AB 414 — Revises provisions governing powers of attorney. (BDR 13-797)

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“Nursing home” means a “nursing facility” as facility” as defined in 42 U.S.C.

§ 1396r(a),1395i–3(a), as amended,amended.rsing orSecs. “skilled nursing facility” as defined in 42 U.S.C.

§20-35. 1395i–3(a), as amended.

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You can also use this form to state your wishes, preferences and goals for health care, and to say if you want to be an organ donor after you die.

and to say if you want to be an YOUR NAME AND DATE OF BIRTH Name:.....................................................................

- 82nd Session (2023) – 3 – PART 1:

- *AB414_R1* – 4 – Optional contact information (It is helpful to include information such as the person’s address, phone number and email address.):

6 (2) NAMING AN ALTERNATE AGENT:

I want the following person to make health care decisions for me if I cannotavailable andto mymake agentthem isfor notme:ling, willing, able or reasonably availableName:..................................................................... to make them for me:

Name:.....................................................................

(1)- INSTRUCTIONS82nd Session (2023) – 4 – TREATMENTUCTIONS ABOUT LIFE-SUSTAINING TREATMENT This section gives you the opportunity to say how you want your agent to act while making decisions for you.

- *AB414_R1* – 5 – (__) Always be given to me.

(__) NotNfrom be given to me if I have a medical condition from which I am not expected to recover thatthation prevents me from communicating with people I care about, caring for myself and recognizing family and friends.

(__) NotNfrom be given to me if I have a medical condition from which I am not expected to recover thatthation prevents me from communicating with people I care about, caring for myself and recognizing family and friends.

If- I82nd amSession in(2023) significant– pain,5 care– that will keep me comfortable but is likely to shorten my life should (mark all that apply):

- *AB414_R1* – 6 – (2) INSTRUCTION ABOUT PRIORITIES 3 You can use this section to indicate what is important to you, and what is not important to you.

8 You may mark or initial each item.

(__) very important (__) somewhat important (__) not important Stayingmental alivelimitations asis:as long as possible even if I have substantial mental(__) limitationsvery important (__) somewhat important (__) not important Being free from significant pain is:

(__) very important (__) somewhat important (__) not important Being- free82nd fromSession significant(2023) pain– 6 – Bei(__) very important (__) somewhat important (__) not important Having my agent talk with my family before making decisions about my care is:

(__) very important (__) somewhat important (__) not important Being independent is:

(__) very important (__) somewhat important (__) not important Having my agent talk with my family before making decisions about my care is:

(__) very important (__) somewhat important (__) not important - *AB414_R1* – 7 – (3) OTHER INSTRUCTIONS 3 You can use this section to provide any other information about your goals, values and preferences for treatment, including care you want or do not want.

9 PART 3:

(__) Admit me as a voluntary patient to a facility for mental health treatment for up to 7 days, 14 days or 30 days (circle one).

(If- I82nd doSession not(2023) mark– or7 initial– this, my agent MAY NOT admit me as a voluntary patient to this type of facility.) (__) Place me in a nursing home for more than 100 days even if my needs can be met somewhere else, I am not terminally ill and I object.

(__) IIshare give my agent permission to obtain, examine and share information about my health needs ande and health care whenever he or she thinks it will help me.

- *AB414_R1* – 8 – (3) GUIDANCE FOR MY AGENT 3 The instructions I have stated in this document should guide my agent in making decisions for me (initial or mark one of the below items to tell your agent more about how to use these instructions):

8 (__) I give my agent permission to be flexible in applying these instructions if he or she thinks it would be in my best interest based on what they know about me.

- 82nd Session (2023) – 8 – Filling this out does NOT mean you want or need a guardian right now.

- *AB414_R1* – 9 – (__) I donate my organs, tissues and other body parts, except for those listed below (list any body parts you do not want to donate):.......................................

7 Organs, tissues or body parts that I donate may be used for:

- 82nd Session (2023) – 9 – Today’s date:..........................................................

(Only sign as a witness if you think that the person signing above is doing it voluntarily.) - *AB414_R1* – 10 – PART 6:

INFORMATION FOR AGENTS 3 (1) If this form names you as an agent, you can make decisions about health care for the person who named you when they cannot make their own.

7 (2) If you make a decision for the person, follow any instructions the person gave, including any in this form.

You - 82nd Session (2023) – 10 – should also consider any behaviors or communications from the person that indicate what they currently want.

(4) If this form names you as an agent, you can also get andthe person has said so in this form, you can only get ors share this information when the individual’sperson cannot make their own decisions about their health information.care.

ButSecs. unless the person has said so in this form, you can only get or share this information when the person cannot make their own decisions about their health care.

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(a)(b) AcknowledgedWitnessed beforeby atwo notaryadult public;witnesses .

or (b) Witnessed by two adult witnesses .

- 82nd Session (2023) – 11 – 5.

If the principal resides in a hospital, residential facility for groups, facility for skilled nursing or home for individual residential care, at the time of the execution of the power of attorney, a certification of competency of the principal from an advanced practicemust registeredbe nurse,attached ato physician,the psychologistpower of attorney.ychologist or psychiatrist must6.] beA attachedpower toof attorney executed in a jurisdiction outside of this State is valid in this State if, when the power of attorney.attorney was executed, the execution complied with the laws of that jurisdiction or the requirements for a military power of attorney pursuant to 10 U.S.C.

6.] A power of attorney executed in a jurisdiction outside of this State is valid in this State if, when the power of attorney was executed, the execution complied with the laws of that jurisdiction or the requirements for a military power of attorney pursuant to 10 U.S.C.

- *AB414_R1* – 12 – (a) “Facility for skilled nursing” has the meaning ascribed to it in NRS 449.0039.

(d) “Residential facility for groups” has the meaning ascribed to it in NRS 449.017.] Sec.Secs.

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The administrative officer of a public or private mental health facility or hospital shall ensure that, within 24 hours of the emergency admission of a person alleged to be a person in a mental health crisis who is at least 18 years of age, the person is asked to give permission to provide notice of the emergency admission to a family member, friend or other person identified by the2.ersIf a person alleged to be a person in a mental health crisis who is at least 18 years of age gives permission to notify a family member, friend or other person of the person.emergency admission, the administrative officer shall ensure that:

2.

If a person alleged to be a person in a mental health crisis who is at least 18 years of age gives permission to notify a family member, friend or other person of the emergency admission, the administrative officer shall ensure that:

Except as otherwise provided in subsections 4 and 5, if a person alleged to be a person in a mental health crisis who is at least 18 years of age does not give permission to notify a family member, friend or other person of the emergency admission of the person, notice of the emergency admission must not be provided until permission is obtained.

4.- 82nd Session (2023) – 12 – who is at least 18 years of age is not able to give or refuse crisis permission to notify a family member, friend or other person of the emergency admission, the administrative officer of the mental health facility or hospital may cause notice as described in paragraph (b) of subsection 2 to be provided if the administrative officer determines that it is in the best interest of the person in a mental health crisis.

If a person alleged to be a person in a mental health crisis who is at least 18 years of age is not able to give or refuse permission to notify a family member, friend or other person of the emergency admission, the administrative officer of the mental health facility or hospital may cause notice as described in paragraph (b) of subsection 2 to be provided if the administrative officer determines that it is in the best interest of the person in a mental health crisis.

If a guardian has been appointed for a person alleged to be a person in a mental health crisis who is at least 18 years of age or the person has executed a durable power of attorney for health care pursuant to NRS 162A.700 to 162A.870, inclusive, and sections 3 to 56, inclusive, of this act or appointed an attorney-in-fact using an - *AB414_R1* – 13 – advance directive for psychiatric care pursuant to NRS 449A.600 to 449A.645, inclusive, the administrative officer of the mental health facility or hospital must ensure that the guardian, agent designated by the durable power of attorney or the attorney-in-fact, as applicable, is promptly notified of the admission as described in paragraph (b) of subsection 2, regardless of whether the person alleged to be a person in a mental health crisis has given permission to the notification.

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449A.545 “Representative of the patient” means a legal guardian of the patient, a person designated by the patient to make decisions governing the withholding or withdrawal of life-sustaining treatment pursuant to NRS 449A.433 or a person given power ofoftaining attorney to make decisions concerning health care for the patient pursuant to NRS 162A.700 to 162A.870, inclusive [.] , and sections 3 to 56, inclusive, of this act.

- 82nd Session (2023) – 13 – NOTICE TO PERSON MAKING AN ADVANCE DIRECTIVE FOR PSYCHIATRIC CARE THIS IS AN IMPORTANT LEGAL DOCUMENT.

IT CREATESPSYCHIATRICANCARE.VABEFORE ANDISIGNING ADVANCETHIS DIRECTIVEDOCUMENT FORYOU PSYCHIATRICSHOULD CARE.KNOW THESE IMPORTANT FACTS:

BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS:

THE INSTRUCTIONS YOU INCLUDE IN THIS ADVANCE DIRECTIVE WILL BE - *AB414_R1* – 14 – FOLLOWED IF TWO PROVIDERS OF HEALTH CARE, ONE OF WHOM MUST BE A PHYSICIAN OR LICENSED PSYCHOLOGIST AND THE OTHER OF WHOM MUST BE A PHYSICIAN, A PHYSICIAN ASSISTANT, A LICENSED PSYCHOLOGIST, A PSYCHIATRIST OR AN ADVANCED PRACTICE REGISTERED NURSE WHO HAS THE PSYCHIATRIC TRAINING AND EXPERIENCE PRESCRIBED BY THE STATE BOARD OF NURSING PURSUANT TO NRS 632.120, DETERMINES THAT YOU ARE INCAPABLE OF MAKING OR COMMUNICATING TREATMENT DECISIONS.

YOUR INSTRUCTIONS MAY BE OVERRIDDEN IF YOU ARE BEING HELD IN ACCORDANCEEXECUTING WITHA CIVILDURABLE COMMITMENTPOWER LAW.OF ATTORNEY FOR HEALTH CARE AS SET FORTH IN NRS 162A.700 TO 162A.870, INCLUSIVE, AND SECTIONS 3 TO 56, INCLUSIVE, OF THIS ACT, YOU MAY ALSO APPOINT A PERSON AS YOUR AGENT TO MAKE TREATMENT DECISIONS FOR YOU IF YOU BECOME INCAPABLE.

BY EXECUTING A DURABLE POWER OF ATTORNEY FOR HEALTH CARE AS SET FORTH IN NRS 162A.700 TO 162A.870, INCLUSIVE, AND SECTIONS 3 TO 56, INCLUSIVE, OF THIS ACT, YOU MAY ALSO APPOINT A PERSON AS YOUR AGENT TO MAKE TREATMENT DECISIONS FOR YOU IF YOU BECOME INCAPABLE.

YOU MAY NOT REVOKE THIS ADVANCE DIRECTIVE WHEN YOU ARE FOUND INCAPABLE BY TWO PROVIDERS OF HEALTH CARE, ONE OF WHOM MUST BE A PHYSICIAN OR LICENSED PSYCHOLOGIST AND THE - 82nd Session (2023) – 14 – OTHER OF WHOM MUST BE A PHYSICIAN, A PHYSICIAN ASSISTANT, A LICENSED PSYCHOLOGIST, A PSYCHIATRIST OR AN ADVANCED PRACTICE REGISTERED NURSE WHO HAS THE PSYCHIATRIC TRAINING AND EXPERIENCE PRESCRIBED BY THE STATE BOARD OF NURSINGNURSINGNCE PURSUANT TO NRS 632.120.

TO BE VALID, THIS ADVANCE DIRECTIVE MUST BE SIGNED BY TWO QUALIFIED WITNESSES, PERSONALLY KNOWN TO YOU, WHO ARE PRESENT - *AB414_R1* – 15 – WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE.

5 NOTICE TO PHYSICIAN OR OTHER PROVIDER OF HEALTH CARE 8 Under Nevada law, a person may use this advance directive to provide consent or refuse to consent to future psychiatric care if the person later becomes incapable of making or communicating those decisions.

By executing a durable power of attorney for health care as set forth in NRS 162A.700 to 162A.870, inclusive, and sections 3 to 56, inclusive, of this act, the person may also appoint an agent to make decisions regarding psychiatric care for the personpersongent to when incapable.

If a person is determined to be incapable, the person may be found capable when, in the opinion of the person’s attending physician or an advanced practice registered nurse who has the psychiatric training and experience prescribed by the State Board of Nursing- pursuant82nd toSession NRS(2023) 632.120– and15 has– an established relationship with the person, the person has regainedregainedd sufficient understanding or capacity to make or communicate decisions regarding psychiatric care.

The physician or other provider shall promptly notify the principal and, if applicable, the agent of the principal, and document in the principal’s medical record any act or omission that is not in compliance with any part of - *AB414_R1* – 16 – an advance directive.

A physician or other provider may rely upon the authority of a signed, witnessed, dated and notarized advance directive.

5of a signed, witnessed, dated and notarized ADVANCE DIRECTIVE FOR PSYCHIATRIC CARE 7 I, .............................., being an adult of sound mind or an emancipated minor, willfully and voluntarily make this advance directive for psychiatric care to be followed if it is determined by two providers of health care, one of whom must be my attending physician or a licensed psychologist and the other of whom must be a physician, a physician assistant, a licensed psychologist, a psychiatrist or an advanced practice registered nurse who has the psychiatric training and experience prescribed by the State Board of Nursing pursuant to NRS 632.120, that my ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that I lack the capacity to refuse or consent to psychiatric care.

I understand thatthatacity psychiatric care may not be administered without my express and informed consent or, if I am incapable of giving my informed consent, the express and informed consent of my legally responsible person, my agent named pursuant to a valid durable power of attorney for health care or my consent expressed in this advance directive for psychiatric care.

I understand that I may become incapable of giving or withholding informed consent or refusal for psychiatric care due- to82nd theSession (2023) – 16 – symptoms ofmay include:f a diagnosed mental disorder.

These symptoms.................................................................................................. may include:

..................................................................................................

- *AB414_R1* – 17 – Conditions or limitations:

4 ADMISSION TO AND RETENTION IN FACILITY 6 If I become incapable of giving or withholding informed consent for psychiatric care, my instructions regarding admission to and retention in a medical facility for psychiatric care are as follows:

[...................] This advance directive cannot, by law, provide consent to retainany, meprovided in athis facilityadvance beyonddirective.fic the specific number of days, if any,Conditions providedor inlimitations: this advance directive.

Conditions or limitations:

- 82nd Session (2023) – 17 – 1.

Work Telephone Number:

...........................................

- *AB414_R1* – 18 – The following may cause me to experience a mental health crisis:

...I give permission for the following person or people to........................................

visit me:

I give permission for the following person or people to visit me:

..................................................................................................

[...................] - 82nd Session (2023) – 18 – SHARING OF INFORMATION BY PROVIDERS I understand that the information in this document may be shared by my provider of mental health care with any other provider who may serve me when necessary to provide treatment in accordance with this advance directive.

................................................................................................

Signature of Principal Date - *AB414_R1* – 19 – AFFIRMATION OF WITNESSES 3 We affirm that the principal is personally known to us, that the principal signed or acknowledged the principal’s signature on this advance directive for psychiatric care in our presence, that the principal appears to be of sound mind and not under duress, fraud, or undue influence, and that neither of us is:

WitnessedWitWitness: by:

Witness:.....................................................

.................................................

......................................................................................................

Signature Date [STATE OF NEVADA COUNTY OF......................................] - 82nd Session (2023) – 19 – CERTIFICATION OF NOTARY PUBLIC STATE OF NEVADA COUNTY OF.......................................

I further certify that .....................and..............................and...

(2) not the owner or operator, or employee of the owner or operator, of a - *AB414_R1* – 20 – medical facility in which the principal is a patient or resident;

.................................................................................Notary Public........................................

Notary Public My Commission expires:

and - 82nd Session (2023) – 20 – 5.

The provisions of NRS 449A.700 to 449A.739, inclusive, do not require a provider of health care to inquire whether a patient has an advance directive registered on the Registry or totoher access the Registry to determine the terms of the advance directive.

(Deleted by amendment.) - *AB414_R1* – 21 – Sec.

A qualified patient may apply to the health authority for a do-not-resuscitate identification by submitting an application on a form provided by the health authority.

(b) Certification by the patient’s attending physician or attending advanced practice registered nurse that the patient is capable- of82nd makingSession an(2023) informed– decision21 or,– when the patient was capable of making an informed decision, that the patient:patient:nt was (1) Executed:

(1) Executed:

(d) The name, signature and telephone number of the patient’s attending physician or attending advanced practice registered nurse;

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73.73-76.

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75.

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76.

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An individual who assumed authority to act as a default surrogate beforeuntil Januarythe 1,individual 2024,for maywhom continuethe todefault actsurrogate asislt a default acting no longer lacks capacity or the default surrogate iste is disqualified, whichever occurs first.

- 82nd Session (2023) – 22 – Sec.

TEXT~~~~~ OF23 REPEALED- SECTION82nd 162A.860Session Power(2023) of attorney:

Form.

Except as otherwise provided in NRS 162A.865 and 162A.870, the form of a power of and must be witnessed or executed in the same manner as theing form, following form:

DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS WARNING TO PERSON EXECUTING THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT.

IT CREATES A DURABLE POWER OF ATTORNEY FOR HEALTH CARE.

BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:

1.

THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR AGENT THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU.

THIS POWER IS - *AB414_R1* – 23 – YOUR DESIRES THAT YOU INCLUDE IN THISNT OF DOCUMENT.

THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE CONSENT, REFUSAL OF CONSENT OR WITHDRAWAL OF CONSENT TO ANY CARE, TREATMENT, SERVICE OR PROCEDURE TO MAINTAIN, DIAGNOSE OR TREAT A PHYSICAL OR MENTAL CONDITION.

YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT OR PLACEMENTS THAT YOU DO NOT DESIRE.

2.

THE PERSON YOU DESIGNATE IN THIS DOCUMENT HAS A DUTY TO ACT CONSISTENT WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN OR, IF YOUR DESIRES ARE UNKNOWN, TO ACT IN YOUR BEST INTERESTS.

DOCUMENT, THE POWER OF THE PERSON YOUIN THIS DESIGNATE TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE THE POWER TO CONSENT TO YOUR DOCTOR OR ADVANCED PRACTICE REGISTERED NURSE NOT GIVING TREATMENT OR STOPPING TREATMENT WHICH WOULD KEEP YOU ALIVE.

4.UNLESS YOU SPECIFY A SHORTER PERIOD IN THIS DOCUMENT, THIS POWER WILL EXIST INDEFINITELY FROM THE DATE YOU EXECUTE THIS DOCUMENT AND, IF YOU ARE UNABLE TO MAKE HEALTH CARE DECISIONS FOR YOURSELF, THIS POWER WILL CONTINUE TO EXIST UNTIL THE TIME WHEN YOU BECOME ABLE TO MAKE HEALTH CARE DECISIONS FOR YOURSELF.

HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF SO LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION.

IN ADDITION, NO TREATMENT MAY BE GIVEN TO YOU OVER YOUR OBJECTION, AND HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY NOT BE STOPPED IF YOU OBJECT.

6.YOU HAVE THE RIGHT TO DECIDE WHERE YOU LIVE, EVEN AS YOU AGE.

DECISIONS ABOUT WHERE YOU LIVE ARE PERSONAL.

SOME PEOPLE - *AB414_R1* – 24 – LIVE AT HOME WITH SUPPORT, WHILE OTHERS MOVE TO ASSISTED LIVING FACILITIES OR FACILITIES FOR SKILLED NURSING.

IN SOME CASES, PEOPLE ARE MOVED TO FACILITIES WITH LOCKED DISORDERS FROM LEAVING OR GETTING LOST OR TO PROVIDE ASSISTANCE TO PEOPLE WHO REQUIRE A HIGHER LEVEL OF CARE.

YOU SHOULD DISCUSS WITH THE PERSON DESIGNATED IN THIS DOCUMENT YOUR DESIRES ABOUT WHERE YOU LIVE AS YOU AGE OR IF YOUR HEALTH DECLINES.

YOU HAVE THE RIGHT TO DETERMINE WHETHER TO AUTHORIZE THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE DECISIONS FOR YOU ABOUT WHERE YOU LIVE WHEN YOU ARE NO LONGER CAPABLE OF MAKING THAT DECISION.

IF YOU DO NOT PROVIDE SUCH AUTHORIZATION TO THE PERSON DESIGNATED IN THIS DOCUMENT, THAT PERSON MAY NOT BE ABLE TO ASSIST YOU TO MOVE TO A MORE SUPPORTIVE LIVING ARRANGEMENT WITHOUT OBTAINING APPROVAL THROUGH A JUDICIAL PROCESS.

7.

YOU HAVE THE RIGHT TO REVOKE THE APPOINTMENT OF THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THAT PERSON OF THE REVOCATION ORALLY OR IN WRITING.

AUTHORITYHAVEGRANTEDGHT TO RETHEE TPERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THE TREATING PHYSICIAN, ADVANCED PRACTICE REGISTERED NURSE, HOSPITAL OR OTHER PROVIDER OF HEALTH CARE ORALLY OR IN WRITING.

9.

THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT.

10.

THIS DOCUMENT REVOKES ANY PRIOR DURABLE POWER OF ATTORNEY FOR HEALTH CARE.

- *AB414_R1* – 25 – THAT YOU DO NOT UNDERSTAND, YOU SHOULDOCUMENT ASK A LAWYER TO EXPLAIN IT TO YOU.

12.

YOU MAY REQUEST THAT THE NEVADA SECRETARY OF STATE ELECTRONICALLY STORE WITH THE NEVADA LOCKBOX A COPY OF THIS DOCUMENT TO ALLOW ACCESS BY AN AUTHORIZED PROVIDER OF HEALTH CARE AS DEFINED IN NRS 629.031.

1.

DESIGNATION OF HEALTH CARE AGENT.

I, ........................................................................................

(insert your name) do hereby designate and appoint:

Name:

...........................................................................

Address:

.......................................................................

Telephone Number:

.....................................................

as my agent to make health care decisions for me as authorized in this document.

(Insert the name and address of the person you wish to designate as your agent to make health care decisions for you.

Unless the person is also your spouse, legal guardian or the person most closely related to you by blood, none of the following may be designated as your agent:

(1) your treating provider of health care;

(2) an employee of your treating provider of health care;

(3) an operator of a health care facility;

or (4) an employee of an operator of a health care facility.) 2.

CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE.

By this document I intend to create a durable power of attorney by appointing the person designated above to make be affected by my subsequent incapacity.

of attorney shall not 3.

GENERAL STATEMENT OF AUTHORITY GRANTED.

In the event that I am incapable of giving informed consent with respect to health care decisions, I hereby grant to the agent named above full power and authority:

to make health care decisions for me before or after my death, including consent, refusal of consent or withdrawal of consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition;

to request, review and receive any information, verbal or - *AB414_R1* – 26 – written, regarding my physical or mental health, including, without limitation, medical and hospital records;

to execute on my behalf any releases or other documents that may be required to obtain medical care and/or medical and hospital records, EXCEPT any power to enter into any arbitration agreements or execute any arbitration clauses in connection with admission to any health care facility including any skilled nursing facility;

and subject only to the limitations and special provisions, if any, set forth in paragraph 4 or 6.

4.

SPECIAL PROVISIONS AND LIMITATIONS.

(Your agent is not permitted to consent to any of the treatment facility, convulsive treatment, psychosurgery, sterilization or abortion.

If there are any other types of treatment or placement that you do not want your agent’s authority to give consent for or other restrictions you wish to place on his or her agent’s authority, you should list them in the space below.

If you do not write any limitations, your agent will have the broad powers to make health care decisions on your behalf which are set forth in paragraph 3, except to the extent that there are limits provided by law.) In exercising the authority under this durable power of attorney for health care, the authority of my agent is subject to the following special provisions and limitations:

..................................................................................................

..................................................................................................

..................................................................................................

5.

DURATION.

I understand that this power of attorney will exist indefinitely from the date I execute this document unless I establish a shorter time.

If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent will continue to exist until the time when I become able to make health care decisions for myself.

(IF APPLICABLE) I wish to have this power of attorney end on the following date:

..............................................................

6.

STATEMENT OF DESIRES CONCERNING TREATMENT.

- *AB414_R1* – 27 – sustaining treatment, your agent must make health carelife- decisions that are consistent with your known desires.

You can, but are not required to, indicate your desires below.

If your desires are unknown, your agent has the duty to act in your best interests;

and, under some circumstances, a judicial proceeding may be necessary so that a court can determine the health care decision that is in your best interests.

If you wish to indicate your desires, you may INITIAL the statement or statements that reflect your desires and/or write your own statements in the space below.) (If the statement reflects your desires, initial the box next to the statement.) prolonged to the greatest extent possible, without regard to my condition, the chances I have for recovery or long-term survival, or the cost of the procedures.

[...................] B.

If I am in a coma which my doctors or advanced practice registered nurses have reasonably concluded is irreversible, I desire that life-sustaining or prolonging treatments not be used.

[...................] C.

If I have an incurable or terminal condition or illness and no reasonable hope of long-term recovery or survival, I desire that life-sustaining or prolonging treatments not be used.

[...................] D.

Withholding or withdrawal of resultciin ndeathion byd hstarvationayor dehydration.

I want to receive or continue receiving artificial nutrition and hydration by way of the gastrointestinal tract after all other treatment is withheld.

[...................] E.

I do not desire treatment to be provided and/or continued if the burdens of the treatment outweigh the expected benefits.

My agent is to consider the relief of suffering, the preservation or - *AB414_R1* – 28 – quality as well as the extent of the possible extension of my life.

[...................] F.

If I have an incurable or terminal condition, including late stage dementia, or illness and no reasonable hope of long-term recovery or survival, I desire my attending physician to administer any medication to alleviate suffering without regard that the medication is likely to cause addiction or reduce the extension of my life.

[...................] (If you wish to change your answer, you may do so by drawing an “X” through the answer you do not want, and circling the answer you prefer.) Other or Additional Statements of Desires:

..................................................................................................

..................................................................................................

..................................................................................................

..................................................................................................

7.

STATEMENT OF DESIRES CONCERNING LIVING ARRANGEMENTS A.

I desire to live in my home as long as it is safe and my medical needs can be met.

My agent may arrange for a natural person, employee of an agency or provider of community-based services to come into my home to provide care for me.

When it is no longer safe for me to live in my home, I facility or home that can provide any medical assistance and support in my activities of daily living that I require.

Before being placed in such a facility or home, I wish for my agent to discuss and share information concerning the placement with me.

[...................] B.

I desire to live in my home for as long as possible without regard for my medical needs, personal safety or ability to engage in activities of daily - *AB414_R1* – 29 – living.

My agent may arrange for a natural person, an employee of an agency or a provider of community- based services to come into my home and provide care for me.

I understand that, before I may be placed in a facility or home other than the home in which I currently reside, a guardian must be appointed for me.

[...................] (If you wish to change your answer, you may do so by circling the answer you prefer.)r you do not want, and Other or Additional Statements of Desires:

........................

..................................................................................................

..................................................................................................

..................................................................................................

..................................................................................................

8.

DESIGNATION OF ALTERNATE AGENT.

(You are not required to designate any alternative agent but you may do so.

Any alternative agent you designate will be able to make the same health care decisions as the agent designated in paragraph 1, page 2, in the event that he or she designated in paragraph 1 is your spouse, his or herf the agent designation as your agent is automatically revoked by law if your marriage is dissolved.) If the person designated in paragraph 1 as my agent is unable to make health care decisions for me, then I designate the following persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below:

A.

First Alternative Agent Name:

..................................................................

Address:

..............................................................

Telephone Number:

............................................

B.

Second Alternative Agent Name:

..................................................................

Address:

..............................................................

Telephone Number:

............................................

9.

PRIOR DESIGNATIONS REVOKED.

- *AB414_R1* – 30 – I revoke any prior durable power of attorney for health care.

10.

WAIVER OF CONFLICT OF INTEREST.

If my designated agent is my spouse or is one of my children, then I waive any conflict of interest in carrying out the provisions of this Durable Power of Attorney for Health Care that said spouse or child may have by reason of the fact that he or she may be a beneficiary of my estate.

11.

CHALLENGES.

If the legality of any provision of this Durable Power of Attorney for Health Care is questioned by my physician, my then my agent is authorized to commence an action forrd party, declaratory judgment as to the legality of the provision in question.

The cost of any such action is to be paid from my estate.

This Durable Power of Attorney for Health Care must be construed and interpreted in accordance with the laws of the State of Nevada.

12.

NOMINATION OF GUARDIAN.

If, after execution of this Durable Power of Attorney for Health Care, proceedings seeking an adjudication of incapacity are initiated either for my estate or my person, I hereby nominate as my guardian or conservator for consideration by the court my agent herein named, in the orde13.amRELEASE OF INFORMATION.

I agree to, authorize and allow full release of information by any government agency, medical provider, business, creditor or third party who may have information pertaining to my health care, to my agent named herein, pursuant to the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, as amended, and applicable regulations.

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY) I sign my name to this Durable Power of Attorney for (city), .........................

(state).............................

................................................

(Signature) (THIS POWER OF ATTORNEY WILL NOT BE VALID FOR MAKING HEALTH CARE DECISIONS UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO QUALIFIED - *AB414_R1* – 31 – WITNESSES WHO ARE PERSONALLY KNOWN TO YOU AND WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.) CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC (You may use acknowledgment before a notary public instead of the statement of witnesses.) State of Nevada }ss.

County of...................................} On this................

day of................, in the year..., before me,................................

(here insert name of notary public) personally appeared................................

(here insert name of principal) personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it.

NOTARY SEAL ................................................

(Signature of Notary Public) STATEMENT OF WITNESSES (You should carefully read and follow this witnessing procedure.

This document will not be valid unless you comply with the witnessing procedure.

If you elect to use witnesses instead of having this document notarized, you must use two qualified adult witnesses.

None of the following may be used as a witness:

(1) a person you designate as the agent;

(2) a provider of health care;

(3) an employee of a provider of health care;

(4) the operator of a health care facility;

or (5) an employee of an operator of a health care additional declaration set out following the place where the witnesses sign.) I declare under penalty of perjury that the principal is personally known to me, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person - *AB414_R1* – 32 – appointed as agent by this document and that I am not a provider of health care, an employee of a provider of health care, the operator of a health care facility or an employee of an operator of a health care facility.

Signature:

......................

Residence Address:

...................

Print Name:

.......................................................................

Date:

.............................................................................

Signature:

......................

Residence Address:

...................

Print Name:

.......................................................................

Date:

.............................................................................

(AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.) I declare under penalty of perjury that I am not related to the principal by blood, marriage or adoption and that to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

Signature:

....................................

Signature:

....................................

------------------------------------------------------------------------------ Names:

............................

Address:.......................................

Print Name:

.......................................................................

Date:

.............................................................................

COPIES:

You should retain an executed copy of this document and give one to your agent.

The power of attorney should be available so a copy may be given to your providers of health care.

This includes requesting the Nevada Secretary of State to electronically store this document with the Nevada Lockbox to allow access by authorized providers of healthcare.

H - *AB414_R1*