Healthcare Power of Attorney - Nebraska

NEBRASKA POWER OF ATTORNEY FOR HEALTH CARE

Important Information

This document appoints a competent adult as my attorney in fact for health care. The attorney in fact acts only after the incapacity determination required by Nebraska law. This document does not authorize financial decisions or post-death decisions.

I must sign and date this document before either two qualified adult witnesses or a qualified notary. A person designated as my attorney in fact or successor may not act as the notary.

1. Principal

I, [FULL LEGAL NAME], born [__/__/____], residing at [________________________________], am at least 18 years old or otherwise am not a minor. I make this power voluntarily while competent.

Telephone / email: [________________________________]

2. Primary Attorney in Fact

I appoint the following competent adult:

3. Successor Attorney in Fact

If the primary attorney in fact is not reasonably available or is unable or unwilling to serve, I appoint:

If the primary attorney in fact later becomes available, able, and willing to serve, the successor's authority ceases and the primary attorney in fact's authority resumes.

4. Agent Eligibility Review

My attending physician or a member of my mental-health-treatment team may not serve. The following nonrelatives also may not serve: an employee of either of those persons; an owner, operator, or employee of a health-care provider where I am a patient or resident; or a person already serving as attorney in fact for 10 or more principals.

☐ The primary attorney in fact is eligible.

☐ The successor attorney in fact is eligible.

5. When Authority Begins

My attorney in fact's authority begins only when my attending physician makes the written incapacity determination required by Neb. Rev. Stat. § 30-3412. Any physician consulted about that determination must also document the cause and nature of my incapacity, and the required writings must be placed in the applicable medical records.

Choose one:

☐ Statutory default. I do not require a second physician solely to confirm incapacity.

☐ Second-physician confirmation required. In addition to the statutory determination, I require a second physician to confirm in writing that I am incapable of making health-care decisions.

My attorney in fact has no decision-making authority under this document while I retain capacity. If my attending physician determines that I am no longer incapable, the authority ceases and may recommence after a later statutory determination.

6. General Authority and Records

After authority begins, and subject to this document and Nebraska law, my attorney in fact may:

1. Consent to, refuse consent to, or withdraw consent to health care for me.
2. Receive information about proposed health care.
3. Receive and review my medical and clinical records.
4. Consent to disclosure of those records.
5. Communicate and document health-care decisions needed to exercise this authority.

My limitations and additional instructions are:

[____________________________________________________________]

[____________________________________________________________]

7. Decision Standard

My attorney in fact must consult medical personnel, including my attending physician, and follow my wishes expressed here or otherwise made known.

If my wishes are not reasonably known and cannot be found with reasonable diligence, my attorney in fact must act in my best interests with due regard for my known religious and moral beliefs.

My wishes, values, beliefs, and people to consult are:

[____________________________________________________________]

[____________________________________________________________]

8. Life-Sustaining Procedures

My attorney in fact may not withhold or withdraw a life-sustaining procedure unless I have a terminal condition or am in a persistent vegetative state and either this document explicitly grants the authority or my intent is established by clear and convincing evidence.

Choose one:

☐ Grant authority. In those circumstances, my attorney in fact may consent to withholding or withdrawing life-sustaining procedures.

☐ Do not grant authority. My attorney in fact may not consent to withholding or withdrawing life-sustaining procedures.

☐ Specific instructions or limits: [____________________________________________________________]

9. Artificially Administered Nutrition and Hydration

My attorney in fact may not withhold or withdraw artificially administered nutrition or hydration unless I have a terminal condition or am in a persistent vegetative state and either this document explicitly grants the authority or my intent is established by clear and convincing evidence.

Nothing in this document authorizes withholding routine hygiene, nursing, or comfort care, or the usual provision of food and fluids by mouth.

10. Pregnancy Limitation

When I am known to be pregnant, my attorney in fact may not make a decision that will result in the death of my unborn child if continued health care probably would permit development to live birth.

My pregnancy-related values and requests for individualized legal and clinical review are:

[____________________________________________________________]

11. Mental-Health-Care Coordination

Nebraska's health-care-power statute includes mental health care, and a power of attorney may include an advance mental health care directive. This document is not intended to create a self-binding mental-health arrangement or to replace a separately executed directive under the Advance Mental Health Care Directives Act.

☐ I have no separate advance mental health care directive.

☐ I have a separate directive dated [__/__/____], located at [________________________________].

Additional coordination instructions:

[____________________________________________________________]

12. My Objection Controls Unless a Court Rules Otherwise

Even after a physician's incapacity determination, my objection to that determination or to a decision made by my attorney in fact controls unless a Nebraska county court determines that I am incapable of making health-care decisions.

13. Notice to Family or Guardian

Unless I direct otherwise below, an acting attorney in fact who is not my most proximate next of kin must give the notice required by Neb. Rev. Stat. § 30-3414 to my most proximate next of kin and any court-appointed guardian.

My different notice direction, if any:

[____________________________________________________________]

14. Revocation, Later Instruments, and Divorce

While competent, I may revoke this power or a health-care decision made by my attorney in fact at any time and in any manner by which I can communicate my intent. Revocation becomes effective when communicated to my attending physician, health-care provider, or attorney in fact as provided by Neb. Rev. Stat. § 30-3420.

Unless I state otherwise below, a valid later power of attorney for health care revokes an earlier one and supersedes a conflicting preexisting directive. Written wishes, instructions, or limitations do not revoke this power unless they expressly say so.

A divorce or legal-separation decree may state whether a spouse's appointment continues. If the decree is silent, entry of the decree revokes the spouse's appointment.

Other revocation, priority, or divorce instruction:

[____________________________________________________________]

15. Providers, Court Review, and Statutory Protections

A provider is not required to accept decisions from my attorney in fact until the provider receives a signed original or photostatic copy of the signed original. A provider must exercise the same independent medical judgment used when following my own decision.

Nebraska law permits specified persons to ask the county court where I reside or am located to resolve incapacity, validity, revocation, or agent-conduct disputes. The statute does not create an exclusive private probate forum, arbitration clause, jury waiver, fee-shifting clause, cure period, or private injunctive-remedy clause.

My attorney in fact is not personally responsible for my health-care costs. Statutory good-faith immunity does not create a private indemnity or liability cap and does not eliminate provider liability for negligent diagnosis, treatment, or care.

A provider organization or individual provider may decline a decision on the religious, ethical, or moral grounds specified by statute, subject to the applicable notice and transfer-assistance duties.

16. Statutory Warning

I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE-AND-DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT, WHILE COMPETENT, I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE OR A HEALTH-CARE DECISION AS DESCRIBED ABOVE.

17. Principal Signature

I sign and date this document voluntarily while competent.

Do not sign until either two qualified adult witnesses or a qualified notary public are present.

18. Signature Verification — Choose One Route

Route A — Two Qualified Adult Witnesses

Each witness declares that the principal is personally known to the witness; that the principal signed or acknowledged the signature and date in the witness's presence; that the principal appears to be of sound mind and not under duress or undue influence; and that neither witness nor the principal's attending physician is appointed as attorney in fact by this document.

Each witness also confirms:

☐ I am not the principal's spouse, parent, child, grandchild, sibling, presumptive heir, known devisee, attending physician, mental-health-treatment-team member, romantic or dating partner, or attorney in fact.

☐ I am not an employee of a life or health insurance provider for the principal.

☐ No more than one of the two witnesses is an administrator or employee of a health-care provider caring for or treating the principal.

Route B — Notary Acknowledgment

State of Nebraska

County of [________________________________]

On [__/__/____], [PRINCIPAL NAME] acknowledged executing this power of attorney for health care as a voluntary act and appeared to be of sound mind and not under duress or undue influence. I am not the attorney in fact or successor attorney in fact designated in this document.

Notary signature: [________________________________]

Printed name: [________________________________]

Commission expires: [__/__/____] Seal: [________________________________]

19. Distribution and Review

☐ Principal retained a signed original or copy.

☐ Primary and successor attorneys in fact received copies.

☐ Attending physician or clinic received a copy for the medical record.

☐ Hospital, residential facility, hospice, or other provider received a copy.

☐ Separate advance mental health care directive was coordinated, if applicable.

☐ Nebraska attorney reviewed the completed document.

Sources and References

• Nebraska Revised Statutes §§ 30-3401 to 30-3432 — Power of Attorney for Health Care
• Nebraska Revised Statute § 30-3408 — Optional Statutory Form
• Nebraska Revised Statute § 30-3412 — Incapacity Determination
• Nebraska Revised Statutes §§ 30-3417 and 30-3418 — Authority and Decision Standards
• Nebraska Revised Statute § 30-3420 — Revocation and Priority