State of Florida DO NOT RESUSCITATE ORDER

(please use ink)

Patient’s Full Legal Name: ________________________________________________Date:____________________ (Print or Type Name)

PATIENT’S STATEMENT Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn.

(If not signed by patient, check applicable box):

q Surrogate q Proxy (both as defined in Chapter 765, F.S.) q Court appointed guardian q Durable power of attorney (pursuant to Chapter 709, F.S.)

________________________________________________________________________________________________ (Applicable Signature) (Print or Type Name)

PHYSICIAN’S STATEMENT I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient’s cardiac or respiratory arrest.

________________________________________________________________________________________________ (Signature of Physician) (Date) Telephone Number (Emergency)

________________________________________________________________________________________________ (Print or Type Name) (Physician’s Medical License Number)

DH Form 1896, Revised December 2002

PHYSICIAN’S STATEMENT

I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient's cardiac or respiratory arrest.

________________________________________________________ (Signature of Physician) (Date) Telephone Number (Emergency)

________________________________________________________ (Print or Type Name) (Physician’s Medical License Number)

DH Form 1896,Revised December 2002

State of Florida DO NOT RESUSCITATE ORDER

________________________________________________________________ Patient’s Full Legal Name (Print or Type) (Date)

PATIENT’S STATEMENT Based upon informed consent, I , the unders i g n e d ,h e r e by direct that CPR be withheld or withdrawn. (If not signed by patient, check applicable box): q Surrogate q Proxy (both as defined in Chapter 765, F.S.) q Court appointed guardian q Durable power of attorney (pursuant to Chapter 709, F.S.)

________________________________________________________________ (Applicable Signature) (Print or Type Name)

DURABLE POWER OF ATTORNEY

State of Florida County of ____________________________ KNOW ALL MEN BY THESE PRESENTS, that I,__________________________________, of ____________________, (name) (county)

Florida, as authorized by Florida law, do hereby appoint,_______________________________________________________ (name)

To manage and conduct my affairs. This power of attorney shall be non-delegable except as otherwise provided in Florida Statutes,

and shall be valid and effective from date hereof until such time as I shall die or revoke the power. This durable power of attorney is

not affected by subsequent incapacity of the principal except as provided in Florida Statutes.

The property subject to this durable power of attorney shall include all real and personal property owned by me, my

interest in al property held in joint tenancy, my interest in all non-homestead property held in tenancy by the entirety, and all

property over which I hold power of appointment and shall also include authority to sell, mortgage or convey my homestead

property.

Without limiting the broad powers intended to be conferred by the preceding provisions, I expressly authorize my attorney

acting hereunder in a fiduciary capacity to do and execute all or any of the following acts, deeds, and things for my benefit and on

my behalf.

1. COLLECTION POWERS: To ask, demand, sue for, recover, collect, receive all sums of money, bank deposits, chattels

and other real or personal property, tangible or intangible, of whatsoever nature or description that may be due,

owing, payable or belonging to me, and to execute and deliver receipts, releases, cancellations or discharges.

2. PAYMENT POWERS: To settle any account or reckoning whatsoever wherein I now am or at any time hereafter shall

be in any way interested or concerned with any person whomsoever, and to pay or receive the balance thereof as the

case may require.

3. SAFE DEPOSIT BOXES: To enter any safe deposit or other place of safekeeping standing in my name with full authority

to remove any and all the contents thereof and to make additions, substitutions and replacements, specifically

including any safe deposit box in my name jointly with my spouse or any other person.

4. BANKING POWERS:

(a) To borrow any sum or sums of money on such terms and with such security, whether real or personal property

belonging to me, as my attorney may think fit, and to execute any and all notes, mortgages and other

instruments which my attorney may deem necessary or desirable.

(b) To draw, accept, make, endorse or otherwise deal with any checks, promissory notes, bills of exchange or

other commercial or mercantile instruments, specifically including the right to make withdrawals from any

savings account or building or loan deposits.

(c) To redeem or cash in any/or all bonds issued by the United States Government or any of its agencies, any

other bonds and any certificates of deposit or other similar assets or securities belonging to me.

(d) To sell all or any bonds, shares of stock, warrants, debentures, or other securities belonging to me, and to

execute all assignments and other instruments necessary or proper for transferring the same to the purchaser

or purchasers thereof, and to give good receipts and discharges for all monies payable in respect thereof.

(e) To invest the proceeds of any redemptions or sales aforesaid, and any other of my monies, in such, bonds,

shares of stock and other securities as my attorney shall think fit, and from time to time to vary the said

investments or any of them.

*POA* *POA* Page 1 of 3

5. MANAGEMENT POWERS: To vote at all meetings of stockholders of any company or corporation, and otherwise to act

as my attorney or proxy in respect of my shares of stock or other securities or investments which now or hereafter shall

belong to me, and to appoint substitutes or proxies with respect to any such shares of stock.

6. TAX POWERS: To sign and execute in my behalf any tax return, state or federal relating to income, gift, ad valorem,

intangible or other taxes, state or federal, and to act for me in any examinations, audits, hearings, conferences or

litigation relating to any such taxes, including authority to file and prosecute refund claims, and to enter into an effect

any settlements.

7. TRUST POWERS:

(a) To execute a revocable or irrevocable trust which provides that all income and principal shall be paid to me or

the guardian of my estate, or applied for my benefit in such manner as I or my attorney hereunder shall

request or as the trustee shall determine, and that on my death any remaining assets, including income, shall

pass according to my will or intestate succession if I have no will.

(b) To make additions of funds and assets, real and personal, to any trust established by me.

8. BUSINESS INTERESTS:

(a) To sell, rent, lease for any term, or exchange, any real estate or interests therein, for such considerations and

upon such terms and conditions as my attorney may see fit; specifically including the power and authority to

execute acknowledge and deliver deeds, mortgages, leases and other instruments conveying or encumbering

title to property owned by me and my spouse jointly.

(b) To commence, prosecute, discontinue or defend all actions or other legal proceedings touching my estate or

any part thereof, or touching any matter in which I or my estate may be in any way concerned.

(c) The powers herein conferred upon my attorney shall extend to and include all of my right, title and interest in

and to any real and personal property, tangible or intangible, in which I may have an estate by the entirety,

joint tenancy, tenancy in common, as trustee or beneficiary of any trust, or in any other manner.

9. PERSONAL INTERESTS:

(a) To make gifts, outright or in trust, in an amount not greater than $10,000.00 per donee per year or the

amounts allowed without gift tax consequences under the appropriate Internal Revenue code provisions

(including my attorney hereunder appointed).

(b) To arrange for my entrance to and care at any hospital, nursing home, health center, convalescent home,

retirement home or similar institution.

(c) To renounce or disclaim any interest acquired by testate or intestate succession or by inter vivos transfer.

10. HEALTH CARE POWERS:

(a) To authorize, arrange for, consent to, waive and terminate any and all medical and surgical procedures on my

behalf ( including any election or election and agreement under the Life-Prolonging Procedures Act of Florida

with request to providing, withholding or withdrawing life-prolonging procedures should I fail to make a

declaration hereunder) and to pay or arrange compensation for my care.

(b) To make health care decisions for me and to provide informed consent if I am incapable of making health care

decisions or providing informed consent.

(i) To be the final authority to act for me and to make health care decisions for me in matters

regarding my health care during any period in which I have the incapacity to consent.

(ii) To expeditiously consult with appropriate health care providers to provide informed consent in

my best interest and make health care decisions for me which my said Surrogate believes I would

have made under the circumstances if I were capable of making such decisions.

(iii) To give any consent in writing using the appropriate consent form.

(iv) To have access to appropriate clinical records regarding me and have authority to authorize the

release of information and clinical records to appropriate persons to insure the continuity of my

health care.

*POA*

*POA* Page 2 of 3

(v) To apply for public benefits, where necessary, such as Medicare and Medicaid, for me and have

access to information regarding my income and assets to the extent required to make such

application if necessary.

(vi) To make all health care decisions on my behalf including but not limited to those set forth in F.S.

Chapter 765.

11. GENERAL POWERS:

(a) In general to do all other acts, deeds, matters and things whatsoever in or about my estate, property and

affairs, or to concur with persons jointly interested with me therein in doing all acts, deeds, matters and things

herein particularly or generally described, as fully and effectually to all intents and purposes as I could do

myself.

(b) This instrument is executed by me in the State of Florida but it is my intention that the powers and authority

herein conferred upon my attorney as authorized by the laws of Florida now or hereafter in force and effect

shall be exercisable in any other state or jurisdiction where I may have any property or assets.

I hereby ratify and confirm, and promise at all times to ratify and confirm all and whatsoever my duly authorized attorney

hereunder shall lawfully do or cause to be done by virtue of these presents, including anything which shall be done

between the revocation of this instrument by my death or in any other manner and notice of such revocation reaching my

attorney; and I hereby declare that as against me and all persons claiming under me everything which my said attorney

shall do or cause to be done in pursuance hereof after such revocation as aforesaid shall be valid and effectual in favor of

any persons claiming the benefit thereof who, before the doing thereof, shall not have had notice of such revocation.

IN WITNESS WHEREOF, I have executed this Durable Power of Attorney.

___________________________________ ____________________________________________

Witness Signature Date Signature Date

___________________________________ ____________________________________________

Witness Signature Date Print Name

State of Florida

County of ___________________________

Before me, the undersigned authority, duly authorized to take acknowledgements and administer oaths, personally

appeared ________________________________, personally known to me to be the person described above, who being by

me first duly sworn states that (His or Her) is the person who executed the foregoing instrument for the reasons expressed

therein.

Dated this ___________day of ____________,____________.

_______________________________________________________

NOTARY PUBLIC

My Commission Expires:__________________________________

*POA* *POA* 11/2010 Page 3 of 3

CATHOLIC DECLARATION ON LIFE AND DEATH ADVANCE DIRECTIVE

(HEALTH SURROGATE DESIGNATION/LIVING WILL) OF

_________________________________________________________ (Name)

Introduction I am executing this Catholic Declaration on Life and Death while I am of sound mind. It is intended to designate a surrogate and provide guidance in making medical decisions in the event I am incapacitated or unable to express my own wishes.

Statement of Faith I believe that I have been created for eternal life in union with God. The truth that my life is a precious gift from God has profound implications for the question of stewardship over my life. I have a duty to preserve my life and to use it for God’s glory, but the duty to preserve my life is not absolute, for I may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome. Suicide and euthanasia are never morally acceptable options.1 If I should become irreversibly and terminally ill, I request to be fully informed of my condition so that I can prepare myself spiritually for death and witness to my belief in Christ’s redemption.

Designation of Health Care Surrogate In the event that I become incapacitated, I designate as my surrogate for health care decisions (if no surrogate is to be appointed, please write “none” in place of “name” below):

Name:_________________________________________________________________

Address:_______________________________________________________________

Phones (H, W, C):________________________________________________________

If my surrogate is unwilling or unable to perform his or her duties or cannot be contacted, I wish to designate as my alternate surrogate (if no alternate surrogate is to be appointed, please write “none” in place of “name” below):

Name:_________________________________________________________________

Address:_______________________________________________________________

Phones (H, W, C):________________________________________________________

This directive will permit my surrogate to make health care decisions, and to provide, withhold, or withdraw consent on my behalf; to apply for public benefits to defray the cost of health care; to receive my personal health care information; and to authorize my admission to or transfer from a health care facility. My surrogate is further appointed as my “Personal Representative.”2 This directive is not being made as a condition of treatment or admission to a health care facility. This document must be signed and witnessed on the other side to be valid.

1 Cf United States Conference of Catholic Bishops, Ethical & Religious Directives for Catholic Health Care Services (USCCB: Washington,

DC 2009), Part Five. 2 As defined by 45 CFR 164.502(g), for purposes of compliance with Federal HIPAA Laws and Regulations (the Health Insurance Portability

and Accountability Act of 1996).

Living Will The following gives guidance for carrying out my wishes at the end of life. If at any time I am incapacitated and I have a terminal condition or I have an end-stage condition, and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition(s), my health care surrogate (designated above, if any) will be authorized to make decisions for me in accordance with my wishes expressed in this Declaration. If my surrogate cannot be contacted (or I have not named a surrogate), then I request and direct that each of the following be considered in making a decision for me.

That:

1. I be provided care and comfort, and that my pain be relieved.

2. No inappropriate, excessively burdensome nor disproportionate means be used to prolong my life. This can include medical or surgical procedures.

3. There should be a presumption in favor of providing nutrition and hydration to me, including medically assisted nutrition and hydration, unless:

 They cannot reasonably be expected to prolong my life; or

 The means used to deliver the nutrition and hydration are excessively burdensome and do not offer sufficient benefit or would cause me significant physical discomfort; or

 I am imminently dying from an irreversible condition.

4. Nothing be done with the intention of causing my death.

5. Spiritual care be provided, including sacraments whenever possible. Additional Instructions

_______________________________________________________________________________________

_______________________________________________________________________________________

Signatures Required It is my intention that my surrogate, family and physicians honor this declaration as the expression of my treatment wishes. I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.

__________________________________________ _______________________________________

DECLARANT Date

Last 4 Social Security Number: ____________

__________________________________________ _______________________________________

Witness Signature Witness Signature

__________________________________________ _______________________________________

Printed/Typed Name Printed/Typed Name The Health Care Surrogate cannot serve as a witness; at least one witness must not be a spouse or blood relative of the person signing. December 7, 2015

Copies of this form are available from the Florida Catholic Conference, 201 West Park Avenue, Tallahassee, FL 32301-7760 www.flaccb.org

END OF LIFE

CONSENT

ADVANCE DIRECTIVES

POWER OF ATTORNEY

DO NOT RESUSCITATE

POLST

MOLST

CONSENT

• FREE AND INFORMED (ERD 28, 27, 26, 59)

28. Each person or the person’s surrogate should have access to medical and moral information and counseling so as to be able to form his or her conscience. The free and informed health care decision of the person or the person’s surrogate is to be followed so long as it does not contradict Catholic principles.

CONSENT

• FREE AND INFORMED (ERD 28, 27, 26, 59)

27. Free and informed consent requires that the person or the person’s surrogate receive all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all.

CONSENT

• FREE AND INFORMED (ERD 28, 27, 26, 59)

26. The free and informed consent of the person or the person’s surrogate is required for medical treatments and procedures, except in an emergency situation when consent cannot be obtained and there is no indication that the patient would refuse consent to the treatment.

CONSENT

• FREE AND INFORMED (ERD 28, 27, 26, 59)

59. The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.

CONSENT

• PROXY (ERD 25, 24)

25. Each person may identify in advance a representative to make health care decisions as his or her surrogate in the event that the person loses the capacity to make health care decisions. Decisions by the designated surrogate should be faithful to Catholic moral principles and to the person’s intentions and values, or if the person’s intentions are unknown, to the person’s best interests. In the event that an advance directive is not executed, those who are in a position to know best the patient’s wishes—usually family members and loved ones—should participate in the treatment decisions for the person who has lost the capacity to make health care decisions.

CONSENT

• PROXY (ERD 25, 24)

24. In compliance with federal law, a Catholic health care institution will make available to patients information about their rights, under the laws of their state, to make an advance directive for their medical treatment. The institution, however, will not honor an advance directive that is contrary to Catholic teaching. If the advance directive conflicts with Catholic teaching, an explanation should be provided as to why the directive cannot be honored.

PROXY CONSENT (LEGAL):

Process by which people with the legal right to consent to medical treatment for themselves or for a minor or a ward delegate that right to another person.

3 fundamental constraints:

1. Person making the delegation must have the right to consent.

2. Person must be legally and medically competent to delegate the right to consent.

3. Right to consent must be delegated to a legally and medically competent adult.

ADVANCE DIRECTIVES

• Written instructions

• Regarding medical care preferences

• When unable to make one’s own health care decisions

• Guide for one’s family and doctors

• Can help reduce confusion or disagreement

• Generally legally binding

Advance directives include:

• Living will

• Medical or health care power of attorney (POA)

• Do not resuscitate (DNR) order

LIVING WILL

Florida Conference of Catholic Bishops (https://flaccb.org/)

CATHOLIC DECLARATION ON LIFE AND DEATH, BOTH:

• ADVANCE DIRECTIVE

• HEALTH SURROGATE DESIGNATION

https://www.flacathconf.org/declaration-on-life-and-death

POWER OF ATTORNEY (POA)

Medical or health care power of attorney (POA). The medical POA is a legal document that designates an individual — referred to as your health care agent or proxy — to make medical decisions for you in the event that you're unable to do so.

Related Tags