STATE OF OHIO LIVING WILL PACKET

Includes:

Choices - Living Well at the End of Life

Living Will Declaration

Health Care Power of Attorney

Franklin County Recorder http://recorder.franklincountyohio.gov

Revised May 2015

Daniel J. O'Connor Jr.

373 South High Street, 18th Floor, Columbus, Ohio 43215

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11

Ohio  Health  Care  Power  of  Attorney   Page  One  of  Twelve  

State  of  Ohio  Health  Care  Power  of  Attorney  

                   [R.C.  §1337]  

__________________________________________________________________  (Print  Full  Name)  

_____________________________________________  (Birth  Date)  

This  is  my  Health  Care  Power  of  Attorney.  I  revoke  all  prior  Health  Care  Powers  of  Attorney    signed  by  me.  I  understand  the  nature  and  purpose  of  this  document.  If  any  provision  is  found  to  be  invalid  or  unenforceable,  it  will  not  affect  the  rest  of  this  document.    

I  understand  that  my  agent  can  make  health  care  decisions  for  me  only  whenever  my  attending  physician  has  determined  that  I  have  lost  the  capacity  to  make  informed  health  care  decisions.  However,  this  does  not  require  or  imply  that  a  court  must  declare  me  incompetent.    

Definitions  Adult  means  a  person  who  is  18  years  of  age  or  older.    

Agent  or  attorney-­‐in-­‐fact  means  a  competent  adult  who  a  person  (the  “principal”)  can  name  in  a  Health  Care  Power  of  Attorney  to  make  health  care  decisions  for  the  principal.    

Artificially  or  technologically  supplied  nutrition  or  hydration  means  food  and  fluids  provided  through  intravenous  or  tube  feedings.  [You  can  refuse  or  discontinue  a  feeding  tube  or  authorize  your  Health  Care  Power  of  Attorney  agent  to  refuse  or  discontinue  artificial  nutrition  or  hydration.]  

Bond  means  an  insurance  policy  issued  to  protect  the  ward’s  assets  from  theft  or  loss  caused  by  the  Guardian  of  the  Estate’s  failure  to  properly  perform  his  or  her  duties.  

Comfort  care  means  any  measure,  medical  or  nursing  procedure,  treatment  or  intervention,  including  nutrition  and/or  hydration,  that  is  taken  to  diminish  a  patient’s  pain  or  discomfort,  but  not  to  postpone  death.  

CPR  means  cardiopulmonary  resuscitation,  one  of  several  ways  to  start  a  person’s  breathing  or  heartbeat  once  either  has  stopped.  It  does  not  include  clearing  a  person’s  airway  for  a  reason  other  than  resuscitation.    

Do  Not  Resuscitate  or  DNR  Order  means  a  physician’s  medical  order  that  is  written  into  a  patient’s  record  to  indicate  that  the  patient  should  not  receive  cardiopulmonary  resuscitation.  

12

Ohio  Health  Care  Power  of  Attorney     Page  Two  of  Twelve  

Guardian  means  the  person  appointed  by  a  court  through  a  legal  procedure  to  make  decisions  for  a  ward.  A  Guardianship  is  established  by  such  court  appointment.      Health  care  means  any  care,  treatment,  service  or  procedure  to  maintain,  diagnose  or  treat  an  individual’s  physical  or  mental  health.  Health  care  decision  means  giving  informed  consent,  refusing  to  give  informed  consent,  or  withdrawing  informed  consent  to  health  care.                  Health  Care  Power  of  Attorney  means  a  legal  document  that  lets  the  principal  authorize  an  agent  to  make  health  care  decisions  for  the  principal  in  most  health  care  situations  when  the  principal  can  no  longer  make  such  decisions.  Also,  the  principal  can  authorize  the  agent  to  gather  protected  health  information  for  and  on  behalf  of  the  principal  immediately  or  at  any  other  time.  A  Health  Care  Power  of  Attorney  is  NOT  a  financial  power  of  attorney.        The  Health  Care  Power  of  Attorney  document  also  can  be  used  to  nominate  person(s)  to  act  as  guardian  of  the  principal's  person  or  estate.  Even  if  a  court  appoints  a  guardian  for  the  principal,  the  Health  Care  Power  of  Attorney  remains  in  effect  unless  the  court  rules  otherwise.                            Life-­‐sustaining  treatment  means  any  medical  procedure,  treatment,  intervention  or  other  measure  that,  when  administered  to  a  patient,  mainly  prolongs  the  process  of  dying.    

Living  Will  Declaration  means  a  legal  document  that  lets  a  competent  adult  (“declarant”)  specify  what  health  care  the  declarant  wants  or  does  not  want  when  he  or  she  becomes  terminally  ill  or  permanently  unconscious  and  can  no  longer  make  his  or  her  wishes  known.  It  is  NOT  and  does  not  replace  a  will,  which  is  used  to  appoint  an  executor  to  manage  a  person’s  estate  after  death.                                          

Permanently  unconscious  state  means  an  irreversible  condition  in  which  the  patient  is  permanently  unaware  of  himself  or  herself  and  surroundings.  At  least  two  physicians  must  examine  the  patient  and  agree  that  the  patient  has  totally  lost  higher  brain  function  and  is  unable  to  suffer  or  feel  pain.      

Principal  means  a  competent  adult  who  signs  a  Health  Care  Power  of  Attorney.    

Terminal  condition  means  an  irreversible,  incurable,  and  untreatable  condition  caused  by  disease,  illness,  or  injury  from  which,  to  a  reasonable  degree  of  medical  certainty  as  determined  in  accordance  with  reasonable  medical  standards  by  a  principal's  attending  physician  and  one  other  physician  who  has  examined  the  principal,  both  of  the  following  apply:  (1)  there  can  be  no  recovery  and  (2)  death  is  likely  to  occur  within  a  relatively  short  time  if  life-­‐sustaining  treatment  is  not  administered.    Ward  means  the  person  the  court  has  determined  to  be  incompetent.  The  ward’s  person,  financial  estate,  or  both,  is  protected  by  a  guardian  the  court  appoints  and  oversees.

13

Ohio  Health  Care  Power  of  Attorney     Page  Three  of  Twelve  

Naming  of  My  Agent.  The  person  named  below  is  my  agent  who  will  make  health  care  decisions  for  me  as  authorized  in  this  document.      Agent’s  name  and  relationship:__________________________________________________      Address:_______________________________________________________________        Telephone  number(s):  ___________________________________________________              By  placing  my  initials,  signature,  check  or  other  mark  in  this  box,  I  specifically  authorize          my  agent  to  obtain  my  protected  health  care  information  immediately  and  at  any  future                        time.      

Guidance  to  Agent.  My  agent  will  make  health  care  decisions  for  me  based  on  my  instructions    in  this  document  and  my  wishes  otherwise  known  to  my  agent.  If  my  agent  believes  that  my  wishes  conflict  with  what  is  in  this  document,  this  document  will  take  precedence.  If  there  are  no  instructions  and  if  my  wishes  are  unclear  or  unknown  for  any  particular  situation,  my  agent  will  determine  my  best  interests  after  considering  the  benefits,  the  burdens  and  the  risks  that  might  result  from  a  given  decision.  If  no  agent  is  available,  this  document  will  guide  decisions  about  my  health  care.                  

Naming  of  alternate  agent(s).  If  my  agent  named  above  is  not  immediately  available  or  is    unwilling  or  unable  to  make  decisions  for  me,  then  I  name,  in  the  following  order  of  priority,  the    persons  listed  below  as  my  alternate  agents  [cross  out  any  unused  lines]:       First  alternate  agent’s  name  and  relationship:  ______________________________________       Address:  ____________________________________________________________________         Telephone  number(s):_________________________________________________________         Second  alternate  agent’s  name  and  relationship:  ____________________________________         Address:  ____________________________________________________________________           Telephone  number(s):_________________________________________________________    Any  person  can  rely  on  a  statement  by  any  alternate  agent  named  above  that  he  or  she  is  properly  acting  under  this  document  and  such  person  does  not  have  to  make  any  further  investigation  or  inquiry.

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14

 

Ohio  Health  Care  Power  of  Attorney     Page  Four  of  Twelve  

Authority  of  Agent.  Except  for  those  items  I  have  crossed  out  and  subject  to  any  choices  I  have    made  in  this  Health  Care  Power  of  Attorney,  my  agent  has  full  and  complete  authority  to  make  all  health  care  decisions  for  me.  This  authority  includes,  but  is  not  limited  to,  the  following:    

1.  To  consent  to  the  administration  of  pain-­‐relieving  drugs  or  treatment  or  procedures  (including  surgery)  that  my  agent,  upon  medical  advice,  believes  may  provide  comfort  to  me,  even  though  such  drugs,  treatment  or  procedures  may  hasten  my  death.      

2.  If  I  am  in  a  terminal  condition  and  I  do  not  have  a  Living  Will  Declaration  that  addresses  treatment  for  such  condition,  to  make  decisions  regarding  life-­‐sustaining  treatment,  including  artificially  or  technologically  supplied  nutrition  or  hydration.    

3.  To  give,  withdraw  or  refuse  to  give  informed  consent  to  any  health  care  procedure,  treatment,  interventions  or  other  measure.      

4.  To  request,  review  and  receive  any  information,  verbal  or  written,  regarding  my  physical  or    mental  condition,  including,  but  not  limited  to,  all  my  medical  and  health  care  records.                                                  5.  To  consent  to  further  disclosure  of  information  and  to  disclose  medical  and  related  information  concerning  my  condition  and  treatment  to  other  persons.      

6.  To  execute  for  me  any  releases  or  other  documents  that  may  be  required  in  order  to  obtain    medical  and  related  information.                

7.  To  execute  consents,  waivers  and  releases  of  liability  for  me  and  for  my  estate  to  all  persons  who  comply  with  my  agent’s  instructions  and  decisions.  To  indemnify  and  hold  harmless,  at  my  expense,  any  person  who  acts  while  relying  on  this  Health  Care  Power  of  Attorney.  I  will  be  bound  by  such  indemnity  entered  into  by  my  agent.      

8.  To  select,  employ  and  discharge  health  care  personnel  and  services  providing  home  health  care    and  the  like.      

9.  To  select,  contract  for  my  admission  to,  transfer  me  to  or  authorize  my  discharge  from  any    medical  or  health  care  facility,  including,  but  not  limited  to,  hospitals,  nursing  homes,  assisted    living  facilities,  hospices,  adult  homes  and  the  like.      

10.  To  transport  me  or  arrange  for  my  transportation  to  a  place  where  this  Health  Care  Power  of    Attorney  is  honored,  if  I  am  in  a  place  where  the  terms  of  this  document  are  not  enforced.      

11.  To  complete  and  sign  for  me  the  following:    • Consents  to  health  care  treatment,  or  to  the  issuing  of  Do  Not  Resuscitate  (DNR)  Orders  or  

other  similar  orders;  and    • Requests  to  be  transferred  to  another  facility,  to  be  discharged  against  health  care    

advice,  or  other  similar  requests;  and    • Any  other  document  desirable  or  necessary  to  implement  health  care  decisions  that    

my  agent  is  authorized  to  make  pursuant  to  this  document.

15

 

Ohio  Health  Care  Power  of  Attorney     Page  Five  of  Twelve  

Special  Instructions.  [These  instructions  apply  only  if  I  DO  NOT  have  an  active  Living  Will  Declaration.]      

By  placing  my  initials,  signature,  check  or  other  mark  in  this  box,  I  specifically  authorize  my  agent  to  refuse  or,  if  treatment  has  started,  to  withdraw  consent  to,    the  provision  of  artificially  or  technologically  supplied  nutrition  or  hydration  if  I  am    

in  a  permanently  unconscious  state  AND  my  physician  and  at  least  one  other  physician  who  has  examined  me  have  determined,  to  a  reasonable  degree  of  medical  certainty,  that  artificially  or  technologically  supplied  nutrition  and  hydration  will  not  provide  comfort  to  me  or  relieve  my  pain.  [R.C.  §1337.13(E)(2)(a)  and  (b)]                        

Limitations  of  Agent’s  Authority.  I  understand  there  are  limitations  to  the  authority  of  my  agent    under  Ohio  law:    

1.  My  agent  does  not  have  authority  to  refuse  or  withdraw  informed  consent  to  health  care  necessary    to  provide  comfort  care.      

2.  My  agent  does  not  have  the  authority  to  refuse  or  withdraw  informed  consent  to  health  care  if  I    am  pregnant,  if  the  refusal  or  withdrawal  of  the  health  care  would  terminate  the  pregnancy,  unless    the  pregnancy  or  the  health  care  would  pose  a  substantial  risk  to  my  life,  or  unless  my  attending    physician  and  at  least  one  other  physician  to  a  reasonable  degree  of  medical  certainty  determines    that  the  fetus  would  not  be  born  alive.      

3.  My  agent  cannot  order  the  withdrawal  of  life-­‐sustaining  treatment,  including  artificially  or  technologically  supplied  nutrition  or  hydration,  unless  I  am  in  a  terminal  condition  or  in  a    permanently  unconscious  state  and  two  physicians  have  determined  that  life-­‐sustaining  treatment    would  not  or  would  no  longer  provide  comfort  to  me  or  alleviate  my  pain.      

4.  If  I  previously  consented  to  any  health  care,  my  agent  cannot  withdraw  that  treatment  unless    my  condition  has  significantly  changed  so  that  the  health  care  is  significantly  less  beneficial  to  me,    or  unless  the  health  care  is  not  achieving  the  purpose  for  which  I  chose  the  health  care.        

Additional  Instructions  or  Limitations.  I  may  give  additional  instructions  or  impose  additional  limitations  on  the  authority  of  my  agent.  Below  are  my  specific  instructions  or  limitations:    

[If  the  space  below  is  not  sufficient,  you  may  attach  additional  pages.  If  you  do  not  have  any  additional  instructions  or  limitations,  write  “None”  below.]  

 

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NOMINATION  OF  GUARDIAN  [R.C.  §1337.28  (A)  and  R.C.  §2111.121]  [You  may,  but  are  not  required  to,  use  this  document  to  nominate  a  guardian,  should  guardianship  proceedings  be  started,  for  your  person  or  your  estate.]      I  understand  that  any  person  I  nominate  is  not  required  to  accept  the  duties  of  guardianship,  and    that  the  probate  court  maintains  jurisdiction  over  any  guardianship.  [R.C.  §2111.121(C)]        I  understand  that  the  court  will  honor  my  nominations  except  for  good  cause  shown  or    disqualification.  [R.C.  §2111.121(B)]    I  understand  that,  if  a  guardian  of  the  person  is  appointed  for  me,  such  guardian’s  duties  would  include  making  day-­‐to-­‐day  decisions  of  a  personal  nature  on  my  behalf,  such  as  food,  clothing,  and  living  arrangements,  but  this  or  any  subsequent  Health  Care  Power  of  Attorney  would  remain  in  effect  and  control  health  care  decisions  for  me,  unless  determined  otherwise  by  the  court.    The  court  will  determine  limits,  suspend  or  terminate  this  or  any  subsequent  Health  Care  Power  of  Attorney,  if  they  find  that  the  limitation,  suspension  or  termination  is  in  my  best  interests.  [R.C.  §1337.28  (C)]      I  intend  that  the  authority  given  to  my  agent  in  my  Health  Care  Power  of  Attorney  will    eliminate  the  need  for  any  court  to  appoint  a  guardian  of  my  person.  However,  should  such  proceedings  start,  I  nominate  the  person(s)  below  in  the  order  listed  as  guardian  of  my  person.       By  writing  my  initials,  signature,  a  check  mark  or  other  mark  in  this  box,  I  nominate  my     agent  and  alternate  agent(s),  if  any,  to  be  guardian  of  my  person,  in  the  order  named     above.      

If  I  do  not  choose  my  agent  or  an  alternate  agent  to  be  the  guardian  of  my  person,  I  choose     the  following  person(s),  in  this  order  [cross  out  any  unused  lines]:     Guardian  of  my  person’s  name  and  relationship:  _____________________________________       Address:  ____________________________________________________________________         Telephone  number(s):_________________________________________________________         Alternate  guardian  of  my  person’s  name  and  relationship:  _____________________________         Address:  ____________________________________________________________________           Telephone  number(s):_________________________________________________________  

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Guardian  of  the  estate  means  the  person  appointed  by  a  court  to  make  financial  decisions  on  behalf  of  the  ward,  with  the  court’s  involvement.  The  guardian  of  the  estate  is  required  to  be  bonded,  unless  bond  is  waived  in  writing  or  the  court  finds  it  unnecessary.           By  placing  my  initials,  signature,  check  or  other  mark  in  this  box,  I  nominate  my  agent  or                           alternate  agent(s),  if  any,  as  guardian  of  my  estate,  in  the  order  named  above.         If  I  do  not  choose  my  agent  or  an  alternate  agent  to  be  the  guardian  of  my  estate,  I  choose     the  following  person(s),  in  this  order  [cross  out  any  unused  lines]:       Guardian  of  my  estate  and  relationship:  __________________________________________       Address:  ____________________________________________________________________         Telephone  number(s):_________________________________________________________         Alternate  guardian  of  my  estate  and  relationship:  __________________________________         Address:  ____________________________________________________________________           Telephone  number(s):_________________________________________________________                                                    By  placing  my  initials,  signature,  check  or  other  mark  in  this  box,  I  direct  that  bond  be  waived                          for  guardian  or  successor  guardian  of  my  estate.  [R.C.  §1337.28  (B)]    

If  I  do  not  make  any  mark  in  this  box,  it  means  that  I  expect  the  guardian  or  successor  guardian  of  my  estate  to  be  bonded.  [R.C.  §1337.28  (B)]  

 No  Expiration  Date.  This  Health  Care  Power  of  Attorney  will  have  no  expiration  date  and  will  not  be  affected  by  my  disability  or  by  the  passage  of  time.      

Enforcement  by  Agent.  My  agent  may  take  for  me,  at  my  expense,  any  action  my  agent  considers  advisable  to  enforce  my  wishes  under  this  document.    Release  of  Agent’s  Personal  Liability.  My  agent  will  not  be  liable  to  me  or  any  other  person  for  any  breach  of  duty  unless  such  breach  of  duty  was  committed  dishonestly,  with  an  improper  motive,  or  with  reckless  indifference  to  the  purposes  of  this  document  or  my  best  interests.  [R.C.  §1337.35]      

Copies  are  the  Same  as  Original.  Any  person  may  rely  on  a  copy  of  this  document.  [R.C.  §1337.26(D)]    

Out  of  State  Application.  I  intend  that  this  document  be  honored  in  any  jurisdiction  to  the  extent  allowed  by  law.  [R.C.  §1337.26(C)]    

I  have  completed  a  Living  Will:         Yes  ________  No  ________  

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SIGNATURE  of  PRINCIPAL      I  understand  that  I  am  responsible  for  telling  members  of  my  family  and  my  physician,  my  lawyer,  my  religious  advisor  and  others  about  this  Health  Care  Power  of  Attorney.  I  understand  I  may  give  copies  of  this  Health  Care  Power  of  Attorney  to  any  person.    I  understand  that  I  may  file  a  copy  of  this  Health  Care  Power  of  Attorney  with  the  probate  court  for  safekeeping.  [R.C.  §1337.12(E)(3)]    I  understand  that  I  must  sign  this  Health  Care  Power  of  Attorney  and  state  the  date  of  my  signing,  and  that  my  signing  either  must  be  witnessed  by  two  adults  who  are  eligible  to  witness  my  signing  OR  the  signing  must  be  acknowledged  before  a  notary  public.  [R.C.  §1337.12]    I  sign  my  name  to  this  Health  Care  Power  of  Attorney    

on  _______________,  20___,  at           ,  Ohio.               ___________________________________________                   Principal    

 

[Choose  Witnesses  OR  a  Notary  Acknowledgment.]  

 

WITNESSES  [R.C.  §1337.12(B)]  

[The  following  persons  CANNOT  serve  as  a  witness  to  this  Health  Care  Power  of  Attorney:  • Your  agent,  if  any;  • The  guardian  of  your  person  or  estate,  if  any;  • Any  alternate  or  successor  agent  or  guardian,  if  any;  • Anyone  related  to  you  by  blood,  marriage,  or  adoption  (for  example,  your  spouse  and  children);  

• Your  attending  physician;  and  • The  administrator  of  any  nursing  home  where  you  are  receiving  care.]    

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I  attest  that  the  principal  signed  or  acknowledged  this  Health  Care  Power  of  Attorney  in  my    presence,  and  that  the  principal  appears  to  be  of  sound  mind  and  not  under  or  subject  to  duress,  fraud  or  undue  influence.                                                                                                                                            /                                                                                                                                        /  Witness  One’s  Signature                          Witness  One’s  Printed  Name            Date    

 Witness  One’s  Address  

   

                                                                                                                                       /                                                                                                                                        /  Witness  Two’s  Signature                          Witness  Two’s  Printed  Name                                      Date  

 

 Witness  Two’s  Address  

   

OR,  if  there  are  no  witnesses:    

NOTARY  ACKNOWLEDGMENT  [R.C.  §1337.12]    

State  of  Ohio                        County  of  _____________________  ss.      On  ________________,  20_____,  before  me,  the  undersigned  notary  public,  personally  appeared    

____________________________________,  principal  of  the  above  Health  Care  Power  of  Attorney,    and  who  has  acknowledged  that  (s)he  executed  the  same  for  the  purposes  expressed  therein.  I  attest  that  the  principal  appears  to  be  of  sound  mind  and  not  under  or  subject  to  duress,  fraud  or  undue  influence.  

   

            ____________________________________                        Notary  Public                         My  Commission  Expires:  ______________________               My  Commission  is  Permanent:  _________________      ©  March  2015.  May  be  reprinted  and  copied  for  use  by  the  public,  attorneys,  medical  and  osteopathic  physicians,    hospitals,  bar  associations,  medical  societies  and  nonprofit  associations  and  organizations.  It  may  not  be  reproduced  commercially  for  sale  at  a  profit.

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NOTICE  TO  ADULT  EXECUTING  THIS  DOCUMENT  This  is  an  important  legal  document.  Before  executing  this  document,  you  should  know  these  facts:    This  document  gives  the  person  you  designate  (the  attorney  in  fact)  the  power  to  make  MOST  health  care  decisions  for  you  if  you  lose  the  capacity  to  make  informed  health  care  decisions  for  yourself.  This  power  is  effective  only  when  your  attending  physician  determines  that  you  have  lost  the  capacity  to  make  informed  health  care  decisions  for  yourself  and,  notwithstanding  this  document,  as  long  as  you  have  the  capacity  to  make  informed  health  care  decisions  for  yourself,  you  retain  the  right  to  make  all  medical  and  other  health  care  decisions  for  yourself.    You  may  include  specific  limitations  in  this  document  on  the  authority  of  the  attorney  in  fact  to  make  health  care  decisions  for  you.    Subject  to  any  specific  limitations  you  include  in  this  document,  if  your  attending  physician  determines  that  you  have  lost  the  capacity  to  make  an  informed  decision  on  a  health  care  matter,  the  attorney  in  fact  GENERALLY  will  be  authorized  by  this  document  to  make  health  care  decisions  for  you  to  the  same  extent  as  you  could  make  those  decisions  yourself,  if  you  had  the  capacity  to  do  so.  The  authority  of  the  attorney  in  fact  to  make  health  care  decisions  for  you  GENERALLY  will  include  the  authority  to  give  informed  consent,  to  refuse  to  give  informed  consent,  or  to  withdraw  informed  consent  to  any  care,  treatment,  service,  or  procedure  to  maintain,  diagnose,  or  treat  a  physical  or  mental  condition.    HOWEVER,  even  if  the  attorney  in  fact  has  general  authority  to  make  health  care  decisions  for  you  under  this  document,  the  attorney  in  fact  NEVER  will  be  authorized  to  do  any  of  the  following:    (1)  Refuse  or  withdraw  informed  consent  to  life-­‐sustaining  treatment,  unless  your  attending  physician  and  one  other  physician  who  examines  you  determine,  to  a  reasonable  degree  of  medical  certainty  and  in  accordance  with  reasonable  medical  standards,  that  either  of  the  following  applies:    

(a)  You  are  suffering  from  an  irreversible,  incurable  and  untreatable  condition  caused  by  disease,  illness,  or  injury  from  which    

(i)  there  can  be  no  recovery  and    (ii)  your  death  is  likely  to  occur  within  a  relatively  short  time  if  life-­‐sustaining  treatment  is  not  administered,  and  your  attending  physician  additionally  determines,  to  a  reasonable  degree  of  medical  certainty  and  in  accordance  with  reasonable  medical  standards,  that  there  is  no  reasonable  possibility  that  you  will  regain  the  capacity  to  make  informed  health  care  decisions  for  yourself.  

 (b)  You  are  in  a  state  of  permanent  unconsciousness  that  is  characterized  by  you  being  irreversibly  unaware  of  yourself  and  your  environment  and  by  a  total  loss  of  cerebral  cortical  functioning,  resulting  in  you  having  no  capacity  to  experience  pain  or  suffering,  and  your  attending  physician  additionally  determines,  to  a  reasonable  degree  of  medical  certainty  and  in  accordance  with  reasonable  medical  standards,  that  there  is  no  reasonable  possibility  that  you  will  regain  the  capacity  to  make  informed  health  care  decisions  for  yourself;  

 (2)  Refuse  or  withdraw  informed  consent  to  health  care  necessary  to  provide  you  with  comfort  care  (except  that,  if  the  attorney  in  fact  is  not  prohibited  from  doing  so  under  (4)  below,  the  attorney  in  fact  could  refuse  or  withdraw  informed  consent  to  the  provision  of  nutrition  or  hydration  to  you  as  described  under  (4)  below).  (You  should  understand  that  comfort  care  is  defined  in  Ohio  law  to  mean  artificially  or  technologically  administered  sustenance  (nutrition)  or  fluids  (hydration)  when  administered  to  diminish  your  pain  or  discomfort,  not  to  postpone  your  death,  and  any  other    

     

Notice  as  required  by  Ohio  Revised  Code  §1337.17    

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Ohio  Health  Care  Power  of  Attorney     Page  Eleven  of  Twelve  

medical  or  nursing  procedure,  treatment,  intervention,  or  other  measure  that  would  be  taken  to  diminish  your  pain  or  discomfort,  not  to  postpone  your  death.  Consequently,  if  your  attending  physician  were  to  determine  that  a  previously  described  medical  or  nursing  procedure,  treatment,  intervention,  or  other  measure  will  not  or  no  longer  will  serve  to  provide  comfort  to  you  or  alleviate  your  pain,  then,  subject  to  (4)  below,  your  attorney  in  fact  would  be  authorized  to  refuse  or  withdraw  informed  consent  to  the  procedure,  treatment,  intervention,  or  other  measure.);    (3)  Refuse  or  withdraw  informed  consent  to  health  care  for  you  if  you  are  pregnant  and  if  the  refusal  or  withdrawal  would  terminate  the  pregnancy  (unless  the  pregnancy  or  health  care  would  pose  a  substantial  risk  to  your  life,  or  unless  your  attending  physician  and  at  least  one  other  physician  who  examines  you  determine,  to  a  reasonable  degree  of  medical  certainty  and  in  accordance  with  reasonable  medical  standards,  that  the  fetus  would  not  be  born  alive);    (4)  Refuse  or  withdraw  informed  consent  to  the  provision  of  artificially  or  technologically  administered  sustenance  (nutrition)  or  fluids  (hydration)  to  you,  unless:    

(a)  You  are  in  a  terminal  condition  or  in  a  permanently  unconscious  state.    (b)  Your  attending  physician  and  at  least  one  other  physician  who  has  examined  you  determine,  to  a  reasonable  degree  of  medical  certainty  and  in  accordance  with  reasonable  medical  standards,  that  nutrition  or  hydration  will  not  or  no  longer  will  serve  to  provide  comfort  to  you  or  alleviate  your  pain.    (c)  If,  but  only  if,  you  are  in  a  permanently  unconscious  state,  you  authorize  the  attorney  in  fact  to  refuse  or  withdraw  informed  consent  to  the  provision  of  nutrition  or  hydration  to  you  by  doing  both  of  the  following  in  this  document:  

(i)  Including  a  statement  in  capital  letters  or  other  conspicuous  type,  including,  but  not  limited  to,  a  different  font,  bigger  type,  or  boldface  type,  that  the  attorney  in  fact  may  refuse  or  withdraw  informed  consent  to  the  provision  of  nutrition  or  hydration  to  you  if  you  are  in  a  permanently  unconscious  state  and  if  the  determination  that  nutrition  or  hydration  will  not  or  no  longer  will  serve  to  provide  comfort  to  you  or  alleviate  your  pain  is  made,  or  checking  or  otherwise  marking  a  box  or  line  (if  any)  that  is  adjacent  to  a  similar  statement  on  this  document;  (ii)  Placing  your  initials  or  signature  underneath  or  adjacent  to  the  statement,  check,  or  other  mark  previously  described.  

 (d)  Your  attending  physician  determines,  in  good  faith,  that  you  authorized  the  attorney  in  fact  to  refuse  or  withdraw  informed  consent  to  the  provision  of  nutrition  or  hydration  to  you  if  you  are  in  a  permanently  unconscious  state  by  complying  with  the  above  requirements  of  (4)(c)(i)  and  (ii)  above.    

(5)  Withdraw  informed  consent  to  any  health  care  to  which  you  previously  consented,  unless  a  change  in  your  physical  condition  has  significantly  decreased  the  benefit  of  that  health  care  to  you,  or  unless  the  health  care  is  not,  or  is  no  longer,  significantly  effective  in  achieving  the  purposes  for  which  you  consented  to  its  use.    Additionally,  when  exercising  authority  to  make  health  care  decisions  for  you,  the  attorney  in  fact  will  have  to  act  consistently  with  your  desires  or,  if  your  desires  are  unknown,  to  act  in  your  best  interest.  You  may  express  your  desires  to  the  attorney  in  fact  by  including  them  in  this  document  or  by  making  them  known  to  the  attorney  in  fact  in  another  manner.    

When  acting  pursuant  to  this  document,  the  attorney  in  fact  GENERALLY  will  have  the  same  rights  that  you  have  to  receive  information  about  proposed  health  care,  to  review  health  care  records,  and  to  consent  to  the  disclosure  of  health  care  records.  You  can  limit  that  right  in  this  document  if  you  so  choose.    Notice  as  required  by  Ohio  Revised  Code  §1337.17  

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 Ohio  Health  Care  Power  of  Attorney     Page  Twelve  of  Twelve  

Generally,  you  may  designate  any  competent  adult  as  the  attorney  in  fact  under  this  document.  However,  you  CANNOT  designate  your  attending  physician  or  the  administrator  of  any  nursing  home  in  which  you  are  receiving  care  as  the  attorney  in  fact  under  this  document.  Additionally,  you  CANNOT  designate  an  employee  or  agent  of  your  attending  physician,  or  an  employee  or  agent  of  a  health  care  facility  at  which  you  are  being  treated,  as  the  attorney  in  fact  under  this  document,  unless  either  type  of  employee  or  agent  is  a  competent  adult  and  related  to  you  by  blood,  marriage,  or  adoption,  or  unless  either  type  of  employee  or  agent  is  a  competent  adult  and  you  and  the  employee  or  agent  are  members  of  the  same  religious  order.    This  document  has  no  expiration  date  under  Ohio  law,  but  you  may  choose  to  specify  a  date  upon  which  your  durable  power  of  attorney  for  health  care  will  expire.  However,  if  you  specify  an  expiration  date  and  then  lack  the  capacity  to  make  informed  health  care  decisions  for  yourself  on  that  date,  the  document  and  the  power  it  grants  to  your  attorney  in  fact  will  continue  in  effect  until  you  regain  the  capacity  to  make  informed  health  care  decisions  for  yourself.    

You  have  the  right  to  revoke  the  designation  of  the  attorney  in  fact  and  the  right  to  revoke  this  entire  document  at  any  time  and  in  any  manner.  Any  such  revocation  generally  will  be  effective  when  you  express  your  intention  to  make  the  revocation.  However,  if  you  made  your  attending  physician  aware  of  this  document,  any  such  revocation  will  be  effective  only  when  you  communicate  it  to  your  attending  physician,  or  when  a  witness  to  the  revocation  or  other  health  care  personnel  to  whom  the  revocation  is  communicated  by  such  a  witness  communicates  it  to  your  attending  physician.    If  you  execute  this  document  and  create  a  valid  durable  power  of  attorney  for  health  care  with  it,  it  will  revoke  any  prior,  valid  durable  power  of  attorney  for  health  care  that  you  created,  unless  you  indicate  otherwise  in  this  document.    

This  document  is  not  valid  as  a  durable  power  of  attorney  for  health  care  unless  it  is  acknowledged  before  a  notary  public  or  is  signed  by  at  least  two  adult  witnesses  who  are  present  when  you  sign  or  when  you  acknowledge  your  signature.  No  person  who  is  related  to  you  by  blood,  marriage,  or  adoption  may  be  a  witness.  The  attorney  in  fact,  your  attending  physician,  and  the  administrator  of  any  nursing  home  in  which  you  are  receiving  care  also  are  ineligible  to  be  witnesses.  If  there  is  anything  in  this  document  that  you  do  not  understand,  you  should  ask  your  lawyer  to  explain  it  to  you.        Notice  as  required  by  Ohio  Revised  Code  §1337.17    ADDENDUM    

This  notice  was  not  updated  when  certain  provisions  of  the  law  regarding  the  Health  Care  Power  of  Attorney  were  changed  in  March  2014.  Please  be  advised  of  the  following  changes:        You  may,  but  are  not  required  to,  authorize  your  agent  to  get  your  health  information,  including  information  that  is  protected  by  law  and  otherwise  not  available  to  your  agent.  You  can  authorize  your  agent  to  have  access  to  your  health  information  immediately  upon  your  signing  of  this  document  or  at  any  later  time,  even  though  you  are  still  able  to  make  your  own  health  care  decisions.     You  may  also,  but  are  not  required  to,  use  this  document  to  name  guardians  for  you  or  your  estate  should  guardianship  proceedings  be  started.            ©  March  2015.  May  be  reprinted  and  copied  for  use  by  the  public,  attorneys,  medical  and  osteopathic  physicians,  hospitals,  bar  associations,  medical  societies  and  nonprofit  associations  and  organizations.  It  may  not  be  reproduced  commercially  for  sale  at  a  profit.  

23

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27

 

 Ohio  Living  Will     Page  One  of  Seven  

State  of  Ohio  Living  Will  Declaration  

Notice  to  Declarant    

The   purpose   of   this   Living   Will   Declaration   is   to   document   your   wish   that   life-­‐sustaining   treatment,   including   artificially   or   technologically   supplied   nutrition   and  hydration,   be   withheld   or   withdrawn   if   you   are   unable   to   make   informed   medical  decisions  and  are  in  a  terminal  condition  or  in  a  permanently  unconscious  state.  This  Living   Will   Declaration   does   not   affect   the   responsibility   of   health   care   personnel   to  provide  comfort  care  to  you.  Comfort  care  means  any  measure  taken  to  diminish  pain  or  discomfort,  but  not  to  postpone  death.    If  you  would  not  choose  to  limit  any  or  all  forms  of  life-­‐sustaining  treatment,  including  CPR,   you   have   the   legal   right   to   so   choose   and   may   wish   to   state   your   medical  treatment  preferences  in  writing  in  a  different  document.    Under  Ohio  law,  a  Living  Will  Declaration  is  applicable  only  to  individuals  in  a  terminal  condition  or  a  permanently  unconscious  state.  If  you  wish  to  direct  medical  treatment  in  other  circumstances,  you  should  prepare  a  Health  Care  Power  of  Attorney.  If  you  are  in  a  terminal  condition  or  a  permanently  unconscious  state,  this  Living  Will  Declaration  takes  precedence  over  a  Health  Care  Power  of  Attorney.    [You   should   consider   completing   a   new   Living   Will   Declaration   if   your   medical  condition  changes  or  if  you  later  decide  to  complete  a  Health  Care  Power  of  Attorney.  If   you  have  both  a  Living  Will  Declaration  and  a  Health  Care  Power  of  Attorney,  you  should   keep   copies   of   these   documents   together.   Bring   your   document(s)   with   you  whenever  you  are  a  patient  in  a  health  care  facility  or  when  you  update  your  medical  records  with  your  physician.]            

                         

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 Ohio  Living  Will       Page  Two  of  Seven  

Ohio  Living  Will  Declaration  

                 [R.C.  §2133]      

___________________________________________________  (Print  Full  Name)  

 ____________________________  

(Birth  Date)    

This   is   my   Living   Will   Declaration.   I   revoke   all   prior   Living   Will   Declarations   signed   by   me.   I  understand  the  nature  and  purpose  of  this  document.  If  any  provision  is  found  to  be  invalid  or  unenforceable,  it  will  not  affect  the  rest  of  this  document.      

I   am   of   sound   mind   and   not   under   or   subject   to   duress,   fraud   or   undue   influence.   I   am   a  competent   adult   who   understands   and   accepts   the   consequences   of   this   action.   I   voluntarily  declare  my  direction  that  my  dying  not  be  artificially  prolonged.  [R.C.  §2133.02  (A)(1]]    

I  intend  that  this  Living  Will  Declaration  will  be  honored  by  my  family  and  physicians  as  the  final  expression  of  my  legal  right  to  refuse  certain  health  care.  [R.C.§2133.03(B)(2)]      

Definitions    

Adult  means  a  person  who  is  18  years  of  age  or  older.      Agent  or  attorney-­‐in-­‐fact  means  a  competent  adult  who  a  person  (the  “principal”)  can  name  in  a  Health  Care  Power  of  Attorney  to  make  health  care  decisions  for  the  principal.      Anatomical  gift  means  a  donation  of  part  or  all  of  a  human  body  to  take  effect  after  the  donor’s  death  for  the  purpose  of  transplantation,  therapy,  research  or  education.    Artificially  or  technologically  supplied  nutrition  or  hydration  means  food  and  fluids  provided  through  intravenous  or  tube  feedings.  [You  can  refuse  or  discontinue  a  feeding  tube,  or  authorize  your  Health  Care  Power  of  Attorney  agent  to  refuse  or  discontinue  artificial  nutrition  or  hydration.]    Comfort  care  means  any  measure,  medical  or  nursing  procedure,  treatment  or  intervention,  including  nutrition  and  or  hydration,  that  is  taken  to  diminish  a  patient’s  pain  or  discomfort,  but  not  to  postpone  death.      CPR  means  cardiopulmonary  resuscitation,  one  of  several  ways  to  start  a  person’s  breathing  or  heartbeat  once  either  has  stopped.  It  does  not  include  clearing  a  person’s  airway  for  a  reason  other  than  resuscitation.

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Declarant  means  the  person  signing  the  Living  Will  Declaration.    

Do  Not  Resuscitate  or  DNR  Order  means  a  physician’s  medical  order  that  is  written  into  a  patient’s  record  to  indicate  that  the  patient  should  not  receive  cardiopulmonary  resuscitation.      

Health  care  means  any  care,  treatment,  service  or  procedure  to  maintain,  diagnose  or  treat  an  individual’s  physical  or  mental  health.      

Health  care  decision  means  giving  informed  consent,  refusing  to  give  informed  consent,  or  withdrawing  informed  consent  to  health  care.      

Health  Care  Power  of  Attorney  means  a  legal  document  that  lets  the  principal  authorize  an  agent  to  make  health  care  decisions  for  the  principal  in  most  health  care  situations  when  the  principal  can  no  longer  make  such  decisions.  Also,  the  principal  can  authorize  the  agent  to  gather  protected  health  information  for  and  on  behalf  of  the  principal  immediately  or  at  any  other  time.  A  Health  Care  Power  of  Attorney  is  NOT  a  financial  power  of  attorney.      

The  Health  Care  Power  of  Attorney  document  also  can  be  used  to  nominate  person(s)  to  act  as  guardian  of  the  principal's  person  or  estate.  Even  if  a  court  appoints  a  guardian  for  the  principal,  the  Health  Care  Power  of  Attorney  remains  in  effect  unless  the  court  rules  otherwise.        

Life-­‐sustaining  treatment  means  any  medical  procedure,  treatment,  intervention  or  other  measure  that,  when  administered  to  a  patient,  mainly  prolongs  the  process  of  dying.    

Living  Will  Declaration  means  a  legal  document  that  lets  a  competent  adult  (“declarant”)  specify  what  health  care  the  declarant  wants  or  does  not  want  when  he  or  she  becomes  terminally  ill  or  permanently  unconscious  and  can  no  longer  make  his  or  her  wishes  known.  It  is  NOT  and  does  not  replace  a  will,  which  is  used  to  appoint  an  executor  to  manage  a  person’s  estate  after  death.                      

Permanently  unconscious  state  means  an  irreversible  condition  in  which  the  patient  is  permanently  unaware  of  himself  or  herself  and  surroundings.  At  least  two  physicians  must  examine  the  patient  and  agree  that  the  patient  has  totally  lost  higher  brain  function  and  is  unable  to  suffer  or  feel  pain.      

Principal  means  a  competent  adult  who  signs  a  Health  Care  Power  of  Attorney.    

Terminal  condition  means  an  irreversible,  incurable,  and  untreatable  condition  caused  by  disease,  illness,  or  injury  from  which,  to  a  reasonable  degree  of  medical  certainty  as  determined  in  accordance  with  reasonable  medical  standards  by  a  declarant's  attending  physician  and  one  other  physician  who  has  examined  the  declarant,  both  of  the  following  apply:  (1)  there  can  be  no  recovery  and  (2)  death  is  likely  to  occur  within  a  relatively  short  time  if  life-­‐sustaining  treatment  is  not  administered.  

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No  Expiration  Date.  This  Living  Will  Declaration  will  have  no  expiration  date.  However,  I  may  revoke  it  at  any  time.  [R.C.  §2133.04(A)]    

Copies  the  Same  as  Original.  Any  person  may  rely  on  a  copy  of  this  document.  [R.C.  §2133.02(C)]    

Out  of  State  Application.  I  intend  that  this  document  be  honored  in  any  jurisdiction  to  the  extent  allowed  by  law.  [R.C.  §2133.14]    I  have  completed  a  Health  Care  Power  of  Attorney:       Yes________  No  ________                          Notifications.  [Note:    You  do  not  need  to  name  anyone.  If  no  one  is  named,  the  law  requires    your  attending  physician  to  make  a  reasonable  effort  to  notify  one  of  the  following  persons  in    the  order  named:    your  guardian,  your  spouse,  your  adult  children  who  are  available,  your    parents,  or  a  majority  of  your  adult  siblings  who  are  available.]      

In  the  event  my  attending  physician  determines  that  life-­‐sustaining  treatment  should  be    withheld  or  withdrawn,  my  physician  shall  make  a  reasonable  effort  to  notify  one  of  the    persons  named  below,  in  the  following  order  of  priority  [cross  out  any  unused  lines]:  [R.C.  §2133.05(2)(a)]        

     First  contact’s  name  and  relationship:          Address:          Telephone  number(s):      

     Second  contact’s  name  and  relationship:          Address:          Telephone  number(s):            Third  contact’s  name  and  relationship:          Address:          Telephone  number(s):      If  I  am  in  a  TERMINAL  CONDITION  and  unable  to  make  my  own  health  care  decisions,  OR  if  I  am  in  a  PERMANENTLY  UNCONSCIOUS  STATE  and  there  is  no  reasonable  possibility  that  I  will  regain  the  capacity  to  make  informed  decisions,  then  I  direct  my  physician  to  let  me  die  naturally,  providing  me  only  with  comfort  care.

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For  the  purpose  of  providing  comfort  care,  I  authorize  my  physician  to:  1. Administer  no  life-­‐sustaining  treatment,  including  CPR;    2. Withhold  or  withdraw  artificially  or  technologically  supplied  nutrition  or  hydration,  provided  

that,  if  I  am  in  a  permanently  unconscious  state,  I  have  authorized  such  withholding  or  withdrawal  under  Special  Instructions  below  and  the  other  conditions  have  been  met;    

3. Issue  a  DNR  Order;  and  4. Take  no  action  to  postpone  my  death,  providing  me  with  only  the  care  necessary  to  make  me  

comfortable  and  to  relieve  pain.              

Special  Instructions.                                                                By  placing  my  initials,  signature,  check  or  other  mark  in  this  box,  I  specifically                                                                authorize  my  physician  to  withhold,  or  if  treatment  has  commenced,  to  withdraw,                                                                consent  to  the  provision  of  artificially  or  technologically  supplied  nutrition  or  hydration  if  I  am  in  a  permanently  unconscious  state  AND  my  physician  and  at  least  one  other  physician  who  has  examined  me  have  determined,  to  a  reasonable  degree  of  medical  certainty,  that  artificially  or  technologically  supplied  nutrition  and  hydration  will  not  provide  comfort  to  me  or  relieve  my  pain.  [R.C.  §2133.02(A)(3)  and  R.C.  §2133.08]        Additional  instructions  or  limitations.  

[If  the  space  below  is  not  sufficient,  you  may  attach  additional  pages.    If  you  do  not  have  any  additional  instructions  or  limitations,  write  “None”  below.]  

             

     

[The   “anatomical   gift”   language   provided   below   is   required   by  ORC   §2133.07(C).   Donate   Life  Ohio  recommends  that  you  indicate  your  authorization  to  be  an  organ,  tissue  or  cornea  donor  at  the   Ohio   Bureau   of   Motor   Vehicles   when   receiving   a   driver   license   or,   if   you   wish   to   place  restrictions  on  your  donation,  on  a  Donor  Registry  Enrollment  Form  (attached)  sent  to  the  Ohio  Bureau  of  Motor  Vehicles.]    

[If  you  use  this  living  will  to  declare  your  authorization,  indicate  the  organs  and/or  tissues  you  wish  to  donate  and  cross  out  any  purposes  for  which  you  do  not  authorize  your  donation  to  be  used.  Please  see  the  attached  Donor  Registry  Enrollment  Form  for  help  in  this  regard.    In  all  cases,  let  your  family  know  your  declared  wishes  for  donation.]

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ANATOMICAL  GIFT  (optional)  

Upon  my  death,  the  following  are  my  directions  regarding  donation  of  all  or  part  of  my  body:  In  the  hope  that  I  may  help  others  upon  my  death,  I  hereby  give  the  following  body  parts:    [Check  all  that  apply.]  

!  All  organs,  tissue  and  eyes  for  any  purposes  authorized  by  law.  

OR  

!  Heart   !  Lungs   !  Liver  (and  associated  vessels)   !  Pancreas/Islet  Cells    !  Small  Bowel   !  Intestines   !  Kidneys  (and  associated  vessels)   !  Eyes/Corneas  !  Heart  Valves   !  Bone   !  Tendons   !  Ligaments  !  Veins   !  Fascia   !  Skin   !  Nerves  

For  the  following  purposes  authorized  by  law:  !All  purposes          !Transplantation          !Therapy          !Research          !Education  

If  I  do  not  indicate  a  desire  to  donate  all  or  part  of  my  body  by  filling  in  the  lines  above,  no  presumption  is  created  about  my  desire  to  make  or  refuse  to  make  an  anatomical  gift.  

SIGNATURE  of  DECLARANT  I  understand  that  I  am  responsible  for  telling  members  of  my  family,  the  agent  named  in  my  Health  Care  Power  of  Attorney  (if  I  have  one),  my  physician,  my  lawyer,  my  religious  advisor  and  others  about  this  Living  Will  Declaration.  I  understand  I  may  give  copies  of  this  Living  Will  Declaration  to  any  person.  

I  understand  that  I  must  sign  (or  direct  an  individual  to  sign  for  me)  this  Living  Will  Declaration  and  state  the  date  of  the  signing,  and  that  the  signing  either  must  be  witnessed  by  two  adults  who  are  eligible  to  witness  the  signing  OR  the  signing  must  be  acknowledged  before  a  notary  public.  [R.C.  §2133.02]  

I  sign  my  name  to  this  Living  Will  Declaration  

on  _______________,  20___,  at   ,  Ohio.  

___________________________________________  Declarant  

[Choose  Witnesses  OR  a  Notary  Acknowledgment.]  

WITNESSES  [R.C.  §2133.02(B)(1)]  

[The  following  persons  CANNOT  serve  as  a  witness  to  this  Living  Will  Declaration:  • Your  agent  in  your  Health  Care  Power  of  Attorney,  if  any;• The  guardian  of  your  person  or  estate,  if  any;

The following selected items:

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• Any  alternate  agent  or  guardian,  if  any;  •  Anyone  related  to  you  by  blood,  marriage  or  adoption  (for  example,  your    spouse  and  children);    

• Your  attending  physician;  and    • The  administrator  of  the  nursing  home  where  you  are  receiving  care.]    

I  attest  that  the  Declarant  signed  or  acknowledged  this  Living  Will  Declaration  in  my  presence,  and  that  the  Declarant  appears  to  be  of  sound  mind  and  not  under  or  subject  to  duress,  fraud  or  undue  influence.    

_______________________________/_______________________________  /_____________  Witness  One’s  Signature                          Witness  One’s  Printed  Name              Date    _____________________________________________________________________________  

                 Witness  One’s  Address    

______________________________  /________________________________  /______________  Witness  Two’s  Signature                            Witness  Two’s  Printed  Name                  Date    ______________________________________________________________________________  

           Witness  Two’s  Address    

OR,  if  there  are  no  witnesses,    

NOTARY  ACKNOWLEDGMENT  [R.C.  §2133.02(B)(2)]  State  of  Ohio                        County  of  _____________________  ss.      On  ________________,  20_____,  before  me,  the  undersigned  notary  public,  personally  appeared    

____________________________________,  declarant  of  the  above  Living  Will  Declaration,  and  who      

has  acknowledged  that  (s)he  executed  the  same  for  the  purposes  expressed  therein.  I  attest  that  the      

declarant  appears  to  be  of  sound  mind  and  not  under  or  subject  to  duress,  fraud  or  undue  influence.      

            ____________________________________                      Notary  Public                         My  Commission  Expires:  ______________________               My  Commission  is  Permanent:  _________________    ©  March  2015.  May  be  reprinted  and  copied  for  use  by  the  public,  attorneys,  medical  and  osteopathic  physicians,  hospitals,  bar  associations,  medical  societies  and  nonprofit  associations  and  organizations.  It  may  not  be  reproduced    commercially  for  sale  at  a  profit.

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State  of  Ohio  Donor  Registry  Enrollment  Form  

Notice  to  Declarant    

The  purpose  of  the  Donor  Registry  Enrollment  Form  is  to  document  your  wish  to  donate  organs,  tissues  and/or  corneas  at  the  time  of  your  death.      This  form  should  be  completed  only  if  you  have  NOT  already  registered  as  a  donor  with  the  Ohio  Bureau  of  Motor  Vehicles  (BMV)  when  renewing  a  driver  license  or  state  identification  card;  online  through  the  BMV  website;  or  previously  through  a  paper  form.    If  you  wish  to  make  an  anatomical  gift  or  modify  an  existing  registration  this  form  must  be  sent  to  the  BMV  to  ensure  your  wishes  for  organ,  tissue  and/or  cornea  donation  will  be  honored.    This  document  will  serve  as  your  authorization  to  recover  the  organs,  tissue  and/or  corneas  indicated  at  the  time  of  your  death,  if  medically  possible.    In  submitting  this  form  your  wishes  will  be  recorded  in  the  Ohio  Donor  Registry  maintained  by  the  BMV  and  will  be  accessible  only  to  the  appropriate  organ,  tissue  and  cornea  recovery  agencies  at  the  time  of  death.    You  are  encouraged  to  share  your  wishes  with  your  next  of  kin  so  they  are  aware  of  your  intentions  to  be  a  donor.    This  form  can  also  be  used  to  amend  or  revoke  your  wishes  for  donation.    The  completed  form  should  be  mailed  to:  

Ohio  Bureau  of  Motor  Vehicles  Attn:  Records  Request  

P.  O.  Box  16583  Columbus,  OH  43216-­‐6583  

 Frequently  asked  questions  about  organ,  tissue  and  cornea  donation  are  addressed  on  page  three  of  this  section.  If  you  have  more  specific  questions,  contact  information  for  the  state’s  organ  and  tissue  recovery  agencies  is  also  listed,  and  you  are  encouraged  to  contact  them  or  visit  their  websites.                      

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Ohio  Organ/Tissue  Donation     Page  Two  of  Three  

Ohio  Donor  Registry  Enrollment  Form  

If   you   have   NOT   already   registered   as   a   donor   with   the   Ohio   Bureau   of   Motor   Vehicles   (BMV)   when  renewing   a   driver   license   or   state   ID,   the   Ohio   Donor   Registry   Form   must   be   filed   with   the   BMV   to  ensure  your  wishes  concerning  organ  and  tissue  donation  will  be  honored.  This  document  will  serve  as  your  authorization  to  recover  the  organs  and/or  tissues  indicated  at  the  time  of  your  death,  if  medically  possible.  In  submitting  this  form,  your  wishes  will  be  recorded  in  the  Ohio  Donor  Registry  maintained  by  the  BMV  and  will  be  accessible  only  to  the  appropriate  organ  and  tissue  recovery  agencies  at  the  time  of  death.  Be  sure  to  share  your  wishes  with  loved  ones  so  they  are  aware  of  your  intentions.  This  form  can  also  be  used  to  amend  or  revoke  your  wishes  for  donation.  

 To  register,  please  complete  and  mail  this  enrollment  form  to:  

Ohio  Bureau  of  Motor  Vehicles  Attn:  Records  Request  

P.O.  Box  16583  Columbus,  OH  43216-­‐6583  

PLEASE PRINT LAST NAME

FIRST MIDDLE

MAILING ADDRESS CITY

STATE ZIP

PHONE ( ) -

DATE OF BIRTH / / /

STATE OF OHIO DL/ID CARD # OR SOCIAL SECURITY #

DONOR REGISTRY ENROLLMENT OPTIONS OPTION 1

Upon my death, I make an anatomical gift of my organs, tissues, and eyes for any purpose authorized by law. OPTION 2

Upon my death, I make an anatomical gift of the following organs, tissues, and/or eyes selected below:

All organs, tissues and eyes ORGANS TISSUES

Heart Intestines Eyes/Corneas Veins

Lungs Small Bowel Heart Valves Fascia

Liver (and associated vessels) Bone Skin

Kidneys (and associated vessels) Tendons Nerves

Pancreas/Islet Cells Ligaments

For the following purposes authorized by law:

All purposes Transplantation Therapy Research Education

OPTION 3 Please take me out of the Ohio Donor Registry.

SIGNATURE OF DONOR REGISTRANT X

DATE

37

 

Ohio  Organ/Tissue  Donation     Page  Three  of  Three  

Organ  and  Tissue  Donation  in  Ohio    

One   individual   can   save   or   improve   the   quality   of   life   for   people   who   suffer   from   organ   failure,  congenital  defects,  bone  cancer,  orthopedic   injuries,  burns,  blindness  and  more.  One  organ  donor  can  save   up   to   8   lives   by   donating   heart,   lungs,   kidneys,   pancreas,   small   intestine   and   liver.   More   than  123,000   Americans   are   on   the   national   waiting   list   for   a   life-­‐saving   organ   transplant;   3,400   in   Ohio.  Statistically,  18  people  in  the  U.S.  die  every  day  while  waiting  for  transplants.  If  you  register  as  a  donor,  be  sure  to  share  the  decision  with  your  family  members.    

Who   can   become   a   donor?   All   individuals   over   the   age   of   15½   can   register   and   give   advance  authorization   for   donation.   Medical   suitability   for   donation   is   determined   at   the   time   of   death.   If   a  minor  dies  before  the  age  of  18,  a  parent  can  amend  or  revoke  the  donation  decision.      

Are   there  age   limits   for  donors?   People   of   all   ages   and   medical   histories   should   consider   themselves  potential  donors.  Newborns  as  well  as  senior  citizens  have  been  organ  donors.  Medical  condition  at  the  time  of  death  will  determine  what  organs  and  tissues  can  be  donated.      

If   I   join   the   Donor   Registry,   will   it   affect   the   quality   of   medical   care   I   receive   at   the   hospital?   No,  doctors  at  hospitals  are  concerned  with  caring  for  the  patient  in  front  of  them  and  are  not  involved  with  donation  and  transplantation.  Every  effort  is  made  to  save  your  life  before  donation  is  considered.      

Will  donation  disfigure  my  body?  Can  there  be  an  open  casket  funeral?  Donation  does  not  disfigure  the  body  and  does  not  interfere  with  or  delay  a  funeral,  including  open  casket  services.    

Are   there  any  costs   to  my   family   for  donation?   The  donor’s   family  does  NOT  pay   for   the  cost  of   the  donation.  All  costs  related  to  donation  of  organs,  eyes  and  tissues  are  paid  by  the  designated  recovery  agency.    

Does  my  religion  approve  of  donation?  All  major  religions  support  organ,  eye  and  tissue  donation  as  an  unselfish  act  of  charity.    

Can  I  sell  my  organs?  No.  The  National  Organ  Transplant  Act  makes  it   illegal  to  sell  human  organs  and  tissue.  Violators  are  subject  to  fines  and  imprisonment.  Among  the  reasons  for  this  rule  is  the  concern  of  Congress   that  buying  and  selling  of  organs  might   lead  to   inequitable  access   to  donor  organs,  with   the  wealthy  having  an  unfair  advantage.      

How   are   organs   distributed?   Donor   organs   are   matched   to   recipients   through   a   federally-­‐regulated  system  based  on  a  number  of  factors  including  blood  type,  body  size,  medical  urgency,  time  on  waiting  list  and  geographical  location.      

Can   I  be  an  organ  and  tissue  donor  and  also  donate  my  body   to  science?   Total  body  donation   takes  precedence   over   organ   and   tissue   donation.   If   you   wish   to   donate   your   entire   body,   you   must   make  arrangements  with  a  medical  school  or  research  facility  prior  to  your  death.  Medical  schools,  research  facilities   and   other   agencies   study   bodies   to   gain   greater   understanding   of   anatomy   and   disease  mechanisms  in  humans.  This  research  is  also  vital  to  saving  and  improving  lives.      

Does  the  registry  authorize   living  donation?  No,   living  donation   is  not  authorized  by  the  registry.   It   is  possible  to  donate  a  kidney,  or  part  of  a   liver  or   lung  while  alive,  but  that   is  arranged  on  an  individual  basis  through  specific  transplant  centers.      

For  more  information  on  donation,  contact  one  of  the  state’s  four  federally  designated  organ  procurement  organizations:    

Northeastern  Ohio          Western  Ohio     Central  and  Southeastern  Ohio   Southwestern  Ohio  LifeBanc                  Life  Connection  of  Ohio   Lifeline  of  Ohio       LifeCenter  www.lifebanc.org              www.lifeconnectionofohio.org   www.lifelineofohio.org     www.lifepassiton.org  216.752.5433                937.223.8223                                                                800.525.5667                                                                              513.558.5555  

38

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DNR/CPR Care: The Facts Ohio first adopted a law concerning DNR orders in 1998. DNR stands for “do not resuscitate.” A person who does not wish to have cardiopulmonary resuscitation (CPR) performed may make this wish known through a physician’s order called a DNR order. A DNR order addresses the various methods used to revive people whose hearts have stopped functioning or who have stopped breathing. Cardiopulmonary Resuscitation (CPR) has a broad meaning. It includes any or all of the following:

Administration of chest compressions; Insertion of an artificial airway; Administration of resuscitation drugs; Defibrillation or cardioversion; Provision of respiratory assistance; Initiation of a resuscitative intravenous line; or Initiation of cardiac monitoring.

CPR can be life-saving but some people may not want it administered in certain cases. In some cases, CPR saves lives. In many cases, it is not effective. Many people overestimate the success of CPR. A person who is revived may be left with permanent or painful injury. Resuscitation also may include other treatment, such as drugs, tubes and electric shock. People with terminal illnesses or other serious medical conditions may prefer to focus on comfort care at the end of life rather than receiving CPR when the time comes. For more information about the pros and cons of CPR and whether it is right for you, ask your physician. It is easy to make your wishes about CPR known. If you want to receive CPR when appropriate, you do not need to do anything. Health care providers are required to perform CPR when necessary. If you do not want CPR, you need to discuss your wishes with your physician and ask your physician to write a DNR Order. If your physician agrees that you should not get CPR, he or she can fill out the required form to make your wishes known in case of an emergency. There are different DNR orders that you can choose and discuss with your physician. Under Ohio’s DNR Law, the Ohio Department of Health has established a standardized DNR form. When completed by a physician (certified nurse practitioner or advance practice nurse, as appropriate), these standardized DNR orders allow patients to choose the extent of the treatment they wish to receive or not receive at the end of life. Your physician can further explain the differences in DNR orders. Even if you are healthy now, you may want to state that you do not want to receive CPR if you ever become terminally ill. Ohio has a standard Living Will Declaration form. This form specifically allows you to direct your physician not to administer life-sustaining treatments, including CPR, and to issue a DNR Order if two physicians have agreed that you are either terminally ill or permanently unconscious.

41 

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