Rhode Island Durable Power of Attorney for Health Care
(a/k/a “Health-Care Proxy” or “Health-Care Directive”)
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 FULL LEGAL NAME], residing at [ADDRESS] (“Principal”).
b. Primary Agent: [AGENT FULL LEGAL NAME], residing at [ADDRESS] (“Agent”).
c. Successor Agent(s) (optional): [NAME(S)] (“Alternate Agent”).
-
Recitals.
a. Principal desires to appoint an Agent to make health-care decisions pursuant to the Rhode Island Durable Power of Attorney for Health Care Act, R.I. Gen. Laws § 23-4.10-1 et seq. (“Act”).
b. Principal is of sound mind and executes this instrument voluntarily for adequate legal consideration. -
Effective Date. This instrument becomes effective on the date executed below (“Effective Date”) and remains durable as provided in § 23-4.10-2 of the Act.
-
Governing Law & Venue. This instrument is governed by the laws of the State of Rhode Island. Exclusive venue for disputes lies in the [COUNTY] Probate Court.
II. DEFINITIONS
For ease of reference, capitalized terms have the meanings set forth below:
A. “Act” – The Rhode Island Durable Power of Attorney for Health Care Act, R.I. Gen. Laws § 23-4.10-1 et seq.
B. “Advance Directive” – Any written statement relating to the provision of health-care services when the Principal lacks capacity, including this instrument.
C. “Artificial Nutrition and Hydration” – Nutrients or fluids administered invasively (e.g., via gastrostomy, IV, or nasogastric tube).
D. “Good Faith” – Honesty in fact and the observance of reasonable standards of health-care practice.
E. “Health-Care Decision” – Any consent, refusal, or withdrawal of care, treatment, service, or diagnostic procedure to maintain, diagnose, or treat a physical or mental condition.
F. “HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and implementing regulations, 45 C.F.R. Parts 160 & 164.
G. “Life-Sustaining Treatment” – Any medical intervention that serves only to prolong the dying process for a terminally ill patient.
H. “Protected Health Information” or “PHI” – Individually identifiable health information as defined in 45 C.F.R. § 160.103.
I. “Terminal Condition” – An incurable or irreversible condition that, without Life-Sustaining Treatment, will result in death within a relatively short period of time.
[// GUIDANCE: Add or delete definitions as needed, ensuring cross-references remain accurate.]
III. OPERATIVE PROVISIONS
3.1 Appointment of Agent.
a. Principal hereby appoints Agent as true and lawful attorney-in-fact for the sole and limited purpose of making Health-Care Decisions on Principal’s behalf whenever Principal is determined by an attending physician to lack decision-making capacity.
b. If Agent is unwilling, unable, or disqualified, the next-listed Alternate Agent shall serve with identical authority.
3.2 Scope of Authority. Subject to Section 3.3 and any limitations stated in Section 3.5, Agent may:
i. Give or withhold consent to any treatment, including surgery, medication, artificial respiration, Artificial Nutrition and Hydration, and resuscitation;
ii. Admit, discharge, or transfer Principal from any health-care facility;
iii. Contract with and discharge health-care providers;
iv. Access and disclose PHI;
v. Authorize donation of organs or tissues; and
vi. Take any lawful actions incidental to the foregoing.
3.3 HIPAA Authorization.
a. Pursuant to 45 C.F.R. § 164.508, Principal authorizes any covered entity to disclose Principal’s PHI to Agent.
b. This authorization is effective immediately and remains valid until revoked in writing or upon the Principal’s death, except to the extent disclosures have already occurred.
3.4 Effectiveness & Durability.
a. Durable Nature. This instrument is not terminated by Principal’s incapacity.
b. Commencement. Agent’s authority commences upon the attending physician’s written determination that Principal lacks capacity or, if the checkbox below is selected, ☐ immediately upon execution.
c. Termination. Authority ends on revocation pursuant to Section 6.1 or the Principal’s death, except with respect to anatomical gifts or arrangements under Section 3.2(v).
3.5 End-of-Life Instructions. (Strike or complete any provisions not desired.)
a. Life-Sustaining Treatment. If I am in a Terminal Condition or persistent vegetative state and two physicians certify there is no reasonable medical probability of recovery:
☐ I direct that Life-Sustaining Treatment be WITHHELD OR WITHDRAWN.
☐ I direct that Life-Sustaining Treatment be PROVIDED.
b. Artificial Nutrition & Hydration.
☐ WITHHOLD OR WITHDRAW unless pregnancy dictates otherwise.
☐ PROVIDE regardless of prognosis.
c. Palliative Care. I direct that medication be administered to relieve pain even if it may hasten my death.
3.6 Organ & Tissue Donation (initial one):
_ Authorize donation for any lawful purpose.
Authorize donation for transplantation/therapy only.
__ Decline to donate.
IV. REPRESENTATIONS & WARRANTIES
4.1 Principal.
a. Capacity. Principal affirms being at least eighteen (18) years of age and of sound mind.
b. Voluntariness. Execution is voluntary and not the product of duress or undue influence.
4.2 Agent.
a. Acceptance. Agent accepts the appointment and acknowledges the fiduciary duty to act in Good Faith and in accordance with Principal’s known wishes.
b. Eligibility. Agent is not the Principal’s attending physician, nor an employee of the treating facility, unless related to Principal by blood, marriage, or adoption as permitted under § 23-4.10-2.
V. COVENANTS & RESTRICTIONS
5.1 Agent Covenants. Agent shall:
i. Act consistently with Principal’s directions contained herein or otherwise known;
ii. Consult, when feasible, with family and medical personnel; and
iii. Keep reasonable records of decisions made and the basis therefor.
5.2 Prohibited Actions. Agent may not:
a. Consent to voluntary admission to a mental health facility for more than seventy-two (72) hours without court order;
b. Authorize experimental treatment without Principal’s prior consent unless lifesaving; or
c. Execute a new or amend this Durable Power of Attorney on Principal’s behalf.
VI. DEFAULT & REMEDIES
6.1 Revocation by Principal. This instrument may be revoked at any time by:
i. Written revocation delivered to Agent and attending physician;
ii. Oral revocation in the presence of two adults; or
iii. Execution of a subsequent valid Durable Power of Attorney for Health Care.
6.2 Removal or Resignation of Agent.
a. Principal, or a court of competent jurisdiction, may remove Agent for cause (e.g., breach of fiduciary duty, incapacity).
b. Agent may resign by written notice to Principal (if capacitated) or Alternate Agent and attending physician.
6.3 Remedies. Injunctive or declaratory relief may be sought in Probate Court to enforce or clarify this instrument. Attorney fees may be awarded to the prevailing party upon a showing of bad faith.
VII. RISK ALLOCATION
7.1 Indemnification. Principal shall indemnify and hold Agent harmless from any liability, loss, or expense (including reasonable attorney fees) arising out of Health-Care Decisions made in Good Faith.
7.2 Limitation of Liability. No Agent shall be liable for monetary damages for actions taken in Good Faith and in accordance with the Act.
7.3 Insurance. [OPTIONAL PLACEHOLDER]: The Principal’s estate shall maintain or procure directors-and-officers–type fiduciary coverage for the Agent, if available.
7.4 Force Majeure. No party shall be liable for failure to perform under circumstances of impossibility, illegality, or substantial impracticability.
VIII. DISPUTE RESOLUTION
8.1 Governing Law. Rhode Island substantive law governs.
8.2 Forum Selection. Exclusive jurisdiction and venue shall lie with the [COUNTY] Probate Court.
8.3 Arbitration. Not available.
8.4 Jury Waiver. Not applicable.
8.5 Injunctive Relief. Nothing herein limits the Probate Court’s power to grant emergent injunctive relief to implement or restrain Health-Care Decisions consistent with this directive.
IX. GENERAL PROVISIONS
9.1 Amendment & Waiver. Any amendment must be executed with the formalities required by the Act. The failure to enforce any provision is not a waiver.
9.2 Assignment & Delegation. Agent may not delegate authority except to an Alternate Agent as provided herein.
9.3 Successors & Assigns. The provisions of this instrument bind and benefit the parties and their respective heirs, executors, administrators, and permitted assigns.
9.4 Severability. If any provision is held invalid under applicable law, the remainder shall remain enforceable, and the invalid provision shall be reformed to most closely effectuate the parties’ intent.
9.5 Integration. This instrument constitutes the entire understanding with respect to the subject matter and supersedes all prior directives to the extent of any conflict.
9.6 Counterparts & Electronic Signatures. This instrument may be executed in one or more counterparts, each of which is deemed an original. Facsimile, PDF, and electronic signatures are legally binding.
[// GUIDANCE: Rhode Island does not currently recognize remote online notarization for health-care proxies; physical signatures are strongly recommended.]
X. EXECUTION BLOCK
IN WITNESS WHEREOF, the Principal executes this Durable Power of Attorney for Health Care as of the Effective Date written below.
A. Principal
[PRINCIPAL NAME], Principal
Date: ______
B. Agent Acceptance
I, the undersigned, have read this instrument and accept appointment as Agent, acknowledging the accompanying fiduciary duties.
[AGENT NAME], Agent
Date: ______
C. Alternate Agent(s) Acceptance (if any)
[ALTERNATE AGENT NAME], Alternate Agent
Date: ______
D. Witness Attestation*
We declare that the Principal signed or acknowledged this instrument in our presence; that we are each at least eighteen (18) years of age; that we are not named as Agent or Alternate Agent; that we are not related to the Principal by blood, marriage, or adoption; and that we are not the Principal’s attending physician or employee of a health-care facility where the Principal is a patient.
Witness #1: ____ Date: _
Print Name: _______
Address: ___________
Witness #2: ____ Date: _
Print Name: _______
Address: ___________
*Two qualified witnesses are REQUIRED under R.I. Gen. Laws § 23-4.10-2. Notarization is optional but recommended.
E. Notary Acknowledgment (optional)
State of Rhode Island )
County of [____] ) ss.:
On the _ day of _, 20____, before me, the undersigned notary, personally appeared [PRINCIPAL NAME], satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged executing the same for the purposes herein contained.
Notary Public
My Commission Expires: __
[// GUIDANCE:
1. Review statutory witness disqualification rules in § 23-4.10-2.
2. Provide each health-care provider with a copy of the executed document.
3. Advise Principal to discuss wishes with Agent and alternates in advance to reduce uncertainty.
4. Consider executing a separate “Living Will” if more detailed treatment preferences are desired, though Section 3.5 may suffice.
]