Healthcare Power of Attorney

MICHIGAN PATIENT ADVOCATE DESIGNATION

(Durable Power of Attorney for Health Care)

Compliant with Michigan Compiled Laws § 700.5501 et seq.

I. DOCUMENT HEADER

1. Title
   Michigan Patient Advocate Designation and Durable Power of Attorney for Health Care (“Healthcare Power of Attorney”).

2. Parties
   a. Principal: [PRINCIPAL LEGAL NAME], residing at [ADDRESS] (“Principal”).
   b. Primary Patient Advocate: [AGENT LEGAL NAME], residing at [ADDRESS] (“Patient Advocate” or “Agent”).
   c. Successor Patient Advocate(s) (in order of priority): [NAME / ADDRESS].
   d. Qualified Witnesses: Witness #1 – [NAME / ADDRESS]; Witness #2 – [NAME / ADDRESS].

3. Effective Date
   This Designation is effective on the later of (i) the date signed by the Principal, or (ii) the date the Patient Advocate executes the Acceptance in Section XI.

4. Governing Law & Forum
   This instrument is governed by the laws of the State of Michigan that relate to health-care powers of attorney and patient advocate designations. Any judicial proceeding shall be brought exclusively in the probate court of the county in which the Principal resides.

II. DEFINITIONS

For purposes of this Designation, capitalized terms have the meanings below:

1. “Advance Directive” – Any written statement expressing the Principal’s wishes concerning health-care treatment, including this Designation, a living will, or any do-not-resuscitate order.
2. “Health-Care Decision” – Any decision related to the Principal’s medical, psychiatric, surgical, diagnostic, hospice, palliative, nursing, personal, or custodial care.
3. “HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, 45 C.F.R. Parts 160 & 164.
4. “Life-Sustaining Treatment” – Any medical treatment that serves only to prolong the process of dying when death is otherwise imminent.
5. “Qualified Witness” – An adult who is not (a) the Patient Advocate, Successor Advocate, or their spouse, parent, child, grandchild, sibling, or presumptive heir; (b) the attending physician; (c) an employee of a health facility where the Principal is receiving care; (d) an employee of a life or health insurance provider for the Principal; or (e) financially responsible for the Principal’s care. See MCL 700.5501(4).
6. “Serious Incapacity” – A condition in which the Principal is unable to participate in medical treatment decisions, as determined under applicable Michigan law.

III. APPOINTMENT & GRANT OF AUTHORITY

1. Appointment
   The Principal appoints the Patient Advocate to make Health-Care Decisions on the Principal’s behalf whenever the Principal is determined to have a Serious Incapacity.

2. Scope of Authority
   Subject to the limitations in Section IV, the Patient Advocate is authorized to:
   a. Consent to, refuse, or withdraw any type of medical treatment, including Life-Sustaining Treatment.
   b. Employ and discharge health-care providers.
   c. Access, obtain, and disclose protected health information (“PHI”) and medical records in accordance with the HIPAA Authorization in Section V.
   d. Arrange admission to or discharge from hospitals, nursing homes, assisted-living, or similar facilities.
   e. Execute documents required to obtain or pay for medical care, including insurance claims and Medicare/Medicaid applications.
   f. Authorize pain-relieving medications, including controlled substances, even if they may hasten death.
   g. Make decisions regarding mental-health treatment pursuant to MCL 330.1703(2).
   h. Make anatomical gifts, authorize autopsy, and determine disposition of remains, unless the Principal has executed a separate document addressing such matters.

3. Successor Patient Advocate
   If the Primary Patient Advocate is unable, unwilling, or disqualified to serve, the next-listed Successor shall assume all rights and obligations herein without further act.

IV. LIMITATIONS & SPECIAL INSTRUCTIONS

1. End-of-Life Decisions
   a. If I am in a terminal condition or permanent unconsciousness, I desire that Life-Sustaining Treatment be:
   [PLACEHOLDER: SELECT “WITHHELD,” “WITHDRAWN,” or “PROVIDED.”]
   b. Nutrition & Hydration:
   [PLACEHOLDER: STATE WHETHER ARTIFICIAL NUTRITION/HYDRATION MAY BE WITHHELD OR WITHDRAWN.]

2. Pregnancy
   If I am known to be pregnant, decisions shall be limited to the extent required by applicable Michigan law to preserve the life of the embryo or fetus.

3. Faith-Based or Moral Directives
   [PLACEHOLDER: INSERT ANY RELIGIOUS OR MORAL DIRECTIVES THAT MUST GUIDE CARE.]

4. Prohibited Actions
   The Patient Advocate may not:
   a. Make a Health-Care Decision to withhold care that would have the primary purpose of causing my death, except as expressly authorized in Sub-Section IV(1).
   b. Delegate authority granted under this Designation.
   c. Receive compensation beyond reimbursement of reasonable expenses, unless expressly authorized here: [PLACEHOLDER].

V. HIPAA AUTHORIZATION

1. Authorization Grant
   Pursuant to 45 C.F.R. § 164.508, the Patient Advocate is my “personal representative” and is hereby authorized to request, receive, and release any and all PHI relating to my past, present, or future physical or mental health.

2. Duration
   This HIPAA Authorization is effective on execution and survives my death to the extent necessary to carry out the purposes of this Designation.

3. Redisclosure
   Information disclosed under this Authorization may be subject to redisclosure by the Patient Advocate and may no longer be protected by HIPAA.

VI. REPRESENTATIONS & WARRANTIES

1. Principal’s Capacity
   The Principal affirms being at least 18 years of age and of sound mind.

2. Reliance
   Third parties may rely on the authenticity of this Designation without liability to the Principal, provided they act in good faith.

3. No Coercion
   The Principal signs voluntarily and not as a condition of obtaining insurance, health-care services, or discharge from a facility.

VII. COVENANTS OF PATIENT ADVOCATE

1. Act in good faith, with reasonable diligence, and consistent with the Principal’s known wishes or best interests.
2. Consult available medical professionals and religious or ethical advisors, as appropriate.
3. Maintain contemporaneous records of material decisions.
4. Notify named Successor Advocate(s) upon resignation, incapacity, or disqualification.
5. Comply with all requirements of MCL 700.5509, including the duty to visit the Principal unless impracticable.

VIII. DEFAULTS & REMEDIES

1. Events of Default
   a. Patient Advocate acts outside the authority granted.
   b. Breach of the duties enumerated in Section VII.
   c. Failure to act when a decision is required and no Successor is available.

2. Remedies
   a. Any interested person may petition the probate court for (i) removal of the Patient Advocate; (ii) appointment of a guardian; or (iii) injunctive relief to enforce the Principal’s Advance Directives.
   b. Reasonable attorney fees and costs shall be awarded to the prevailing party upon a finding of bad faith.

IX. RISK-ALLOCATION

1. Indemnification
   The Principal agrees to indemnify and hold harmless the Patient Advocate from any liability, claim, or expense arising from Health-Care Decisions made in good faith and in accordance with this Designation.

2. Limitation of Liability
   The Patient Advocate shall not be liable for damages so long as actions or omissions are in good faith and with reasonable care, consistent with MCL 700.5512(5).

X. GENERAL PROVISIONS

1. Revocation
   The Principal may revoke this Designation at any time by (i) written or oral statement to any person; (ii) burning, tearing, canceling, obliterating, or destroying this document; or (iii) execution of a later-dated patient advocate designation.

2. Amendment
   May be amended only by a writing signed by the Principal with the same formalities as this instrument.

3. Severability
   If any provision is held invalid, the remaining provisions shall remain in effect to the maximum extent permitted.

4. Integration
   This instrument constitutes the entire patient advocate designation and supersedes any prior inconsistent directives.

5. Counterparts & Electronic Signatures
   This Designation may be executed in counterparts and by electronic signature, each of which shall constitute an original.

XI. ACCEPTANCE BY PATIENT ADVOCATE

I, [AGENT LEGAL NAME], voluntarily accept the role of Patient Advocate and agree to act in accordance with Michigan law and the instructions herein.

__________________________________      ____________
Signature of Patient Advocate           Date

Required Acceptance Language (MCL 700.5509(1)):
“I have received a copy of the patient advocate designation, understand its contents, and agree to act as patient advocate. I understand that I may make a decision to withhold or withdraw treatment which could or would allow the patient to die. I also understand that the patient may revoke this designation at any time and that my authority ceases at the time the patient is able to participate in treatment decisions.”

XII. EXECUTION & ATTESTATION

1. Principal’s Signature

__________________________________      ____________
[PRINCIPAL LEGAL NAME]                  Date

2. Witnesses’ Statement
   We declare that (a) the Principal appeared to be of sound mind and under no duress, fraud, or undue influence; (b) we are each at least 18 years old; and (c) we are not disqualified persons under MCL 700.5501(4).

__________________________________      ____________
Witness #1 Signature                     Date
Printed Name: _________________________

__________________________________      ____________
Witness #2 Signature                     Date
Printed Name: _________________________

3. Notary Public (optional but recommended)

State of Michigan     )
County of __________  )  ss.

On __________, before me, the undersigned Notary Public, personally appeared ________________________, known to me or satisfactorily proven to be the person who executed the foregoing Patient Advocate Designation, and acknowledged the same for the purposes therein contained.

__________________________________      ____________
Notary Public                            My Commission Expires
Acting in __________________ County