As Amended
SEC. 41-41-163. Form of durable power of attorney; required notice.
The durable power of attorney shall contain substantially the following notice:
"NOTICE TO PERSON EXECUTING THIS DOCUMENT
This is an important legal document. Before executing this document, you should know these important facts:
This document gives the person you designate as the attorney in fact (your agent) the power to make health care decisions for you. This power exists only as to those health care decisions to which you are unable to give informed consent. The attorney in fact must act consistently with your desires as stated in this document or otherwise made known.
Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.
Notwithstanding this document, you 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 or withheld if you object at the time.
The document gives your agent authority to consent, to refuse to consent or to withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition. This power is subject to any statement of your desires and any limitations that you include in this document. You may state in this document any types of treatment that you do not desire.
In addition, a court can take away the power of your agent to make health care decisions for you if your agent (a) authorizes anything that is illegal, (b) acts contrary to your known desires, or (c) where your desires are not known, does anything that is clearly contrary to your best interests.
You have the right to revoke the authority of your agent by notifying your agent or your treating doctor, hospital or other health care provider in writing of the revocation.
Your agent has the right to examine your medical records and to consent to this disclosure unless you limit this right in this document.
Unless you otherwise specify in this document, this document gives your agent the power after you die to (a) authorize an autopsy, (b) donate your body or parts thereof for transplant or for educational, therapeutic or scientific purposes, and (c) direct the disposition of your remains.
If there is anything in this document that you do not understand, you should ask your lawyer to explain it to you.
This power of attorney will not be valid for making health care decisions unless it is either (a) signed by two (2) qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature or (b) acknowledged before a notary public in the state."
The durable power of attorney itself may be substantially the following form, and if so, shall be sufficient to satisfy all requirements of law:
"DURABLE POWER OF ATTORNEY FOR HEALTH CARE
I, (name), hereby appoint:
_______________________________________________________________ _______
Name
_______________________________________________________________
Home Address
_____________________ ________________________
Work Telephone Number Home Telephone Number
as my attorney in fact to make health care decisions for me in the
event I become unable to give informed consent with respect to a given
health care decision.
Subject to my special instructions below, this document gives my
attorney in fact the full power to make health care decisions for me,
before or after my death, to the same extent I could make decisions for
myself and to the full extent permitted by law, including power to grant,
refuse or withdraw consent on my behalf for any health care service, to
make a disposition under the state's anatomical gift act, to authorize
an autopsy, and to direct the disposition of remains. Ny attorney in fact
also has the authority to talk to health care personnel, get information
and sign forms necessary to carry out these decisions, and also the power
provided in Sections 41-41-101 through 41-41-121, Mississippi Code of 1972,
as now enacted or hereafter amended, being the statutes governing the
withdrawal of life-saving mechanisms.
Special instructions: _______________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
If the person named as my attorney in fact is not available or is
unable to act as my attorney in fact, I appoint the following person to
serve in his or her place:
___________________________________________________________________
Name
___________________________________________________________________
Home Address
_____________________ __________________________
Work Telephone Number Home Telephone Number
By my signature I do hereby indicate that I understand the purpose
and effect of this document.
__________________________
SIGNATURE
DATE: ____________________
SOURCES: Laws, 1990, ch. 571, Sec. 7; 1993, ch. 394, Sec. 1, eff from and after July 1, 1993.