration located at: [________________________________]

7. Subjects Outside This Consent Subpart

R.S. 40:1159.2 excludes abortion and sterilization from the medical-consent subpart. R.S. 40:1159.3 generally excludes care and treatment of persons with mental illness, subject to its statutory exception for developmental disabilities. This mandate does not by itself supply authority under those separate laws.

8. Special Designation to Make an End-of-Life Declaration

If I have not made a prior declaration, I specifically designate the acting mandatary to make a declaration on my behalf under R.S. 40:1151.4 only when:

• Two physicians who personally examined me, one of whom is my attending physician, certify in writing that I have a terminal and irreversible condition;
• I am comatose, incompetent, or otherwise physically or mentally incapable of communication;
• No judicially appointed tutor or curator with higher statutory priority is acting; and
• The declaration is made in the presence of at least two witnesses as required by R.S. 40:1151.4(B).

My mandatary should make that declaration consistently with my known wishes and the instructions in this mandate. The absence of my own living-will declaration creates no presumption that I consent to or refuse life-sustaining procedures.

9. Statutory Priority and Emergencies

For general surgical or medical consent, a judicially appointed tutor or curator has priority over an agent under a health-care mandate. The mandate agent has priority over the remaining family and friend classes listed in R.S. 40:1159.4.

When an emergency exists and no person authorized to consent is readily available, Louisiana law may imply consent under R.S. 40:1159.5. This mandate does not delay emergency care.

10. Termination and Notice

I may terminate this mandate and the mandatary's authority at any time.

Under Civil Code article 3024, a mandate and mandatary's authority also terminate upon the death of the principal or mandatary, interdiction of the mandatary, or qualification of the curator after interdiction of the principal. Each alternate's appointment is a separate contingent grant subject to the same law.

I will communicate a termination promptly to the mandatary, alternate mandataries, physicians, and facilities that received this document. Prompt delivery helps prevent continued reliance on terminated authority.

This mandate contains no automatic spouse-agent divorce rule, estate indemnity, prevailing-party fee clause, liability cap, insurance right, cure period, force-majeure excuse, or exclusive court forum.

11. Principal Signature

I confer the authority stated above and intend this mandate to continue during incapacity as provided by Louisiana law.

Signature: ________________________________________

Printed name: [________________________________]

Date: [__/__/____]

12. Two Witnesses for the Special End-of-Life Designation

Louisiana Civil Code article 2993 does not generally require a mandate to use a particular form. However, the special designation in Section 8 must be in a written instrument that the principal signs in the presence of at least two witnesses. Each witness should satisfy the Living Will Law definition: a competent adult unrelated to the principal by blood or marriage and not entitled to any portion of the principal's estate. A notary does not replace these witnesses.

We witnessed the principal sign this mandate and special designation voluntarily.

13. Optional Mandatary Acknowledgment

I accept the appointment and acknowledge the principal's instructions and the limits of this mandate.

Mandatary signature: ________________________________________

Printed name: [________________________________]

Date: [__/__/____]

14. Distribution

Give copies to the primary and alternate mandataries, physicians, and health-care facilities. Keep any separate Louisiana living-will declaration with this mandate.

Sources and References

• La. Civ. Code art. 2989 — mandate defined
• La. Civ. Code art. 2993 — form
• La. Civ. Code art. 3024 — termination events
• La. Civ. Code art. 3025 — termination by principal
• La. Civ. Code art. 3026 — incapacity of principal
• La. R.S. 40:1151.1 — qualified patient and witness definitions
• La. R.S. 40:1151.4 — designated representative and end-of-life declaration
• La. R.S. 40:1159.2 — abortion and sterilization exclusion
• La. R.S. 40:1159.3 — mental-health exclusion
• La. R.S. 40:1159.4 — health-care mandate agent, priority, and consent
• La. R.S. 40:1159.5 — emergencies
• La. R.S. 40:1159.6 — construction
• La. R.S. 40:1159.7 — adult's right to refuse treatment