PENNSYLVANIA DURABLE HEALTHCARE POWER OF ATTORNEY

(a/k/a “Advance Health-Care Directive”)

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block
11. Exhibits
        A. Statutory “Notice to the Principal”
        B. Agent’s Acknowledgment
        C. HIPAA Authorization & Release

1. DOCUMENT HEADER

1.1 Title. Pennsylvania Durable Healthcare Power of Attorney and Advance Directive (“Agreement”).

1.2 Parties.
(a) “Principal”: [PRINCIPAL FULL LEGAL NAME], residing at [ADDRESS].
(b) “Agent”: [PRIMARY AGENT NAME], residing at [ADDRESS].
(c) “Successor Agent(s)” (in order of priority): [SUCCESSOR AGENT #1]; [SUCCESSOR AGENT #2].

1.3 Effective Date. This Agreement becomes effective on the earlier of:
(i) the date executed by the Principal; or
(ii) the date on which the Principal’s attending physician determines, and records in the Principal’s medical record, that the Principal lacks capacity to make or communicate healthcare decisions.

1.4 Governing Law. Commonwealth of Pennsylvania healthcare law.

1.5 Recitals.
WHEREAS, the Principal desires to appoint an Agent to make healthcare decisions when the Principal is unable to do so; and
WHEREAS, the Principal intends this document to be valid as a durable healthcare power of attorney under 20 Pa. Cons. Stat. §§ 5451–5465 and to satisfy HIPAA privacy rules;
NOW, THEREFORE, the Principal hereby agrees as follows:

2. DEFINITIONS

For purposes of this Agreement, capitalized terms have the meanings set forth below:

2.1 “Advance Directive” means a written instruction, such as this Agreement, recognized under Pennsylvania law that relates to the provision of healthcare when the Principal is incapacitated.

2.2 “Agent” means the individual designated in Section 1.2(b) (or any Successor Agent pursuant to Section 6.2) who is authorized to make Healthcare Decisions on the Principal’s behalf.

2.3 “Good Faith” means honesty in fact in the conduct or transaction concerned.

2.4 “Healthcare Decision” includes consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat the Principal’s physical or mental condition.

2.5 “HIPAA” means the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations at 45 C.F.R. pts. 160 & 164.

2.6 “Incapacity” means the inability to understand or communicate informed decisions about healthcare, as certified by the attending physician.

2.7 “Life-Prolonging Treatment” means any medical procedure that serves only to prolong the dying process and where, in the attending physician’s judgment, death is imminent whether or not the procedure is utilized.

2.8 “Principal” is defined in Section 1.2(a).

3. OPERATIVE PROVISIONS

3.1 Appointment of Agent. The Principal hereby appoints the Agent to make all Healthcare Decisions on the Principal’s behalf whenever the Principal lacks Capacity.

3.2 Scope of Authority. Subject to the limitations in Sections 3.3–3.8, the Agent may:
(a) consent to, refuse, or withdraw any medical or surgical procedure, including Life-Prolonging Treatment;
(b) hire, discharge, or transfer the Principal to or from any healthcare facility;
(c) review, obtain, and disclose medical records;
(d) execute waivers and releases of liability for healthcare providers;
(e) authorize autopsy and determine disposition of remains.

3.3 End-of-Life Instructions.
(a) Artificial Nutrition & Hydration: [SELECT ONE: (i) I desire / (ii) I do not desire] artificial nutrition or hydration if my attending physician determines I am permanently unconscious.
(b) CPR & Resuscitation: [SELECT ONE: Attempt / Do Not Attempt] cardiopulmonary resuscitation if my heart or breathing stops.
(c) Pain Management: The Agent [is / is not] authorized to approve medication that may hasten death secondarily to pain relief.

3.4 Mental Health Treatment. The Agent is [AUTHORIZED / NOT AUTHORIZED] to consent to psychiatric admission or electroconvulsive therapy.

3.5 Pregnancy Considerations. If I am pregnant, my instructions regarding Life-Prolonging Treatment [SHALL / SHALL NOT] be honored if such treatment would maintain the pregnancy to viability.

3.6 Anatomical Gifts. The Agent [is / is not] authorized to make organ and tissue donation decisions pursuant to 20 Pa. Cons. Stat. § 8611 et seq.

3.7 HIPAA Authorization. By executing this Agreement and Exhibit C, the Principal authorizes all Covered Entities to disclose Protected Health Information (“PHI”) to the Agent, to the extent necessary for the Agent to fulfill duties herein.

3.8 Effect of Copies. Photographic or electronic copies of this Agreement shall have the same force and effect as the original.

4. REPRESENTATIONS & WARRANTIES

4.1 Principal’s Capacity. The Principal represents that, as of the Effective Date, the Principal is of sound mind and acting voluntarily.

4.2 Agent Eligibility. The Agent represents, by countersigning Exhibit B, that the Agent:
(a) is at least 18 years of age;
(b) is not currently the Principal’s attending physician or a healthcare provider acting under that physician’s direction; and
(c) will act in Good Faith and in accordance with the Principal’s known wishes.

4.3 Survival. The representations and warranties herein shall survive execution and remain in effect for the duration of this Agreement.

5. COVENANTS & RESTRICTIONS

5.1 Agent’s Duty of Substituted Judgment. The Agent shall, to the extent possible, make Healthcare Decisions in accordance with the Principal’s explicit instructions and known values; if unknown, the Agent shall act in the Principal’s Best Interests.

5.2 Record-Keeping. The Agent shall maintain contemporaneous records of material decisions and provide such records to (i) the Principal, if capacity is regained, or (ii) a court of competent jurisdiction upon request.

5.3 Conflicts of Interest. The Agent shall promptly disclose any potential conflict that could materially affect decision-making and, if directed by a court, step aside for a Successor Agent.

6. DEFAULT & REMEDIES

6.1 Revocation by Principal. The Principal may revoke this Agreement, in whole or in part, at any time by:
(a) executing a subsequent advance directive;
(b) destroying all executed originals; or
(c) oral or written notice to the Agent or attending healthcare provider, which shall be documented in the medical record.

6.2 Removal of Agent; Successor Appointment. If the Agent resigns, is removed by court order, or is unwilling or unable to serve, the next Successor Agent listed in Section 1.2(c) shall automatically assume authority.

6.3 Dispute Resolution Mechanism. In the event of disagreement among healthcare providers, family members, or Agents, any interested person may petition the [COUNTY] Orphans’ Court Division for expedited resolution.

7. RISK ALLOCATION

7.1 Indemnification. The Principal shall indemnify and hold harmless the Agent from any civil liability for actions taken in Good Faith under this Agreement, except for willful misconduct or gross negligence.

7.2 Limitation of Liability. No Agent shall be liable for monetary damages in excess of the actual out-of-pocket expenses incurred in performing duties hereunder, provided the Agent acted in Good Faith.

7.3 Reliance by Third Parties. Any healthcare provider or third party may rely upon the validity of this Agreement and the representations of the Agent regarding its continued effectiveness.

8. DISPUTE RESOLUTION

8.1 Governing Law. This Agreement is governed by the laws of the Commonwealth of Pennsylvania, without regard to conflict-of-laws principles.

8.2 Forum Selection. The parties agree that exclusive jurisdiction for any proceeding arising under this Agreement shall lie in the [COUNTY] Court of Common Pleas, Orphans’ Court Division.

8.3 Arbitration; Jury Waiver. Arbitration is not available, and no party waives the right to a jury trial unless separately agreed in writing.

8.4 Injunctive Relief. Nothing herein limits a party’s right to seek injunctive or declaratory relief to enforce this healthcare directive.

9. GENERAL PROVISIONS

9.1 Amendment. This Agreement may be amended only by a writing signed by the Principal and witnessed in accordance with Pennsylvania law.

9.2 Assignment. Rights and obligations hereunder are personal and shall not be assigned, except as expressly provided for Successor Agents.

9.3 Severability. If any provision is held invalid, the remaining provisions shall remain in full force, and, if feasible, the invalid provision shall be reformed to reflect the parties’ intent.

9.4 Entire Agreement. This document constitutes the entire advance directive and supersedes all prior oral and written healthcare powers of attorney executed by the Principal.

9.5 Counterparts; Electronic Signatures. This Agreement may be executed in counterparts and by electronic signature, each of which shall be deemed an original.

10. EXECUTION BLOCK

IN WITNESS WHEREOF, the Principal has executed this Pennsylvania Durable Healthcare Power of Attorney on the date set forth below.

Witness Attestation

We, the undersigned, declare that the Principal is personally known to us, appears to be of sound mind, and signed or acknowledged the above Advance Directive in our presence.

Optional Notarization

State of Pennsylvania )
County of [COUNTY] ) ss:

On this ___ day of __________, 20__, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], 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 therein contained.

Notary Public ______________________________
My Commission Expires: ______________________

11. EXHIBITS

Exhibit A

STATUTORY “NOTICE TO THE PRINCIPAL”
(Required by 20 Pa. Cons. Stat. § 5456)

[Insert full statutory notice text here.]

Exhibit B

AGENT’S ACKNOWLEDGMENT
(Required by 20 Pa. Cons. Stat. § 5456)

I, [AGENT NAME], have read the above Durable Healthcare Power of Attorney. I hereby accept the appointment and agree to act in Good Faith and in accordance with the Principal’s directions and Pennsylvania law.

Exhibit C

HIPAA AUTHORIZATION & RELEASE

1. Authorization. I, [PRINCIPAL NAME], authorize the disclosure of my Protected Health Information (“PHI”) to the Agent named in Section 1.2 for the purpose of making Healthcare Decisions.

2. Scope. This authorization applies to all PHI, including mental health, substance-abuse, and HIV-related information, unless limited as follows: [LIMITATIONS, if any].

3. Expiration. This authorization is effective upon execution and expires on the earlier of:
   (a) revocation per Section 6.1; or
   (b) [DATE / EVENT].

4. Redisclosure. PHI disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA.