MISSOURI DURABLE POWER OF ATTORNEY

FOR HEALTH CARE DECISIONS

(Complying with Mo. Rev. Stat. §§ 404.800 – 404.865)

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. Parties.
   a. Principal: [PRINCIPAL LEGAL NAME], residing at [ADDRESS] (“Principal”).
   b. Primary Agent: [AGENT LEGAL NAME], residing at [ADDRESS] (“Agent”).
   c. Alternate Agent(s): [ALTERNATE AGENT 1] → Successor rank 1; [ALTERNATE AGENT 2] → Successor rank 2.

2. Recitals.
   WHEREAS, the Principal desires, in accordance with Mo. Rev. Stat. §§ 404.800 – 404.865 (the “Missouri Act”), to delegate authority to make health-care decisions if the Principal becomes incapacitated; and
   WHEREAS, the Principal intends this instrument to be a “Durable Power of Attorney for Health Care” and, to the extent expressed herein, an “Advance Health-Care Directive”;
   NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of which are hereby acknowledged, the Principal executes this instrument on the Effective Date set forth below.

3. Effective Date.
   This instrument becomes effective upon the Principal’s incapacity as determined under § 404.822 of the Missouri Act, and remains effective until revoked pursuant to Section IX.2.

4. Governing Jurisdiction.
   This instrument shall be governed by the substantive laws of the State of Missouri relating to health-care powers of attorney (the “Governing Law”).

II. DEFINITIONS

(The following definitions apply throughout. Section cross-references are to this instrument unless otherwise noted.)

“Advance Directive” – Collectively, the end-of-life instructions in Section III.3.
“Capacity” – The ability to understand and appreciate the nature and consequences of proposed health-care decisions, as determined by a licensed physician.
“Good Faith” – Honesty in fact and the observance of reasonable standards of health-care decision making under the circumstances then prevailing.
“Health-Care Decision” – Any consent, refusal of consent, or withdrawal of consent to health-care, treatment, service, or procedure.
“HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, including 45 C.F.R. § 164.502(g)(2).
“Missouri Probate Court” – The probate division of the circuit court in [COUNTY], Missouri, having subject-matter jurisdiction.
“Principal,” “Agent,” and “Alternate Agent” – As identified in Section I.1.

III. OPERATIVE PROVISIONS

3.1 Appointment of Health-Care Agent

The Principal hereby appoints the Agent (and, if the Agent is unable or unwilling to serve, the Alternate Agent(s) in the order listed) as the Principal’s lawful attorney-in-fact for Health-Care Decisions.

3.2 Scope of Authority

The Agent is authorized to:
a. Consent to, refuse, or withdraw any medical care, diagnostic test, surgical procedure, life-support, or mental-health treatment;
b. Access, obtain, and disclose protected health information pursuant to Section 3.4;
c. Employ and discharge health-care providers;
d. Authorize admission to or discharge from any hospital, hospice, or other facility;
e. Sign any waivers of liability or releases required by providers;
f. Take any ancillary action necessary to implement the foregoing.
[// GUIDANCE: Delete or revise any authority the Principal wishes to withhold.]

3.3 End-of-Life Directives

1. Life-Prolonging Measures. [SELECT ONE AND DELETE OTHERS]
   • [ ] I direct that life-prolonging procedures be withheld or withdrawn if I am terminally ill or in a persistent vegetative state.
   • [ ] I direct that life-prolonging procedures be provided under all circumstances.
2. Artificial Nutrition & Hydration. [SELECT]
   • [ ] Withhold/withdraw if only delaying dying.
   • [ ] Provide regardless of prognosis.
3. Pain Management. The Agent may authorize medication to alleviate pain even if it hastens death, consistent with Good Faith medical practice.
4. Do-Not-Resuscitate (DNR). The Agent may sign or revoke DNR orders consistent with these directives.
   [// GUIDANCE: Missouri does not require a separate living will when these directives are integrated.]

3.4 HIPAA Authorization

Pursuant to 45 C.F.R. § 164.502(g)(2), the Agent is the Principal’s “personal representative” for all purposes under HIPAA and may request, receive, and disclose any protected health information.

3.5 Nomination of Guardian or Conservator

If a court deems a guardian and/or conservator necessary, the Principal nominates the Agent (or Alternate Agent, in order) pursuant to Mo. Rev. Stat. § 404.839.

IV. REPRESENTATIONS & WARRANTIES

1. Principal. The Principal represents that:
   a. The Principal is at least eighteen (18) years old, of sound mind, and executing this instrument voluntarily.
   b. No other durable power of attorney for health care inconsistent with this instrument is in effect.
2. Agent & Alternate Agent(s). Each designated person represents, upon acceptance:
   a. Age eighteen (18) or older and not disqualified under the Missouri Act;
   b. Will act in Good Faith and in accordance with the Principal’s known wishes.

V. COVENANTS & RESTRICTIONS

1. Agent Covenants. The Agent shall:
   a. Consult with health-care professionals and family as reasonable;
   b. Follow the Principal’s known wishes and, if unknown, the Principal’s best interests;
   c. Keep reasonably detailed records of decisions made.
2. Restrictions. The Agent shall not:
   a. Authorize non-therapeutic sterilization or psychosurgery without court order;
   b. Make decisions inconsistent with Sections 3.3 or IX.
   [// GUIDANCE: Add or delete restrictions per client preference.]

VI. DEFAULT & REMEDIES

1. Events of Default.
   a. Agent resignation, incapacity, or death;
   b. Judicial removal for breach of fiduciary duty or lack of Good Faith.
2. Remedies.
   a. Automatic succession to next Alternate Agent;
   b. Petition to the Missouri Probate Court for injunctive relief or appointment of a guardian;
   c. Recovery of reasonable attorneys’ fees by the prevailing party.

VII. RISK ALLOCATION

1. Indemnification. The Principal shall indemnify and hold harmless the Agent and any health-care provider that relies on the Agent’s Good Faith instructions, except to the extent of the Agent’s bad faith, gross negligence, or willful misconduct.
2. Limitation of Liability. No Agent shall be liable for monetary damages to the Principal or any third party arising from Good Faith Health-Care Decisions.
3. Insurance. No separate fiduciary bond or insurance is required unless ordered by a court.

VIII. DISPUTE RESOLUTION

1. Governing Law. This instrument is governed by the law identified in Section I.4.
2. Forum Selection. Any judicial proceeding arising hereunder shall be brought exclusively in the Missouri Probate Court.
3. Arbitration / Jury Waiver. Intentionally Omitted.
4. Injunctive Relief. Nothing herein limits the court’s power to grant equitable relief to enforce the Advance Directive or remove an Agent for cause.

IX. GENERAL PROVISIONS

1. Amendment & Waiver. The Principal may amend or revoke this instrument at any time in writing, signed, dated, and acknowledged before a notary public. No oral waiver or modification is effective.
2. Revocation. Revocation is effective upon delivery to the Agent and, when feasible, to health-care providers then treating the Principal.
3. Severability. If any provision is held invalid, the remainder shall remain in full force.
4. Integration. This document constitutes the entire Durable Power of Attorney for Health Care between the parties.
5. Counterparts & Electronic Signatures. Executed counterparts and electronic signatures are deemed originals.

X. EXECUTION BLOCK

10.1 Principal

I, [PRINCIPAL NAME], sign my name to this Missouri Durable Power of Attorney for Health Care on this ___ day of ____, 20__, in the presence of the undersigned witness(es) OR notary public.

Principal Signature

10.2 Agent Acceptance

I, [AGENT NAME], accept the appointment as Agent and acknowledge my fiduciary duties under this instrument and the Missouri Act.

Agent Signature & Date

10.3 Alternate Agent Acceptance(s)

[Duplicate acceptance lines as necessary.]

10.4 Witness Attestation (Use if NOT notarized)

We declare that the Principal is personally known to us, appears to be of sound mind, and signed this instrument voluntarily.

Requirements: 18 + years old; not Agent, Alternate Agent, spouse, descendant, heir, or directly involved health-care provider.

10.5 Notary Acknowledgment (Use in lieu of witnesses)

State of Missouri )
County of __ ) ss.

On _, 20, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed it freely and voluntarily.

Notary Public
My commission expires: ____

[// GUIDANCE:
1. File copies with the Principal’s primary physician and hospital.
2. Review every three (3) years or upon major life changes.
3. Confirm that the end-of-life selections in Section 3.3 match any existing Living Will to avoid conflicts.
4. Consider attaching a separate organ donation form if desired.
5. Missouri permits either two qualified witnesses OR notarization. Using both increases enforceability.]