NEBRASKA LIVING WILL & DURABLE POWER OF ATTORNEY FOR HEALTH CARE

(Advance Directive pursuant to Neb. Rev. Stat. §§ 30-3401 – 30-3432)

[// GUIDANCE: This template is designed to comply with Nebraska’s Natural Death Act and related statutes. Customize all bracketed language before execution. Review current statutory text before finalization.]

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

1.1 Title

Nebraska Living Will and Durable Power of Attorney for Health Care (“Advance Directive”).

1.2 Parties

a. Declarant: [DECLARANT NAME], of [ADDRESS] (“Declarant”).
b. Primary Health Care Agent: [PRIMARY AGENT NAME], of [ADDRESS] (“Agent”).
c. First Alternate Agent: [ALTERNATE AGENT 1 NAME], of [ADDRESS] (optional).
d. Second Alternate Agent: [ALTERNATE AGENT 2 NAME], of [ADDRESS] (optional).

1.3 Effective Date & Jurisdiction

This Advance Directive is effective on the date executed below (“Effective Date”) and shall be governed by the laws of the State of Nebraska.

1.4 Recitals

A. Declarant is of sound mind and desires to ensure that health-care decisions made in the event of Declarant’s incapacity reflect Declarant’s wishes and values.
B. This document is executed pursuant to and in conformity with Neb. Rev. Stat. §§ 30-3401 – 30-3432.
C. Consideration is the mutual promises herein and the statutory recognition of this Directive.

II. DEFINITIONS

For purposes of this Advance Directive:

“Agent” means the person authorized to make health-care decisions for the Declarant under Section III.
“Artificial Nutrition and Hydration” means invasive provision of nutrients or fluids via intravenous, gastronomy, or similar medical intervention.
“Attending Physician” means the physician who has primary responsibility for the health-care of the Declarant.
“Declarant” has the meaning set forth in Section 1.2.
“Health-Care Decision” means any decision regarding the health-care of the Declarant, including consent, refusal, or withdrawal of treatment.
“Life-Sustaining Treatment” means any medical procedure that merely prolongs the dying process and where, in the judgment of the attending physician, death is imminent whether or not such treatment is provided.
“Persistent Vegetative State” means an irreversible condition in which Declarant is not conscious of self or environment and will not recover to a sentient state.
“Principal” means the Declarant.
“Revocation” has the meaning given in Section 9.2.
“Terminal Condition” means an incurable and irreversible condition that will result in death within a relatively short time without life-sustaining treatment.

[// GUIDANCE: Add or delete definitions to reflect Declarant’s preferences.]

III. OPERATIVE PROVISIONS

3.1 Appointment of Agent

a. Declarant appoints [PRIMARY AGENT NAME] as Agent with full authority to make any and all health-care decisions when Declarant is incapable.
b. If the Primary Agent is unable or unwilling to serve, authority passes in the following order:
1. [ALTERNATE AGENT 1 NAME]
2. [ALTERNATE AGENT 2 NAME]
c. Each Agent shall act in good faith, consistent with Declarant’s expressed wishes and best interests.

3.2 Grant of Authority

Subject to the limitations in Section 3.3, the Agent may:
1. Consent to, refuse, or withdraw any treatment, including Artificial Nutrition and Hydration.
2. Employ and discharge health-care providers.
3. Authorize admission to or discharge from health-care facilities.
4. Access medical records and disclose information under 45 C.F.R. § 164.502 (HIPAA).
5. Take any lawful action necessary to effectuate Declarant’s wishes.

3.3 Statement of Treatment Preferences

a. Terminal Condition: If I have a Terminal Condition and life-sustaining treatment would only artificially prolong the dying process, [INITIAL one]
• __ I direct that such treatment be withheld or withdrawn.
• ____ I direct that such treatment be provided.

b. Persistent Vegetative State: If I am in a Persistent Vegetative State, [INITIAL one]
• __ Withhold or withdraw life-sustaining treatment.
• ____ Provide life-sustaining treatment.

c. Artificial Nutrition and Hydration (check if applicable):
• __ I do not want Artificial Nutrition and Hydration if it only prolongs dying.
• ____ I do want Artificial Nutrition and Hydration.

d. Pain Relief: I direct that pain-relieving or comfort care be provided even if it may hasten death.

[// GUIDANCE: Nebraska statute permits a broad or narrow scope; tailor accordingly.]

3.4 Organ & Tissue Donation

[INITIAL if applicable]
• __ I authorize any needed organ/tissue donations.
• _ I authorize the following specific donations: [SPECIFY]
• ___ I decline to make anatomical gifts.

3.5 Health Insurance Portability and Accountability Act (HIPAA) Release

The Agent is deemed a personal representative under 45 C.F.R. § 164.502(g) with full access to Protected Health Information (“PHI”) to the same extent as Declarant.

3.6 Reliance & Execution by Providers

Any health-care provider, insurer, or other third party may rely on the representations of the Agent as to the scope of authority granted herein.

IV. REPRESENTATIONS & WARRANTIES

4.1 Declarant Representation. Declarant represents that:
a. Declarant is at least nineteen (19) years old or an emancipated minor, and of sound mind.
b. Declarant is executing this document voluntarily and not as a condition of insurance or medical treatment.

4.2 Agent Representation. Each Agent, by signing in Section 10.4, represents that they:
a. Are at least nineteen (19) years old; and
b. Are not presently disqualified from acting as an Agent under Neb. Rev. Stat. § 30-3404.

4.3 Survival. The representations in this Article survive the incapacity or death of Declarant to the extent necessary to enforce this document.

V. COVENANTS & RESTRICTIONS

5.1 Agent’s Fiduciary Duties.
a. Duty of Good Faith and Loyalty to Declarant.
b. Duty to Consult. The Agent shall consult with health-care providers and family when feasible.

5.2 Limitations on Agent’s Authority. The Agent may not:
a. Authorize non-therapeutic sterilization or psychosurgery without court approval.
b. Override Declarant’s expressed wishes herein.

VI. DEFAULT & REMEDIES

6.1 Events of Default. An “Event of Default” occurs if an Agent:
a. Acts outside the scope of authority;
b. Fails to act when required under Section 3.2; or
c. Engages in willful misconduct or gross negligence.

6.2 Remedies. Upon an Event of Default:
a. Authority immediately passes to the next-named Alternate Agent; and
b. Any interested party may petition the County Court for removal of the Agent and appointment of a guardian.

6.3 Attorneys’ Fees. An Agent found by a court of competent jurisdiction to have breached fiduciary duties shall be liable for reasonable attorneys’ fees incurred in enforcing this Directive.

[// GUIDANCE: Remedies are supplemental to statutory remedies and may be modified.]

VII. RISK ALLOCATION

7.1 Indemnification of Health-Care Providers. Declarant agrees that any health-care provider who relies in good faith on this Advance Directive or the decisions of an Agent shall be indemnified and held harmless by Declarant’s estate to the fullest extent permitted by Neb. Rev. Stat. § 30-3421.

7.2 Limitation of Liability. No Agent shall be liable for exercising powers in good faith and in accordance with this Directive (“Good-Faith Standard”).

7.3 Insurance. Declarant encourages, but does not require, the Agent to obtain errors & omissions insurance if acting in a professional capacity.

VIII. DISPUTE RESOLUTION

8.1 Governing Law. This Directive shall be governed by the laws of the State of Nebraska, without regard to conflict-of-law principles.

8.2 Jurisdiction. Any judicial proceeding arising under this Directive shall be brought in the County Court of [COUNTY], Nebraska.

8.3 Injunctive Relief. Nothing herein shall limit the right of any interested person to seek injunctive or declaratory relief to enforce or challenge this Directive under applicable law.

[// GUIDANCE: Arbitration not recommended for health-care directives; omitted per metadata.]

IX. GENERAL PROVISIONS

9.1 Amendments. Declarant may amend this Directive by executing a written instrument that complies with the witness or notary requirements of Section 10.

9.2 Revocation. Declarant may revoke this Directive at any time and in any manner provided by Neb. Rev. Stat. § 30-3420, including:
a. A signed, dated writing;
b. Physical cancellation or destruction by Declarant or at Declarant’s direction;
c. An oral statement to the attending physician; or
d. Execution of a subsequent Advance Directive.

9.3 Copies. Photostatic or electronic copies of this Directive shall be as effective as the original.

9.4 Severability. If any provision is determined invalid, the remaining provisions remain in full force.

9.5 Integration. This Directive constitutes the entire statement of Declarant’s health-care wishes and supersedes all prior directives.

9.6 Successors & Assigns. Obligations and benefits run to Declarant’s estate and the successors of any Agent.

X. EXECUTION BLOCK

[// GUIDANCE: Nebraska law requires EITHER two qualified witnesses OR a notarial acknowledgment—choose one method only.]

10.1 Declarant Signature

I, [DECLARANT NAME], sign my name to this Advance Directive on [DATE] at [CITY, STATE].

Signature: _______
Printed Name: ______

10.2 Witness Attestation (if chosen)

We declare that the Declarant is personally known to us, appears to be of sound mind, and signed or acknowledged the foregoing Advance Directive in our presence. We are not disqualified under Neb. Rev. Stat. § 30-3404(3).

Witness #1
Name: _______
Address: _______
Signature: _____
Date: _

Witness #2
Name: _______
Address: _______
Signature: _____
Date: _

—OR—

10.3 Notary Acknowledgment (alternative to witnesses)

State of Nebraska )
County of [COUNTY] )

On this __ day of __, 20____, before me, the undersigned Notary Public, personally appeared [DECLARANT NAME], known to me or satisfactorily proven to be the person whose name is subscribed to the foregoing Advance Directive, and acknowledged that they executed the same for the purposes therein contained.

In witness whereof, I hereunto set my hand and official seal.

Notary Public
My Commission Expires: _____

10.4 Agent Acceptance (optional but recommended)

Each undersigned Agent accepts the appointment and fiduciary obligations set forth herein.

Primary Agent: _____ Date: _

Alt. Agent 1: ____ Date: ____

Alt. Agent 2: ____ Date: ____

[// GUIDANCE:
1. Deliver signed originals or copies to each Agent, primary physician, and relevant health-care facilities.
2. Consider registering the Directive with Nebraska’s Advance Directive Registry (if available).
3. Review and update after major life events or every two (2) years.
]