©August2016OhioStateBarAssociation

StateofOhioAdvanceDirectives:

HealthCarePowerofAttorney

LivingWillDeclaration

IhavecompletedaHealthCarePowerofAttorney: Yes ¨ No ¨IhaveaddedspecialnotestomyHealthCarePowerofAttorney: Yes ¨ No ¨IhaveincludedNominationofGuardian(s)onmyHealthCare PowerofAttorney: Yes ¨ No ¨IhavecompletedaLivingWillDeclaration: Yes ¨ No ¨IhaveaddedspecialinstructionstomyLivingWillDeclaration: Yes ¨ No ¨[NOTE:Wheneveryousignanewadvancedirectivedocument,itautomaticallywillrevokepriorsimilardocumentsunlessyouprovideotherwise.[R.C.§1337.14andR.C.§2133.04(C)][NOTE:Ifyoumakechangestoanadvancedirective,remembertomakesimilarchangestoyourotheradvancedirectives.]

OhioHealthCarePowerofAttorney PageOneofTwelve

StateofOhioHealthCarePowerofAttorney

[R.C.§1337]

(FullName)

(BirthDate)

ThisismyHealthCarePowerofAttorney.IrevokeallpriorHealthCarePowersofAttorneysignedbyme.Iunderstandthenatureandpurposeofthisdocument.Ifanyprovisionisfoundtobeinvalidorunenforceable,itwillnotaffecttherestofthisdocument.

IunderstandthatmyagentcanmakehealthcaredecisionsformeonlywhenevermyattendingphysicianhasdeterminedthatIhavelostthecapacitytomakeinformedhealthcaredecisions.However,thisdoesnotrequireorimplythatacourtmustdeclaremeincompetent.

Definitions

Adultmeansapersonwhois18yearsofageorolder.

Agentorattorney-in-factmeansacompetentadultwhoaperson(the“principal”)cannameinaHealthCarePowerofAttorneytomakehealthcaredecisionsfortheprincipal.

Artificiallyortechnologicallysuppliednutritionorhydrationmeansfoodandfluidsprovidedthroughintravenousortubefeedings.[YoucanrefuseordiscontinueafeedingtubeorauthorizeyourHealthCarePowerofAttorneyagenttorefuseordiscontinueartificialnutritionorhydration.]

Bondmeansaninsurancepolicyissuedtoprotecttheward’sassetsfromtheftorlosscausedbytheGuardianoftheEstate’sfailuretoproperlyperformhisorherduties.

Comfortcaremeansanymeasure,medicalornursingprocedure,treatmentorintervention,includingnutritionand/orhydration,thatistakentodiminishapatient’spainordiscomfort,butnottopostponedeath.

CPRmeanscardiopulmonaryresuscitation,oneofseveralwaystostartaperson’sbreathingorheartbeatonceeitherhasstopped.Itdoesnotincludeclearingaperson’sairwayforareasonotherthanresuscitation.

DoNotResuscitateorDNROrdermeansaphysician’smedicalorderthatiswrittenintoapatient’srecordtoindicatethatthepatientshouldnotreceivecardiopulmonaryresuscitation.

OhioHealthCarePowerofAttorney PageTwoofTwelve

Guardianmeansthepersonappointedbyacourtthroughalegalproceduretomakedecisionsforaward.AGuardianshipisestablishedbysuchcourtappointment.Healthcaremeansanycare,treatment,serviceorproceduretomaintain,diagnoseortreatanindividual’sphysicalormentalhealth. Healthcaredecisionmeansgivinginformedconsent,refusingtogiveinformedconsent,orwithdrawinginformedconsenttohealthcare. HealthCarePowerofAttorneymeansalegaldocumentthatletstheprincipalauthorizeanagenttomakehealthcaredecisionsfortheprincipalinmosthealthcaresituationswhentheprincipalcannolongermakesuchdecisions.Also,theprincipalcanauthorizetheagenttogatherprotectedhealthinformationforandonbehalfoftheprincipalimmediatelyoratanyothertime.AHealthCarePowerofAttorneyisNOTafinancialpowerofattorney. TheHealthCarePowerofAttorneydocumentalsocanbeusedtonominateperson(s)toactasguardianoftheprincipal'spersonorestate.Evenifacourtappointsaguardianfortheprincipal,theHealthCarePowerofAttorneyremainsineffectunlessthecourtrulesotherwise. Life-sustainingtreatmentmeansanymedicalprocedure,treatment,interventionorothermeasurethat,whenadministeredtoapatient,mainlyprolongstheprocessofdying.

LivingWillDeclarationmeansalegaldocumentthatletsacompetentadult(“declarant”)specifywhathealthcarethedeclarantwantsordoesnotwantwhenheorshebecomesterminallyillorpermanentlyunconsciousandcannolongermakehisorherwishesknown.ItisNOTanddoesnotreplaceawill,whichisusedtoappointanexecutortomanageaperson’sestateafterdeath.

Permanentlyunconsciousstatemeansanirreversibleconditioninwhichthepatientispermanentlyunawareofhimselforherselfandsurroundings.Atleasttwophysiciansmustexaminethepatientandagreethatthepatienthastotallylosthigherbrainfunctionandisunabletosufferorfeelpain.

PrincipalmeansacompetentadultwhosignsaHealthCarePowerofAttorney.

Terminalconditionmeansanirreversible,incurable,anduntreatableconditioncausedbydisease,illnessorinjuryfromwhich,toareasonabledegreeofmedicalcertaintyasdeterminedinaccordancewithreasonablemedicalstandardsbyaprincipal'sattendingphysicianandoneotherphysicianwhohasexaminedtheprincipal,bothofthefollowingapply:(1)therecanbenorecoveryand(2)deathislikelytooccurwithinarelativelyshorttimeiflife-sustainingtreatmentisnotadministered.Wardmeansthepersonthecourthasdeterminedtobeincompetent.Theward’sperson,financialestate,orboth,isprotectedbyaguardianthecourtappointsandoversees.

OhioHealthCarePowerofAttorney PageThreeofTwelve

NamingofMyAgent.Thepersonnamedbelowismyagent,whowillmakehealthcaredecisionsformeasauthorizedinthisdocument.Agent’snameandrelationship: Address: Telephonenumber(s): Byplacingmyinitials,signature,checkorothermarkinthisbox,Ispecificallyauthorize myagenttoobtainmyprotectedhealthcareinformationimmediatelyandatanyfuture time.

GuidancetoAgent.Myagentwillmakehealthcaredecisionsformebasedonmyinstructionsinthisdocumentandmywishesotherwiseknowntomyagent.Ifmyagentbelievesthatmywishesconflictwithwhatisinthisdocument,thisdocumentwilltakeprecedence.Iftherearenoinstructionsandifmywishesareunclearorunknownforanyparticularsituation,myagentwilldeterminemybestinterestsafterconsideringthebenefits,theburdensandtherisksthatmightresultfromagivendecision.Ifnoagentisavailable,thisdocumentwillguidedecisionsaboutmyhealthcare.

Namingofalternateagent(s).Ifmyagentnamedaboveisnotimmediatelyavailableorisunwillingorunabletomakedecisionsforme,thenIname,inthefollowingorderofpriority,thepersonslistedbelowasmyalternateagents[crossoutanyunusedlines]: Firstalternateagent’snameandrelationship: Address: Telephonenumber(s): Secondalternateagent’snameandrelationship: Address: Telephonenumber(s): Anypersoncanrelyonastatementbyanyalternateagentnamedabovethatheorsheisproperlyactingunderthisdocumentandsuchpersondoesnothavetomakeanyfurtherinvestigationorinquiry.

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OhioHealthCarePowerofAttorney PageFourofTwelve

AuthorityofAgent.ExceptforthoseitemsIhavecrossedoutandsubjecttoanychoicesIhavemadeinthisHealthCarePowerofAttorney,myagenthasfullandcompleteauthoritytomakeallhealthcaredecisionsforme.Thisauthorityincludes,butisnotlimitedto,thefollowing:

1.Toconsenttotheadministrationofpain-relievingdrugsortreatmentorprocedures(includingsurgery)thatmyagent,uponmedicaladvice,believesmayprovidecomforttome,eventhoughsuchdrugs,treatmentorproceduresmayhastenmydeath.

2.IfIaminaterminalconditionandIdonothaveaLivingWillDeclarationthataddressestreatmentforsuchcondition,tomakedecisionsregardinglife-sustainingtreatment,includingartificiallyortechnologicallysuppliednutritionorhydration.

3.Togive,withdraworrefusetogiveinformedconsenttoanyhealthcareprocedure,treatment,interventionsorothermeasure.

4.Torequest,reviewandreceiveanyinformation,verbalorwritten,regardingmyphysicalormentalcondition,including,butnotlimitedto,allmymedicalandhealthcarerecords. 5.Toconsenttofurtherdisclosureofinformationandtodisclosemedicalandrelatedinformationconcerningmyconditionandtreatmenttootherpersons.

6.Toexecuteformeanyreleasesorotherdocumentsthatmayberequiredinordertoobtainmedicalandrelatedinformation.

7.Toexecuteconsents,waiversandreleasesofliabilityformeandformyestatetoallpersonswhocomplywithmyagent’sinstructionsanddecisions.Toindemnifyandholdharmless,atmyexpense,anypersonwhoactswhilerelyingonthisHealthCarePowerofAttorney.Iwillbeboundbysuchindemnityenteredintobymyagent.

8.Toselect,employanddischargehealthcarepersonnelandservicesprovidinghomehealthcareandthelike.

9.Toselect,contractformyadmissionto,transfermetoorauthorizemydischargefromanymedicalorhealthcarefacility,including,butnotlimitedto,hospitals,nursinghomes,assistedlivingfacilities,hospices,adulthomesandthelike.

10.TotransportmeorarrangeformytransportationtoaplacewherethisHealthCarePowerofAttorneyishonored,ifIaminaplacewherethetermsofthisdocumentarenotenforced.

11.Tocompleteandsignformethefollowing:• Consentstohealthcaretreatment,ortotheissuingofDoNotResuscitate(DNR)Orders

orothersimilarorders;and• Requeststobetransferredtoanotherfacility,tobedischargedagainsthealthcare

advice,orothersimilarrequests;and• Anyotherdocumentdesirableornecessarytoimplementhealthcaredecisionsthat

myagentisauthorizedtomakepursuanttothisdocument.

OhioHealthCarePowerofAttorney PageFiveofTwelve

SpecialInstructions.[TheseinstructionsapplyonlyifIDONOThaveanactiveLivingWillDeclaration.]

Byplacingmyinitials,signature,checkorothermarkinthisbox,Ispecificallyauthorizemyagenttorefuseor,iftreatmenthasstarted,towithdrawconsentto,theprovisionofartificiallyortechnologicallysuppliednutritionorhydrationifIam

inapermanentlyunconsciousstateANDmyphysicianandatleastoneotherphysicianwhohasexaminedmehavedetermined,toareasonabledegreeofmedicalcertainty,thatartificiallyortechnologicallysuppliednutritionandhydrationwillnotprovidecomforttomeorrelievemypain.[R.C.§1337.13(E)(2)(a)and(b)]

LimitationsofAgent’sAuthority.IunderstandtherearelimitationstotheauthorityofmyagentunderOhiolaw:

1.Myagentdoesnothaveauthoritytorefuseorwithdrawinformedconsenttohealthcarenecessarytoprovidecomfortcare.

2.MyagentdoesnothavetheauthoritytorefuseorwithdrawinformedconsenttohealthcareifIampregnant,iftherefusalorwithdrawalofthehealthcarewouldterminatethepregnancy,unlessthepregnancyorthehealthcarewouldposeasubstantialrisktomylife,orunlessmyattendingphysicianandatleastoneotherphysiciantoareasonabledegreeofmedicalcertaintydeterminesthatthefetuswouldnotbebornalive.

3.Myagentcannotorderthewithdrawaloflife-sustainingtreatment,includingartificiallyortechnologicallysuppliednutritionorhydration,unlessIaminaterminalconditionorinapermanentlyunconsciousstateandtwophysicianshavedeterminedthatlife-sustainingtreatmentwouldnotorwouldnolongerprovidecomforttomeoralleviatemypain.

4.IfIpreviouslyconsentedtoanyhealthcare,myagentcannotwithdrawthattreatmentunlessmyconditionhassignificantlychangedsothatthehealthcareissignificantlylessbeneficialtome,orunlessthehealthcareisnotachievingthepurposeforwhichIchosethehealthcare.

AdditionalInstructionsorLimitations.Imaygiveadditionalinstructionsorimposeadditionallimitationsontheauthorityofmyagent.Belowaremyspecificinstructionsorlimitations:

[Ifthespacebelowisnotsufficient,youmayattachadditionalpages.Ifyoudonothaveanyadditionalinstructionsorlimitations,write“None”below.]

OhioHealthCarePowerofAttorney PageSixofTwelve

NOMINATIONOFGUARDIAN[R.C.§1337.28(A)andR.C.§2111.121][Youmay,butarenotrequiredto,usethisdocumenttonominateaguardian,shouldguardianshipproceedingsbestarted,foryourpersonoryourestate.]IunderstandthatanypersonInominateisnotrequiredtoacceptthedutiesofguardianship,andthattheprobatecourtmaintainsjurisdictionoveranyguardianship.[R.C.§2111.121(C)]Iunderstandthatthecourtwillhonormynominationsexceptforgoodcauseshownordisqualification.[R.C.§2111.121(B)]Iunderstandthat,ifaguardianofthepersonisappointedforme,suchguardian’sdutieswouldincludemakingday-to-daydecisionsofapersonalnatureonmybehalf,suchasfood,clothingandlivingarrangements,butthisoranysubsequentHealthCarePowerofAttorneywouldremainineffectandcontrolhealthcaredecisionsforme,unlessdeterminedotherwisebythecourt.Thecourtwilldeterminelimits,suspendorterminatethisoranysubsequentHealthCarePowerofAttorney,iftheyfindthatthelimitation,suspensionorterminationisinmybestinterests.[R.C.§1337.28(C)]IintendthattheauthoritygiventomyagentinmyHealthCarePowerofAttorneywilleliminatetheneedforanycourttoappointaguardianofmyperson.However,shouldsuchproceedingsstart,Inominatetheperson(s)belowintheorderlistedasguardianofmyperson. Bywritingmyinitials,signature,acheckmarkorothermarkinthisbox,Inominatemy agentandalternateagent(s),ifany,tobeguardianofmyperson,intheordernamed above.

IfIdonotchoosemyagentoranalternateagenttobetheguardianofmyperson,Ichoose thefollowingperson(s),inthisorder[crossoutanyunusedlines]: Guardianofmyperson’snameandrelationship: Address: Telephonenumber(s): Alternateguardianofmyperson’snameandrelationship: Address: Telephonenumber(s):

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OhioHealthCarePowerofAttorney PageSevenofTwelve

Guardianoftheestatemeansthepersonappointedbyacourttomakefinancialdecisionsonbehalfoftheward,withthecourt’sinvolvement.Theguardianoftheestateisrequiredtobebonded,unlessbondiswaivedinwritingorthecourtfindsitunnecessary. Byplacingmyinitials,signature,checkorothermarkinthisbox,Inominatemyagentor alternateagent(s),ifany,asguardianofmyestate,intheordernamedabove. IfIdonotchoosemyagentoranalternateagenttobetheguardianofmyestate,Ichoose thefollowingperson(s),inthisorder[crossoutanyunusedlines]: Guardianofmyestateandrelationship: Address: Telephonenumber(s): Alternateguardianofmyestateandrelationship: Address: Telephonenumber(s): Byplacingmyinitials,signature,checkorothermarkinthisbox,Idirectthatbondbewaivedfortheguardianorsuccessorguardianofmyestate.[R.C.§1337.28(B)]

IfIdonotmakeanymarkinthisbox,itmeansthatIexpecttheguardianorsuccessorguardianofmyestatetobebonded.[R.C.§1337.28(B)]

NoExpirationDate.ThisHealthCarePowerofAttorneywillhavenoexpirationdateandwillnotbeaffectedbymydisabilityorbythepassageoftime.

EnforcementbyAgent.Myagentmaytakeforme,atmyexpense,anyactionmyagentconsidersadvisabletoenforcemywishesunderthisdocument.ReleaseofAgent’sPersonalLiability.Myagentwillnotbeliabletomeoranyotherpersonforanybreachofdutyunlesssuchbreachofdutywascommitteddishonestly,withanimpropermotive,orwithrecklessindifferencetothepurposesofthisdocumentormybestinterests.[R.C.§1337.35]

CopiesaretheSameasOriginal.Anypersonmayrelyonacopyofthisdocument.[R.C.§1337.26(D)]

OutofStateApplication.Iintendthatthisdocumentbehonoredinanyjurisdictiontotheextentallowedbylaw.[R.C.§1337.26(C)]IhavecompletedaLivingWillDeclaration: Yes ¨ No ¨

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OhioHealthCarePowerofAttorney PageEightofTwelve

SIGNATUREofPRINCIPALIunderstandthatIamresponsiblefortellingmembersofmyfamilyandmyphysician,mylawyer,myreligiousadvisorandothersaboutthisHealthCarePowerofAttorney.IunderstandImaygivecopiesofthisHealthCarePowerofAttorneytoanyperson.IunderstandthatImayfileacopyofthisHealthCarePowerofAttorneywiththeprobatecourtforsafekeeping.[R.C.§1337.12(E)(3)]IunderstandthatImustsignthisHealthCarePowerofAttorneyandstatethedateofmysigning,andthatmysigningeithermustbewitnessedbytwoadultswhoareeligibletowitnessmysigningORthesigningmustbeacknowledgedbeforeanotarypublic.[R.C.§1337.12]IsignmynametothisHealthCarePowerofAttorney

on ,at ,Ohio. Principal

[ChooseWitnessesORaNotaryAcknowledgment.]

WITNESSES[R.C.§1337.12(B)]

[ThefollowingpersonsCANNOTserveasawitnesstothisHealthCarePowerofAttorney:• Youragent,ifany;• Theguardianofyourpersonorestate,ifany;• Anyalternateorsuccessoragentorguardian,ifany;• Anyonerelatedtoyoubyblood,marriage,oradoption(forexample,yourspouse

andchildren);• Yourattendingphysician;and• Theadministratorofanynursinghomewhereyouarereceivingcare.]

OhioHealthCarePowerofAttorney PageNineofTwelve

IattestthattheprincipalsignedoracknowledgedthisHealthCarePowerofAttorneyinmypresence,andthattheprincipalappearstobeofsoundmindandnotunderorsubjecttoduress,fraudorundueinfluence. / / WitnessOne’sSignature WitnessOne’sPrintedName Date

WitnessOne’sAddress

/ / WitnessTwo’sSignature WitnessTwo’sPrintedName Date

WitnessTwo’sAddress

OR,iftherearenowitnesses:

NOTARYACKNOWLEDGMENT[R.C.§1337.12]

StateofOhio Countyof ss. On ,beforeme,theundersignednotarypublic,personallyappeared

,principaloftheaboveHealthCarePowerofAttorney,andwhohasacknowledgedthat(s)heexecutedthesameforthepurposesexpressedtherein.Iattestthattheprincipalappearstobeofsoundmindandnotunderorsubjecttoduress,fraudorundueinfluence.

NotaryPublic

MyCommissionExpires:

MyCommissionisPermanent ¨©August2016.Maybereprintedandcopiedforusebythepublic,attorneys,medicalandosteopathicphysicians,hospitals,barassociations,medicalsocietiesandnonprofitassociationsandorganizations.Itmaynotbereproducedcommerciallyforsaleataprofit.

OhioHealthCarePowerofAttorney PageTenofTwelve

NOTICETOADULTEXECUTINGTHISDOCUMENTThisisanimportantlegaldocument.Beforeexecutingthisdocument,youshouldknowthesefacts:Thisdocumentgivesthepersonyoudesignate(theattorneyinfact)thepowertomakeMOSThealthcaredecisionsforyouifyoulosethecapacitytomakeinformedhealthcaredecisionsforyourself.Thispoweriseffectiveonlywhenyourattendingphysiciandeterminesthatyouhavelostthecapacitytomakeinformedhealthcaredecisionsforyourselfand,notwithstandingthisdocument,aslongasyouhavethecapacitytomakeinformedhealthcaredecisionsforyourself,youretaintherighttomakeallmedicalandotherhealthcaredecisionsforyourself.Youmayincludespecificlimitationsinthisdocumentontheauthorityoftheattorneyinfacttomakehealthcaredecisionsforyou.Subjecttoanyspecificlimitationsyouincludeinthisdocument,ifyourattendingphysiciandeterminesthatyouhavelostthecapacitytomakeaninformeddecisiononahealthcarematter,theattorneyinfactGENERALLYwillbeauthorizedbythisdocumenttomakehealthcaredecisionsforyoutothesameextentasyoucouldmakethosedecisionsyourself,ifyouhadthecapacitytodoso.TheauthorityoftheattorneyinfacttomakehealthcaredecisionsforyouGENERALLYwillincludetheauthoritytogiveinformedconsent,torefusetogiveinformedconsent,ortowithdrawinformedconsenttoanycare,treatment,service,orproceduretomaintain,diagnose,ortreataphysicalormentalcondition.HOWEVER,eveniftheattorneyinfacthasgeneralauthoritytomakehealthcaredecisionsforyouunderthisdocument,theattorneyinfactNEVERwillbeauthorizedtodoanyofthefollowing:(1)Refuseorwithdrawinformedconsenttolife-sustainingtreatment,unlessyourattendingphysicianandoneotherphysicianwhoexaminesyoudetermine,toareasonabledegreeofmedicalcertaintyandinaccordancewithreasonablemedicalstandards,thateitherofthefollowingapplies:

(a)Youaresufferingfromanirreversible,incurableanduntreatableconditioncausedbydisease,illness,orinjuryfromwhich

(i)therecanbenorecoveryand(ii)yourdeathislikelytooccurwithinarelativelyshorttimeiflife-sustainingtreatmentisnotadministered,andyourattendingphysicianadditionallydetermines,toareasonabledegreeofmedicalcertaintyandinaccordancewithreasonablemedicalstandards,thatthereisnoreasonablepossibilitythatyouwillregainthecapacitytomakeinformedhealthcaredecisionsforyourself.

(b)Youareinastateofpermanentunconsciousnessthatischaracterizedbyyoubeingirreversiblyunawareofyourselfandyourenvironmentandbyatotallossofcerebralcorticalfunctioning,resultinginyouhavingnocapacitytoexperiencepainorsuffering,andyourattendingphysicianadditionallydetermines,toareasonabledegreeofmedicalcertaintyandinaccordancewithreasonablemedicalstandards,thatthereisnoreasonablepossibilitythatyouwillregainthecapacitytomakeinformedhealthcaredecisionsforyourself;

(2)Refuseorwithdrawinformedconsenttohealthcarenecessarytoprovideyouwithcomfortcare(exceptthat,iftheattorneyinfactisnotprohibitedfromdoingsounder(4)below,theattorneyinfactcouldrefuseorwithdrawinformedconsenttotheprovisionofnutritionorhydrationtoyouasdescribedunder(4)below).(YoushouldunderstandthatcomfortcareisdefinedinOhiolawtomeanartificiallyortechnologicallyadministeredsustenance(nutrition)orfluids(hydration)whenadministeredtodiminishyourpainordiscomfort,nottopostponeyourdeath,andanyother

NoticeasrequiredbyOhioRevisedCode§1337.17

OhioHealthCarePowerofAttorney PageElevenofTwelve

medicalornursingprocedure,treatment,intervention,orothermeasurethatwouldbetakentodiminishyourpainordiscomfort,nottopostponeyourdeath.Consequently,ifyourattendingphysicianweretodeterminethatapreviouslydescribedmedicalornursingprocedure,treatment,intervention,orothermeasurewillnotornolongerwillservetoprovidecomforttoyouoralleviateyourpain,then,subjectto(4)below,yourattorneyinfactwouldbeauthorizedtorefuseorwithdrawinformedconsenttotheprocedure,treatment,intervention,orothermeasure.);(3)Refuseorwithdrawinformedconsenttohealthcareforyouifyouarepregnantandiftherefusalorwithdrawalwouldterminatethepregnancy(unlessthepregnancyorhealthcarewouldposeasubstantialrisktoyourlife,orunlessyourattendingphysicianandatleastoneotherphysicianwhoexaminesyoudetermine,toareasonabledegreeofmedicalcertaintyandinaccordancewithreasonablemedicalstandards,thatthefetuswouldnotbebornalive);(4)Refuseorwithdrawinformedconsenttotheprovisionofartificiallyortechnologicallyadministeredsustenance(nutrition)orfluids(hydration)toyou,unless:

(a)Youareinaterminalconditionorinapermanentlyunconsciousstate.(b)Yourattendingphysicianandatleastoneotherphysicianwhohasexaminedyoudetermine,toareasonabledegreeofmedicalcertaintyandinaccordancewithreasonablemedicalstandards,thatnutritionorhydrationwillnotornolongerwillservetoprovidecomforttoyouoralleviateyourpain.(c)If,butonlyif,youareinapermanentlyunconsciousstate,youauthorizetheattorneyinfacttorefuseorwithdrawinformedconsenttotheprovisionofnutritionorhydrationtoyoubydoingbothofthefollowinginthisdocument:

(i)Includingastatementincapitallettersorotherconspicuoustype,including,butnotlimitedto,adifferentfont,biggertype,orboldfacetype,thattheattorneyinfactmayrefuseorwithdrawinformedconsenttotheprovisionofnutritionorhydrationtoyouifyouareinapermanentlyunconsciousstateandifthedeterminationthatnutritionorhydrationwillnotornolongerwillservetoprovidecomforttoyouoralleviateyourpainismade,orcheckingorotherwisemarkingaboxorline(ifany)thatisadjacenttoasimilarstatementonthisdocument;(ii)Placingyourinitialsorsignatureunderneathoradjacenttothestatement,check,orothermarkpreviouslydescribed.

(d)Yourattendingphysiciandetermines,ingoodfaith,thatyouauthorizedtheattorneyinfacttorefuseorwithdrawinformedconsenttotheprovisionofnutritionorhydrationtoyouifyouareinapermanentlyunconsciousstatebycomplyingwiththeaboverequirementsof(4)(c)(i)and(ii)above.

(5)Withdrawinformedconsenttoanyhealthcaretowhichyoupreviouslyconsented,unlessachangeinyourphysicalconditionhassignificantlydecreasedthebenefitofthathealthcaretoyou,orunlessthehealthcareisnot,orisnolonger,significantlyeffectiveinachievingthepurposesforwhichyouconsentedtoitsuse.Additionally,whenexercisingauthoritytomakehealthcaredecisionsforyou,theattorneyinfactwillhavetoactconsistentlywithyourdesiresor,ifyourdesiresareunknown,toactinyourbestinterest.Youmayexpressyourdesirestotheattorneyinfactbyincludingtheminthisdocumentorbymakingthemknowntotheattorneyinfactinanothermanner.Whenactingpursuanttothisdocument,theattorneyinfactGENERALLYwillhavethesamerightsthatyouhavetoreceiveinformationaboutproposedhealthcare,toreviewhealthcarerecords,andtoconsenttothedisclosureofhealthcarerecords.Youcanlimitthatrightinthisdocumentifyousochoose.NoticeasrequiredbyOhioRevisedCode§1337.17

OhioHealthCarePowerofAttorney PageTwelveofTwelve

Generally,youmaydesignateanycompetentadultastheattorneyinfactunderthisdocument.However,youCANNOTdesignateyourattendingphysicianortheadministratorofanynursinghomeinwhichyouarereceivingcareastheattorneyinfactunderthisdocument.Additionally,youCANNOTdesignateanemployeeoragentofyourattendingphysician,oranemployeeoragentofahealthcarefacilityatwhichyouarebeingtreated,astheattorneyinfactunderthisdocument,unlesseithertypeofemployeeoragentisacompetentadultandrelatedtoyoubyblood,marriage,oradoption,orunlesseithertypeofemployeeoragentisacompetentadultandyouandtheemployeeoragentaremembersofthesamereligiousorder.ThisdocumenthasnoexpirationdateunderOhiolaw,butyoumaychoosetospecifyadateuponwhichyourdurablepowerofattorneyforhealthcarewillexpire.However,ifyouspecifyanexpirationdateandthenlackthecapacitytomakeinformedhealthcaredecisionsforyourselfonthatdate,thedocumentandthepoweritgrantstoyourattorneyinfactwillcontinueineffectuntilyouregainthecapacitytomakeinformedhealthcaredecisionsforyourself.Youhavetherighttorevokethedesignationoftheattorneyinfactandtherighttorevokethisentiredocumentatanytimeandinanymanner.Anysuchrevocationgenerallywillbeeffectivewhenyouexpressyourintentiontomaketherevocation.However,ifyoumadeyourattendingphysicianawareofthisdocument,anysuchrevocationwillbeeffectiveonlywhenyoucommunicateittoyourattendingphysician,orwhenawitnesstotherevocationorotherhealthcarepersonneltowhomtherevocationiscommunicatedbysuchawitnesscommunicatesittoyourattendingphysician.Ifyouexecutethisdocumentandcreateavaliddurablepowerofattorneyforhealthcarewithit,itwillrevokeanyprior,validdurablepowerofattorneyforhealthcarethatyoucreated,unlessyouindicateotherwiseinthisdocument.Thisdocumentisnotvalidasadurablepowerofattorneyforhealthcareunlessitisacknowledgedbeforeanotarypublicorissignedbyatleasttwoadultwitnesseswhoarepresentwhenyousignorwhenyouacknowledgeyoursignature.Nopersonwhoisrelatedtoyoubyblood,marriage,oradoptionmaybeawitness.Theattorneyinfact,yourattendingphysician,andtheadministratorofanynursinghomeinwhichyouarereceivingcarealsoareineligibletobewitnesses.Ifthereisanythinginthisdocumentthatyoudonotunderstand,youshouldaskyourlawyertoexplainittoyou.NoticeasrequiredbyOhioRevisedCode§1337.17ADDENDUMThisnoticewasnotupdatedwhencertainprovisionsofthelawregardingtheHealthCarePowerofAttorneywerechangedinMarch2014.Pleasebeadvisedofthefollowingchanges:Youmay,butarenotrequiredto,authorizeyouragenttogetyourhealthinformation,includinginformationthatisprotectedbylawandotherwisenotavailabletoyouragent.Youcanauthorizeyouragenttohaveaccesstoyourhealthinformationimmediatelyuponyoursigningofthisdocumentoratanylatertime,eventhoughyouarestillabletomakeyourownhealthcaredecisions. Youmayalso,butarenotrequiredto,usethisdocumenttonameguardiansforyouoryourestateshouldguardianshipproceedingsbestarted.©August2016.Maybereprintedandcopiedforusebythepublic,attorneys,medicalandosteopathicphysicians,hospitals,barassociations,medicalsocietiesandnonprofitassociationsandorganizations.Itmaynotbereproducedcommerciallyforsaleataprofit.

OhioLivingWill PageOneofSeven

StateofOhioLivingWillDeclarationNoticetoDeclarant

The purpose of this Living Will Declaration is to document your wish that life-sustaining treatment, including artificially or technologically supplied nutrition andhydration, be withheld or withdrawn if you are unable to make informed medicaldecisionsandareinaterminalconditionorinapermanentlyunconsciousstate.ThisLivingWillDeclarationdoesnot affect the responsibilityofhealth carepersonnel toprovidecomfortcaretoyou.Comfortcaremeansanymeasuretakentodiminishpainordiscomfort,butnottopostponedeath.Ifyouwouldnotchoosetolimitanyorallformsoflife-sustainingtreatment,includingCPR, you have the legal right to so choose and may wish to state your medicaltreatmentpreferencesinwritinginadifferentdocument.UnderOhiolaw,aLivingWillDeclarationisapplicableonlytoindividualsinaterminalconditionorapermanentlyunconsciousstate.Ifyouwishtodirectmedicaltreatmentinothercircumstances,youshouldprepareaHealthCarePowerofAttorney.Ifyouareinaterminalconditionorapermanentlyunconsciousstate,thisLivingWillDeclarationtakesprecedenceoveraHealthCarePowerofAttorney.[You should consider completing a new Living Will Declaration if your medicalconditionchangesorifyoulaterdecidetocompleteaHealthCarePowerofAttorney.If youhavebothaLivingWillDeclarationandaHealthCarePowerofAttorney,youshould keep copies of these documents together. Bring your document(s) with youwheneveryouareapatientinahealthcarefacilityorwhenyouupdateyourmedicalrecordswithyourphysician.]

OhioLivingWill PageTwoofSeven

OhioLivingWillDeclaration

[R.C.§2133]

(FullName)

(BirthDate)

This is my LivingWill Declaration. I revoke all prior LivingWill Declarations signed byme. Iunderstandthenatureandpurposeofthisdocument.Ifanyprovisionisfoundtobeinvalidorunenforceable,itwillnotaffecttherestofthisdocument.

I am of sound mind and not under or subject to duress, fraud or undue influence. I am acompetent adultwhounderstands andaccepts the consequencesof this action. I voluntarilydeclaremydirectionthatmydyingnotbeartificiallyprolonged.[R.C.§2133.02(A)(1]]

IintendthatthisLivingWillDeclarationwillbehonoredbymyfamilyandphysiciansasthefinalexpressionofmylegalrighttorefusecertainhealthcare.[R.C.§2133.03(B)(2)]

Definitions

Adultmeansapersonwhois18yearsofageorolder.Agentorattorney-in-factmeansacompetentadultwhoaperson(the“principal”)cannameinaHealthCarePowerofAttorneytomakehealthcaredecisionsfortheprincipal.Anatomicalgiftmeansadonationofpartorallofahumanbodytotakeeffectafterthedonor’sdeathforthepurposeoftransplantation,therapy,researchoreducation.Artificiallyortechnologicallysuppliednutritionorhydrationmeansfoodandfluidsprovidedthroughintravenousortubefeedings.[Youcanrefuseordiscontinueafeedingtube,orauthorizeyourHealthCarePowerofAttorneyagenttorefuseordiscontinueartificialnutritionorhydration.]Comfortcaremeansanymeasure,medicalornursingprocedure,treatmentorintervention,includingnutritionandorhydration,thatistakentodiminishapatient’spainordiscomfort,butnottopostponedeath.CPRmeanscardiopulmonaryresuscitation,oneofseveralwaystostartaperson’sbreathingorheartbeatonceeitherhasstopped.Itdoesnotincludeclearingaperson’sairwayforareasonotherthanresuscitation.

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DeclarantmeansthepersonsigningtheLivingWillDeclaration.

DoNotResuscitateorDNROrdermeansaphysician’smedicalorderthatiswrittenintoapatient’srecordtoindicatethatthepatientshouldnotreceivecardiopulmonaryresuscitation.

Healthcaremeansanycare,treatment,serviceorproceduretomaintain,diagnoseortreatanindividual’sphysicalormentalhealth.

Healthcaredecisionmeansgivinginformedconsent,refusingtogiveinformedconsent,orwithdrawinginformedconsenttohealthcare.

HealthCarePowerofAttorneymeansalegaldocumentthatletstheprincipalauthorizeanagenttomakehealthcaredecisionsfortheprincipalinmosthealthcaresituationswhentheprincipalcannolongermakesuchdecisions.Also,theprincipalcanauthorizetheagenttogatherprotectedhealthinformationforandonbehalfoftheprincipalimmediatelyoratanyothertime.AHealthCarePowerofAttorneyisNOTafinancialpowerofattorney.

TheHealthCarePowerofAttorneydocumentalsocanbeusedtonominateperson(s)toactasguardianoftheprincipal'spersonorestate.Evenifacourtappointsaguardianfortheprincipal,theHealthCarePowerofAttorneyremainsineffectunlessthecourtrulesotherwise.

Life-sustainingtreatmentmeansanymedicalprocedure,treatment,interventionorothermeasurethat,whenadministeredtoapatient,mainlyprolongstheprocessofdying.

LivingWillDeclarationmeansalegaldocumentthatletsacompetentadult(“declarant”)specifywhathealthcarethedeclarantwantsordoesnotwantwhenheorshebecomesterminallyillorpermanentlyunconsciousandcannolongermakehisorherwishesknown.ItisNOTanddoesnotreplaceawill,whichisusedtoappointanexecutortomanageaperson’sestateafterdeath.

Permanentlyunconsciousstatemeansanirreversibleconditioninwhichthepatientispermanentlyunawareofhimselforherselfandsurroundings.Atleasttwophysiciansmustexaminethepatientandagreethatthepatienthastotallylosthigherbrainfunctionandisunabletosufferorfeelpain.

PrincipalmeansacompetentadultwhosignsaHealthCarePowerofAttorney.

Terminalconditionmeansanirreversible,incurableanduntreatableconditioncausedbydisease,illnessorinjuryfromwhich,toareasonabledegreeofmedicalcertaintyasdeterminedinaccordancewithreasonablemedicalstandardsbyadeclarant'sattendingphysicianandoneotherphysicianwhohasexaminedthedeclarant,bothofthefollowingapply:(1)therecanbenorecoveryand(2)deathislikelytooccurwithinarelativelyshorttimeiflife-sustainingtreatmentisnotadministered.

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NoExpirationDate.ThisLivingWillDeclarationwillhavenoexpirationdate.However,Imayrevokeitatanytime.[R.C.§2133.04(A)]

CopiestheSameasOriginal.Anypersonmayrelyonacopyofthisdocument.[R.C.§2133.02(C)]

OutofStateApplication.Iintendthatthisdocumentbehonoredinanyjurisdictiontotheextentallowedbylaw.[R.C.§2133.14]IhavecompletedaHealthCarePowerofAttorney: Yes ¨ No ¨ Notifications.[Note:Youdonotneedtonameanyone.Ifnooneisnamed,thelawrequiresyourattendingphysiciantomakeareasonableefforttonotifyoneofthefollowingpersonsintheordernamed:yourguardian,yourspouse,youradultchildrenwhoareavailable,yourparents,oramajorityofyouradultsiblingswhoareavailable.]

Intheeventmyattendingphysiciandeterminesthatlife-sustainingtreatmentshouldbewithheldorwithdrawn,myphysicianshallmakeareasonableefforttonotifyoneofthepersonsnamedbelow,inthefollowingorderofpriority[crossoutanyunusedlines]:[R.C.§2133.05(2)(a)]

Firstcontact’snameandrelationship: Address: Telephonenumber(s):

Secondcontact’snameandrelationship: Address: Telephonenumber(s): Thirdcontact’snameandrelationship: Address: Telephonenumber(s): IfIaminaTERMINALCONDITIONandunabletomakemyownhealthcaredecisions,ORifIaminaPERMANENTLYUNCONSCIOUSSTATEandthereisnoreasonablepossibilitythatIwillregainthecapacitytomakeinformeddecisions,thenIdirectmyphysiciantoletmedienaturally,providingmeonlywithcomfortcare.

Xoutareaifno

tused

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Forthepurposeofprovidingcomfortcare,Iauthorizemyphysicianto:1. Administernolife-sustainingtreatment,includingCPR;2. Withholdorwithdrawartificiallyortechnologicallysuppliednutritionorhydration,provided

that,ifIaminapermanentlyunconsciousstate,IhaveauthorizedsuchwithholdingorwithdrawalunderSpecialInstructionsbelowandtheotherconditionshavebeenmet;

3. IssueaDNROrder;and4. Takenoactiontopostponemydeath,providingmewithonlythecarenecessarytomakeme

comfortableandtorelievepain.

SpecialInstructions.Byplacingmyinitials,signature,checkorothermarkinthisbox,Ispecificallyauthorizemyphysiciantowithhold,oriftreatmenthascommenced,towithdrawconsenttotheprovisionofartificiallyortechnologicallysuppliednutritionorhydrationifIaminapermanentlyunconsciousstateANDmyphysicianandatleastoneotherphysicianwhohasexaminedmehavedetermined,toareasonabledegreeofmedicalcertainty,thatartificiallyortechnologicallysuppliednutritionandhydrationwillnotprovidecomforttomeorrelievemypain.[R.C.§2133.02(A)(3)andR.C.§2133.08]Additionalinstructionsorlimitations.

[Ifthespacebelowisnotsufficient,youmayattachadditionalpages.Ifyoudonothaveanyadditionalinstructionsorlimitations,write“None”below.]

[The “anatomical gift” language provided below is required byORC §2133.07(C). Donate LifeOhiorecommendsthatyouindicateyourauthorizationtobeanorgan,tissueorcorneadonoratthe Ohio Bureau of Motor Vehicles when receiving a driver license or, if you wish to placerestrictionsonyourdonation,onaDonorRegistryEnrollmentForm(attached)senttotheOhioBureauofMotorVehicles.]

[Ifyouusethislivingwilltodeclareyourauthorization,indicatetheorgansand/ortissuesyouwishtodonateandcrossoutanypurposesforwhichyoudonotauthorizeyourdonationtobeused.PleaseseetheattachedDonorRegistryEnrollmentFormforhelpinthisregard.Inallcases,letyourfamilyknowyourdeclaredwishesfordonation.]

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ANATOMICALGIFT(optional)

InthehopethatImayhelpothersuponmydeath,Iherebygivethefollowingbodypartsforthefollowingpurposes:[Completebothsections.]Section1.BodyParts.Check“Allorgans,tissueandeyes”orallthatapplybelowthatbox.¨ Allorgans,tissueandeyes.Ifyoucheckthisbox,donotcheckanyotherboxesinSection1andproceedtoSection2.

¨ Heart ¨ Lungs ¨ Liver(andassociatedvessels) ¨ Pancreas/IsletCells¨ SmallBowel ¨ Intestines ¨ Kidneys(andassociatedvessels) ¨ Eyes/Corneas¨ HeartValves ¨ Bone ¨ Tendons ¨ Ligaments¨ Veins ¨ Fascia ¨ Skin ¨ Nerves

Section2.Purposes.Check“Allpurposes”orallthatapplybelowthatbox.

¨AllPurposes.Ifyoucheckthisbox,donotcheckanyboxesbelow. ¨Transplantation ¨Therapy ¨Research ¨Education

IfIdonotindicateadesiretodonateallorsomeofmybodypartsbyfillinginthelinesabove,nopresumptioniscreatedaboutmydesiretomakeorrefusetomakeananatomicalgift.

SIGNATUREofDECLARANTIunderstandthatIamresponsiblefortellingmembersofmyfamily,theagentnamedinmyHealthCarePowerofAttorney(ifIhaveone),myphysician,mylawyer,myreligiousadvisorandothersaboutthisLivingWillDeclaration.IunderstandImaygivecopiesofthisLivingWillDeclarationtoanyperson.IunderstandthatImustsign(ordirectanindividualtosignforme)thisLivingWillDeclarationandstatethedateofthesigning,andthatthesigningeithermustbewitnessedbytwoadultswhoareeligibletowitnessthesigningORthesigningmustbeacknowledgedbeforeanotarypublic.[R.C.§2133.02]IsignmynametothisLivingWillDeclaration

on ,at ,Ohio. Declarant

[ChooseWitnessesORaNotaryAcknowledgment.]

WITNESSES[R.C.§2133.02(B)(1)]

[ThefollowingpersonsCANNOTserveasawitnesstothisLivingWillDeclaration:• YouragentinyourHealthCarePowerofAttorney,ifany;• Theguardianofyourpersonorestate,ifany;

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• Anyalternateagentorguardian,ifany;• Anyonerelatedtoyoubyblood,marriageoradoption(forexample,your

spouseandchildren);• Yourattendingphysician;and• Theadministratorofthenursinghomewhereyouarereceivingcare.]

IattestthattheDeclarantsignedoracknowledgedthisLivingWillDeclarationinmypresence,andthattheDeclarantappearstobeofsoundmindandnotunderorsubjecttoduress,fraudorundueinfluence.

/ / WitnessOne’sSignature WitnessOne’sPrintedName Date

WitnessOne’sAddress

/ / WitnessTwo’sSignature WitnessTwo’sPrintedName Date

WitnessTwo’sAddress

OR,iftherearenowitnesses,

NOTARYACKNOWLEDGMENT[R.C.§2133.02(B)(2)]

StateofOhio Countyof ss. On ,beforeme,theundersignednotarypublic,personallyappeared

,declarantoftheaboveLivingWillDeclaration,andwho

hasacknowledgedthat(s)heexecutedthesameforthepurposesexpressedtherein.Iattestthatthe

declarantappearstobeofsoundmindandnotunderorsubjecttoduress,fraudorundueinfluence.

NotaryPublic MyCommissionExpires:

MyCommissionisPermanent:¨

©August2016.Maybereprintedandcopiedforusebythepublic,attorneys,medicalandosteopathicphysicians,hospitals,barassociations,medicalsocietiesandnonprofitassociationsandorganizations.Itmaynotbereproducedcommerciallyforsaleataprofit.

OhioOrgan/TissueDonation PageOneofThree

StateofOhioDonorRegistryEnrollmentForm

NoticetoDeclarant

ThepurposeoftheDonorRegistryEnrollmentFormistodocumentyourwishtodonateorgans,tissuesand/orcorneasatthetimeofyourdeath.ThisformshouldbecompletedonlyifyouhaveNOTalreadyregisteredasadonorwiththeOhioBureauofMotorVehicles(BMV)whenrenewingadriverlicenseorstateidentificationcard;onlinethroughtheBMVwebsite;orpreviouslythroughapaperform.IfyouwishtomakeananatomicalgiftormodifyanexistingregistrationthisformmustbesenttotheBMVtoensureyourwishesfororgan,tissueand/orcorneadonationwillbehonored.Thisdocumentwillserveasyourauthorizationtorecovertheorgans,tissueand/orcorneasindicatedatthetimeofyourdeath,ifmedicallypossible.InsubmittingthisformyourwisheswillberecordedintheOhioDonorRegistrymaintainedbytheBMVandwillbeaccessibleonlytotheappropriateorgan,tissueandcornearecoveryagenciesatthetimeofdeath.Youareencouragedtoshareyourwisheswithyournextofkinsotheyareawareofyourintentionstobeadonor.Thisformcanalsobeusedtoamendorrevokeyourwishesfordonation.Thecompletedformshouldbemailedto:

OhioBureauofMotorVehiclesAttn:RecordsRequest

P.O.Box16583Columbus,OH43216-6583

Frequentlyaskedquestionsaboutorgan,tissueandcorneadonationareaddressedonpagethreeofthissection.Ifyouhavemorespecificquestions,contactinformationforthestate’sorganandtissuerecoveryagenciesisalsolisted,andyouareencouragedtocontactthemorvisittheirwebsites.

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OhioDonorRegistryEnrollmentForm

If you haveNOT already registered as a donorwith theOhio Bureau ofMotor Vehicles (BMV)whenrenewing a driver license or state ID, the Ohio Donor Registry Formmust be filed with the BMV toensureyourwishesconcerningorganandtissuedonationwillbehonored.Thisdocumentwillserveasyourauthorizationtorecovertheorgansand/ortissuesindicatedatthetimeofyourdeath,ifmedicallypossible.Insubmittingthisform,yourwisheswillberecordedintheOhioDonorRegistrymaintainedbytheBMVandwillbeaccessibleonlytotheappropriateorganandtissuerecoveryagenciesatthetimeofdeath.Besuretoshareyourwisheswithlovedonessotheyareawareofyourintentions.Thisformcanalsobeusedtoamendorrevokeyourwishesfordonation.

Toregister,pleasecompleteandmailthisenrollmentformto:

OhioBureauofMotorVehiclesAttn:RecordsRequest

P.O.Box16583Columbus,OH43216-6583

PLEASEPRINTLASTNAME

FIRST MIDDLE

MAILINGADDRESSCITY

STATE ZIP

PHONE

DATEOFBIRTH

STATEOFOHIODL/IDCARD#ORSOCIALSECURITY#

DONORREGISTRYENROLLMENTOPTIONSOPTION1

¨ Uponmydeath,Imakeananatomicalgiftofmyorgans,tissues,andeyesforanypurposeauthorizedbylaw.

OPTION2

¨ Uponmydeath,Imakeananatomicalgiftofthefollowingorgans,tissues,and/oreyesselectedbelow:

¨ Allorgans,tissuesandeyesORGANS TISSUES

¨ Heart¨ Lungs¨ Liver(andassociatedvessels)¨ Kidneys(andassociatedvessels)¨ Pancreas/IsletCells

¨ Intestines¨ SmallBowel

¨ Eyes/Corneas¨ HeartValves¨ Bone¨ Tendons¨ Ligaments

¨ Veins¨ Fascia¨ Skin¨ Nerves

Forthefollowingpurposesauthorizedbylaw:

¨Allpurposes ¨Transplantation ¨Therapy ¨Research ¨Education

OPTION3

¨ PleasetakemeoutoftheOhioDonorRegistry.

SIGNATUREOFDONORREGISTRANTX

DATE

OhioOrgan/TissueDonation PageThreeofThree

OrganandTissueDonationinOhio

One individual can save or improve the quality of life for people who suffer from organ failure,congenitaldefects,bonecancer,orthopedic injuries,burns,blindnessandmore.Oneorgandonorcansave up to 8 lives by donating heart, lungs, kidneys, pancreas, small intestine and liver. More than123,000 Americans are on the national waiting list for a life-saving organ transplant; 3,400 in Ohio.Statistically,18peopleintheU.S.dieeverydaywhilewaitingfortransplants.Ifyouregisterasadonor,besuretosharethedecisionwithyourfamilymembers.

Who can become a donor? All individuals over the age of 15½ can register and give advanceauthorization for donation. Medical suitability for donation is determined at the time of death. If aminordiesbeforetheageof18,aparentcanamendorrevokethedonationdecision.

Are thereage limits fordonors? Peopleof all agesandmedicalhistories should consider themselvespotentialdonors.Newbornsaswellasseniorcitizenshavebeenorgandonors.Medicalconditionatthetimeofdeathwilldeterminewhatorgansandtissuescanbedonated.

If I join the Donor Registry, will it affect the quality ofmedical care I receive at the hospital? No,doctorsathospitalsareconcernedwithcaringforthepatientinfrontofthemandarenotinvolvedwithdonationandtransplantation.Everyeffortismadetosaveyourlifebeforedonationisconsidered.

Willdonationdisfiguremybody?Cantherebeanopencasketfuneral?Donationdoesnotdisfigurethebodyanddoesnotinterferewithordelayafuneral,includingopencasketservices.

Are thereanycosts tomy family fordonation? Thedonor’s familydoesNOTpay for thecostof thedonation.Allcostsrelatedtodonationoforgans,eyesandtissuesarepaidbythedesignatedrecoveryagency.

Doesmyreligionapproveofdonation?Allmajorreligionssupportorgan,eyeandtissuedonationasanunselfishactofcharity.

CanIsellmyorgans?No.TheNationalOrganTransplantActmakesit illegaltosellhumanorgansandtissue.Violatorsaresubjecttofinesandimprisonment.AmongthereasonsforthisruleistheconcernofCongress thatbuyingandsellingoforgansmight leadto inequitableaccess todonororgans,with thewealthyhavinganunfairadvantage.

How are organs distributed? Donor organs are matched to recipients through a federally-regulatedsystembasedonanumberoffactorsincludingbloodtype,bodysize,medicalurgency,timeonwaitinglistandgeographicallocation.

Can Ibeanorganandtissuedonorandalsodonatemybody toscience? Totalbodydonation takesprecedence over organ and tissue donation. If youwish to donate your entire body, youmustmakearrangementswithamedicalschoolorresearchfacilitypriortoyourdeath.Medicalschools,researchfacilities and other agencies study bodies to gain greater understanding of anatomy and diseasemechanismsinhumans.Thisresearchisalsovitaltosavingandimprovinglives.

Doestheregistryauthorize livingdonation?No, livingdonation isnotauthorizedbytheregistry. It ispossibletodonateakidney,orpartofa liveror lungwhilealive,butthat isarrangedonanindividualbasisthroughspecifictransplantcenters.

Formoreinformationondonation,contactoneofthestate’sfourfederallydesignatedorganprocurementorganizations:

NortheasternOhioWesternOhio CentralandSoutheasternOhio SouthwesternOhioLifeBanc LifeConnectionofOhio LifelineofOhio LifeCenterwww.lifebanc.orgwww.lifeconnectionofohio.orgwww.lifelineofohio.org www.lifepassiton.org216.752.5433 937.223.8223877.223.6667513.558.5555