OHIO ADVANCE DIRECTIVE FOR HEALTH CARE
(Living Will Declaration & Optional Health-Care Power of Attorney)
[// GUIDANCE: This template combines an Ohio‐compliant Living Will Declaration with an OPTIONAL Health-Care Power of Attorney for practitioners who prefer a single consolidated instrument. Delete the POA portions if the client wishes to execute a stand-alone POA under Ohio Rev. Code § 1337.11 et seq.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Statement of Intent
3.2 Directions for End-of-Life Care
3.3 OPTIONAL: Designation of Health-Care Agent
3.4 HIPAA Authorization - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title and Parties
This Ohio Advance Directive for Health Care (“Advance Directive”) is executed by [FULL LEGAL NAME OF DECLARANT], residing at [ADDRESS] (“Declarant”), pursuant to Ohio Rev. Code §§ 2133.01–2133.15 and related statutory authority.
1.2 Recitals
A. Declarant desires to exercise the fundamental right of self-determination regarding medical and surgical treatment.
B. Declarant is of sound mind and acting voluntarily, free of duress or undue influence.
C. This instrument is intended to constitute:
i. A “declaration” (commonly called a “Living Will”) under Ohio Rev. Code § 2133.02; and
ii. [OPTIONAL] A “durable power of attorney for health care” under Ohio Rev. Code § 1337.11 et seq.
1.3 Effective Date & Governing Law
This Advance Directive becomes effective on the date of Declarant’s signature below (“Effective Date”) and shall be governed exclusively by the laws of the State of Ohio (“Governing Law”).
2. DEFINITIONS
For purposes of this Advance Directive, the following terms shall have the meanings set forth below:
“Advance Directive” – This written instrument, including all attachments, amendments, and counterparts.
“Agent” – The individual designated in Section 3.3 to make health-care decisions on Declarant’s behalf.
“Artificially Supplied Nutrition and Hydration” – Food or fluids provided via intravenous infusion, gastrostomy tube, or other medical device, as distinguished from comfort feeding.
“Attending Physician” – The physician, as defined in Ohio Rev. Code § 2133.01(B), who has primary responsibility for Declarant’s health care.
“Good Faith” – Honesty in fact in the conduct of the transaction concerned, consistent with Ohio Rev. Code § 2133.12.
“Permanently Unconscious State” – A condition in which Declarant is irreversibly unaware of self and surroundings, as certified in writing by two physicians pursuant to Ohio Rev. Code § 2133.01(D).
“Terminal Condition” – An irreversible, incurable condition from which, to a reasonable degree of medical certainty, death is imminent, and life-sustaining treatment serves only to postpone the moment of death.
[// GUIDANCE: Add additional defined terms as client circumstances require.]
3. OPERATIVE PROVISIONS
3.1 Statement of Intent
Declarant directs that all health-care providers, facilities, courts, and other persons honor the provisions of this Advance Directive.
3.2 Directions for End-of-Life Care
3.2.1 Terminal Condition
If Declarant is in a Terminal Condition and unable to express informed consent:
a. Life-Sustaining Treatment: Declarant [CHOOSE ONE → ☐ directs | ☐ refuses] the initiation or continuation of life-sustaining treatment.
b. Artificially Supplied Nutrition & Hydration: Declarant [CHOOSE ONE → ☐ directs | ☐ refuses] artificially supplied nutrition and hydration unless medically required for comfort.
3.2.2 Permanently Unconscious State
If Declarant is in a Permanently Unconscious State:
a. Declarant [CHOOSE ONE → ☐ directs | ☐ refuses] life-sustaining treatment.
b. Declarant [CHOOSE ONE → ☐ directs | ☐ refuses] artificially supplied nutrition and hydration.
3.2.3 Analgesia & Comfort Care
Regardless of Sections 3.2.1–3.2.2, Declarant directs provision of medication or procedures necessary to alleviate pain or provide comfort, even if such care may hasten death.
3.2.4 Pregnancy
If Declarant is pregnant and the fetus is viable, Declarant directs that this Advance Directive [CHOOSE ONE → ☐ shall | ☐ shall not] be enforced to the extent it may result in termination of the pregnancy.
3.2.5 Anatomical Gifts
Upon death, Declarant [CHOOSE ONE → ☐ authorizes | ☐ does not authorize] the donation of organs and tissues. If authorized, Declarant’s specific wishes are: [SPECIFY OR “ANY NEEDED ORGANS”].
3.2.6 Do-Not-Resuscitate (DNR) Order
Declarant requests that, in circumstances covered by an Ohio DNR Comfort Care protocol, the Attending Physician issue a DNR order consistent with Sections 3.2.1–3.2.2 above.
[// GUIDANCE: Attach Ohio Department of Health Form No. DNR-SF if converting this directive into a standing DNR order.]
3.3 OPTIONAL: Designation of Health-Care Agent
3.3.1 Appointment
Declarant hereby appoints [FULL NAME], whose address is [ADDRESS], telephone [PHONE], as Agent to make any and all health-care decisions consistent with this Advance Directive when Declarant lacks decision-making capacity.
3.3.2 Successor Agent(s)
If the primary Agent is unavailable, unwilling, or unable to serve, Declarant appoints in order of priority:
a. [SUCCESSOR NAME #1] – [CONTACT]
b. [SUCCESSOR NAME #2] – [CONTACT]
3.3.3 Scope of Authority
Subject to Section 3.2 and Governing Law, Agent shall have authority to:
a. Consent to, refuse, or withdraw medical treatment;
b. Access medical records pursuant to 45 C.F.R. § 164.508;
c. Apply for public benefits to defray medical costs;
d. Authorize admission to or discharge from health-care facilities;
e. Make anatomical gift decisions.
3.3.4 Limitations
Agent shall not override Declarant’s express instructions in Section 3.2 unless both:
i. The Attending Physician certifies in writing that compliance would cause unnecessary pain without medical benefit; and
ii. Agent’s contrary decision reasonably reflects Declarant’s known wishes or best interests.
3.3.5 Nomination of Guardian
Pursuant to Ohio Rev. Code § 2111.121, Declarant nominates the Agent as guardian of the person if protective proceedings are instituted.
3.4 HIPAA AUTHORIZATION
Declarant authorizes any covered entity to disclose protected health information to the Agent and to comply with the decisions of the Agent, effective immediately and surviving Declarant’s death.
4. REPRESENTATIONS & WARRANTIES
4.1 Capacity & Voluntariness
Declarant represents that Declarant:
a. Is at least eighteen (18) years of age;
b. Is of sound mind; and
c. Executes this Advance Directive voluntarily and not as a condition of treatment or admission.
4.2 Accuracy of Information
Declarant warrants that all information provided herein is accurate to the best of Declarant’s knowledge.
4.3 Survival
Representations and warranties shall survive Declarant’s incapacity and shall bind heirs, personal representatives, and assigns.
5. COVENANTS & RESTRICTIONS
5.1 Declarant’s Covenant to Inform
Declarant shall distribute copies of this Advance Directive to the Agent(s), primary care physician, and appropriate family members.
5.2 Provider Reliance
Any person or entity acting in Good Faith reliance on this Advance Directive may presume its validity and is not subject to civil or criminal liability or professional disciplinary action.
5.3 Agent’s Fiduciary Duties
Agent shall act:
a. In good faith;
b. Within the scope of authority granted; and
c. In a manner consistent with Declarant’s known wishes or, if unknown, best interests.
5.4 Prohibited Transactions
Agent may not make decisions intended to benefit the Agent’s personal or pecuniary interests to the detriment of Declarant’s health-care interests.
6. DEFAULT & REMEDIES
6.1 Conflict Resolution
If a conflict arises among health-care providers, family members, or Agent regarding interpretation or application of this Advance Directive, any interested person may petition the probate court for declaratory or injunctive relief.
6.2 Injunctive Relief
Because money damages would be inadequate, specific performance and injunctive relief are appropriate to enforce this Advance Directive.
6.3 Attorneys’ Fees
The prevailing party in any action to enforce or challenge this Advance Directive shall be entitled to reasonable attorneys’ fees and costs.
7. RISK ALLOCATION
7.1 Indemnification of Providers
Declarant’s estate shall indemnify and hold harmless any health-care provider or facility that, in Good Faith, honors this Advance Directive.
7.2 Limitation of Liability
No provider acting in Good Faith reliance on this Advance Directive shall be liable for civil damages or subject to criminal prosecution exceeding the Good-Faith standard set forth in Ohio Rev. Code § 2133.12.
7.3 Force Majeure
Providers shall not be deemed in breach of this Advance Directive if prevented from compliance by circumstances constituting force majeure, including but not limited to natural disaster, widespread public emergency, or institutional policy required by law.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Advance Directive shall be construed in accordance with the laws of the State of Ohio without regard to its conflict-of-laws principles.
8.2 Forum Selection
Any judicial proceeding arising under or pertaining to this Advance Directive shall be commenced exclusively in the probate court of the Ohio county in which Declarant resides or is located at the time of filing.
[// GUIDANCE: Arbitration and jury-trial waivers are intentionally omitted as they are generally incompatible with health-care directive enforcement and disfavored in probate practice.]
9. GENERAL PROVISIONS
9.1 Amendment & Revocation
Declarant may amend or revoke this Advance Directive at any time and in any manner recognized by Ohio Rev. Code § 2133.04, including:
a. A signed, dated writing;
b. Destroying the instrument with intent to revoke; or
c. An oral or other expression of intent in the presence of two adult witnesses.
Revocation is effective upon communication to the Attending Physician or health-care facility.
9.2 Copies
Photographic or electronic copies of this Advance Directive shall have the same force as the original.
9.3 Severability
If any provision is held invalid, the remaining provisions shall continue in full force to the maximum extent permitted by law.
9.4 Entire Directive
This document constitutes the entire and integrated advance directive of Declarant, superseding all prior directives, to the extent permitted by law.
9.5 Electronic Signatures
Subject to Ohio’s Uniform Electronic Transactions Act, electronic signatures and notarizations are valid and enforceable.
9.6 Counterparts
This Advance Directive may be executed in one or more counterparts, each of which shall be deemed an original.
10. EXECUTION BLOCK
10.1 Declarant
____ ____
[PRINT NAME] Date
10.2 Witness Certification
As witnesses, we declare that:
1. We are at least eighteen (18) years of age;
2. We are not related to Declarant by blood, marriage, or adoption;
3. We are not entitled to any portion of Declarant’s estate;
4. We are not the attending physician or an employee of the health-care facility in which Declarant is a patient;
5. Declarant signed or acknowledged this Advance Directive in our presence, appears to be of sound mind, and is executing the document voluntarily.
| Witness # | Signature | Printed Name | Address | Date |
|---|---|---|---|---|
| 1 | ________ | ____ | _________ | ____ |
| 2 | ________ | ____ | _________ | ____ |
10.3 NOTARY PUBLIC ACKNOWLEDGMENT
[OPTIONAL IN LIEU OF WITNESSES]
State of Ohio )
County of ____)
On this _ day of _, 20____, before me, the undersigned notary public, personally appeared [DECLARANT NAME], personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is signed above, and acknowledged executing the same for the purposes therein contained.
Notary Public, State of Ohio
My Commission Expires: ____
[// GUIDANCE: File the executed original with the client’s primary care physician and advise the client to carry a wallet card noting the existence and location of this Advance Directive.]