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A Time for Listening and CaringSpirituality and the Care of the Chronically Ill and
Dying$

Christina M. Puchalski

Print publication date: 2006

Print ISBN-13: 9780195146820

Published to Oxford Scholarship Online: November 2011

DOI: 10.1093/acprof:oso/9780195146820.001.0001

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(p.393) C Protestant Advance Directives

(p.393) C Protestant Advance Directives

Source:
A Time for Listening and Caring
Publisher:
Oxford University Press

The following were compiled by Dr. Denise Reeves, physician and member of the Vestry of Grace Episcopal Church, Muncie, Indiana, which was one of my parishes. The documents are examples only. It is necessary to check what is important in your state or province.

Document I

LIVING WILL DECLARATION

Declaration made this ___ day of_____, 200__

I,________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare:

If at any time my attending physician certifies in writing that:

  1. (1) I have an incurable injury, disease, or illness;

  2. (2) my death will occur within a short time; and

  3. (3) the use of life-prolonging procedures would serve only to artificially prolong the dying process, I direct that they be withheld or withdrawn and that I be permitted to die naturally, with only the performance or provision of any medical procedure or medication necessary to provide me with comfort, care or to alleviate pain, and, if I have so indicated below, the provision of artificially supplied nutrition and hydration. (Indicate your choice by initialing or making your mark before signing this declaration):

    I wish to receive artificially supplied nutrition and hydration, even if the effort to sustain life is futile or excessively burdensome to me.

I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustain life is futile or excessively burdensome to me.

(p.394) I intentionally make no decision concerning artificially supplied nutrition and hydration, leaving the decision to my healthcare representative, appointed under IC16–36–1–7, or my attorney in fact with healthcare providers, under IC 30–5–5.

____________________________________

WITNESS:

___________________________________

Date:

___________________________________

Document 2

GENERAL DURABLE POWER OF ATTORNEY

I,_______________, now residing at ______________________, by this instrument, do hereby make, constitute, and appoint the person or persons hereinafter named as my true and lawful Attorney-in-fact, for me and in my name, place and stead to do any lawful act for me as provided in this instrument.

THIS Power of Attorney SHALL NOT BE AFFECTED BY MY SUBSEQUENT INCOMPETENCY DISABILITY OR INCAPACITY OR BY LAPSE OF TIME.

I HEREBY REVOKE all other general powers of attorney that I may have executed, if any.

1. When Effective.

My Attorney-in-fact shall not exercise this Power of Attorney until a physician familiar with my condition states in writing to my Attorney-in-fact that I am unable to manage my affairs. My Agent shall be free from any liability for any action taken under this Power of Attorney in reliance upon the physician's statement. My Attorney-in fact shall stop using this Power of Attorney when a physician familiar with my condition states in writing to my Attorney-in-fact that I am unable to manage my affairs

(p.395) 2. Attorney(s)-In-Fact.

As my Attorney-in-fact, I name ____________, whose address is ___________.

  1. (A) limited liability. My Attorney-in-fact shall be liable only for willful default, gross misconduct, or fraud, and not for errors of judgment. My Attorney-in-fact shall have the power to bind me or my property without binding my Attorney-in-fact personally. A Successor Attorney-in-fact shall have no duty to inquire into the acts of any prior Attorney-in-fact and shall not be liable for any act or omission of any prior Attorney-in-fact.

  2. (B) Resignation. Any person serving as my Attorney-in-fact may resign by delivering a written resignation in such person or persons remaining as my Attorney-in-fact, or, if none, to me.

  3. (C) Successor. If my original Attorney-in-fact fails, or ceases to act as my Attorney-in fact, I appoint as my Successor Attorney-in-fact, ________, whose address is

3. ACCOUNTING.Upon termination of this Power of Attorney, or if my Attorney-in-fact fails or ceases to act, my Attorney-in-fact, or the legal representative for my Attorney-in-fact, or his/her estate, or my Attorney-in-fact's beneficiaries or heirs, shall account, within thirty (30)days after termination of the date when my Attorney in- fact fails or ceases to act, to me, to my immediate Successor Attorney-in-fact, to my legal representative, to my estate or to the beneficiaries or heirs of my estate, for all money and property that come into the possession of my Attorney-in-fact.

4. POWERS. I give to my Attorney-in-fact, or any Successor Attorney-in-fact, the powers and authority as follows:

  1. (A) Real Property. General authority with respect to real property transactions pursuant to LC. 30–5–5–2, including the power with respect to any interests in property that I may own in joint tenancy with right of survivorship to sever the joint tenancy, or remove the property from joint ownership, and retitle my interest therein in my individual name.

  2. (B) Tangible Personal Property. General authority with respect to tangible personal property pursuant to LC. 30–5–5–3, including the power with respect to any interests in property that I may own in joint tenancy with right of survivorship to sever the joint tenancy, or remove the property from joint ownership, and retitle my interest therein in my individual name.

  3. (p.396) (c) Bond, Share, and commodity. General authority with respect to bond, share, and commodity transactions pursuant to I.C. 30–5–5–4, including the power to purchase u.s. Bonds, redeemable at par for the payment of U.S. Estate Taxes, and to borrow money to make such purchases.

  4. (D) Banking. General authority with respect to banking transactions pursuant to I.C. 30–5–5–5.

  5. (E) Business. General authority with respect to banking transactions pursuant to I.C. 30–5–5–6.

  6. (F) Insurance. General authority with respect to business transactions pursuant to I.C. 30–5–5–7 provied that references in I.C. 30–5–5–7(a) 2) and (3)to “section 8” are changed to “section g.”

  7. (G) Beneficiary. General authority with respect to beneficiary transactions pursuant to I.C. 30–5–5–8.

  8. (H) Gifts. General authority with respect to gift transactions pursuant to I.C. 30–5–5–9.

  9. (I) fiduciary. General authority with respect to fiduciary transactions pursuant to I.C. 30–5–5–10.

  10. (J) claims and Litigation. General authority with respect to claims and litigation pursuant to I.C. 30–5–5–11.

  11. (K) Family Maintenance. General authority with respect to family maintenance pursuant to I.C. 30–5–5–12.

  12. (L) Military Service. General authority with respect to benefits from military service pursuant to I.C. 30–5–5–13.

  13. (M) Records, Reports, and Statements. General authority with respect to records, reports, and statements pursuant to I.C. 30–5–5–14,including the power to execute on my behalf any specific Power of Attorney required by any taxing authority to allow my Attorney-in-fact to act on my behalf before that taxing authority on any return on issue.

  14. (N) Estate Transactions. General authority with respect to estate transactions pursuant to I.C. 30–5–5–15.

  15. (O) Healthcare. General authority with respect to healthcare pursuant to I.C. 30–5–516, including authority to act as my Healthcare Representative for me in all matters of healthcare in accordance with my Appointment of a Healthcare Representative as provided in I.C. 16–8–12 and I.C. 30–5–5–17.

  16. (p.397) (p) Living will. I have executed a living Will Declaration.

  17. (Q) Delegate. General authority with respect to delegating authority pursuant to I.C. 30–5–5–18.

  18. (R) All Other Matters. General authority with respect to all other matters pursuant to I.C. 30–5–5–19.

PROVIDED, however, my Attorney-in-fact shall not have any power or authority which would cause my Attorney-in-fact to be treated as the owner of any interest in my property and which would cause that property to be taxed as owned by my Attorney-in-fact.

5. THIRD PARTY RELIANCE. Each person, partnership, corporation, or other legal entity relying or acting upon this Power of Attorney shall be entitled to presume conclusively that this Power of Attorney is in full force and effect unless written notice is given by me or my legal representatives that this power is no longer effective, revoked, or terminated. If this power is effective only upon a certificate by a physician stating that I am unable to manage my affairs, those relying upon this instrument shall be fully protected in assuming that such a certificate has been delivered to my Attorney-in-fact.

  1. (A) Copy. I have only executed a limited number of original powers. Any person, partnership, corporation, or other legal entity may rely on a photocopy of this power, if the photocopy is accompanied by a timely affidavit of the Attorney-in-fact stating that the photocopy is a true and accurate copy of the power and that the power has not been terminated as to the date of the affidavit.

  2. (B) Application of Proceeds. No person, partnership, corporation, or other legal entity relying on this Power of Attorney shall be required to see the application and disposition of any property either paid to or delivered to my Attorney-in-fact, or distributed in accordance with the instructions of my Attorney-in-fact.

6.APPOINTMENT OF GUARDIAN. In the event that a court of competent jurisdiction should determine that I am an incapacitated person, and that it is necessary to appoint a conservator, or guardian of my person or estate, or both, then, and in such event, I nominate and appoint ________, as such conservator, or guardian of my person or estate, or both, as the case may be.

7.TERMINATION. This Power of Attorney shall continue in effect until terminated as provided below, regardless of my physical or mental condition.

(p.398) (A) Revocation. I may revoke this Power of Attorney by delivering a written revocation to my Attorney-in-fact, executed in the same manner as the original Power of Attorney. This written revocation shall not be effective until actually received by my Attorney-in-fact, who shall not be liable for any action taken prior to the receipt of the written revocation. My Attorney-in-fact may, in good faith, challenge the revocation in court if there is reason to believe that I am an incapacitated person. If my Attorney-in-fact challenges the revocation, then this Power of Attorney shall be ineffective until the court orders that my attempted revocation does not legally revoke the Power of Attorney.

8. APPLICABLE LAW. This instrument shall be governed in all respects by the laws of the State of Indiana.

EXECUTED THIS _______ DAY OF ______, 200 _____.

_____________________________

_____________________________

Taxpayer Identification Number

STATE OFINDIANA

ss:

DELAWARE COUNTY

Before me, a Notary Public in and for said County and State, personally appeared, _____________,who acknowledged the execution of the foregoing General Durable Power of Attorney, and who, having been duly sworn, stated that any representations therein contained are true.

WITNESS my hand and Notarial Seal this __ day of _____ 200____.

______________________

My Commission Expires:

(p.399) Document 3

APPOINTMENT OFHEALTHCARE REPRESENTATIVE

1,_________________, now residing at ________________________,by this instrument do hereby constitute, appoint, and designate _______________________ whose address is ______________________, as my Healthcare Representative. In the even _________________________ fails or refuses for any reason to act as my Healthcare Representative, then, and in such event, I constitute, appoint, and designate __________________,whose address is _____________, as my Successor Healthcare Representative.

My Healthcare Representative, whether the original, a delegate, or successor, shall have full power and authority to make all healthcare decisions for me relating to my personal healthcare. Byway of illustration, and not intending any limitation, I specifically grant my representative the following powers:

  1. (A) Employment. The power to employ servants, companions, nurses, or doctors to care for me.

  2. (B) Admission. The power to admit me to, or release me from, any hospital or healthcare facility.

  3. (C) Consent. The power to consent, on my behalf, to any treatment, physical or psychiatric, or surgical procedure for any injury or disease from which I may be suffering.

  4. (D) Access Records. The power to have access to any records, including medical records, concerning my condition.

  5. (E) Release. The power to execute any releases, or other documents, which may be required in order to obtain medical information.

  6. (F) Disclosure. The power to disclose such of my medical information as may be deemed necessary by my Healthcare Representative.

  7. (G) Waiver. The power to execute such waiver or release from liability as may be required by a healthcare provider.

  8. (H) Healthcare Consent. The power, as my Healthcare Representative, to act for me in matters of healthcare in accordance with I.C.16–36–1–7, including the authorization to delegate all or part of this authority to any eligible individual who has not been disqualified as provided in said statute.

  9. (p.400) (I) Stop Healthcare. I authorize my Healthcare Representative to make decisions in my best interest concerning withdrawal or withholding of healthcare. If at anytime, based on my previously expressed preferences and the diagnosis and prognosis, my Healthcare Representative is satisfied that certain healthcare is not or would not be beneficial, or that such healthcare is or would be excessively burdensome, then my Healthcare Representative may express my will that such healthcare be withheld or withdrawn and may consent on my behalf that any or all healthcare be discontinued or so instituted, even if death may result.

  10. (J) Consultations. My Healthcare Representative must try to discuss this decision with me. However, if I am unable to communicate, my Healthcare Representative may make such a decision for me, after consultation with my physician or physicians and other relevant healthcare givers. To the extent appropriate, my Healthcare Representative may also discuss this decision with my family and others, to the extent they are available.

Prior Appointments. I hereby revoke any prior appointment or designation of a Healthcare Representative to act in matters of my healthcare.

Reliance. For the purposes of inducing any individual, organization, or entity to act in accordance with instructions of my Healthcare Representative who is authorized in this document, I hereby represent, warrant, and agree that:

  1. (A) No person who relies in good faith upon the authority of my Healthcare Representative under this document shall incur any liability to me, my estate, my heirs, successors, or assigns.

  2. (B) If this document is revoked or amended for any reason. I, my estate, my heirs, successors, and assigns will hold any person harmless for any loss suffered, or liability incurred as a result of such person acting in good faith upon the instructions of my Healthcare Representative prior to the receipt by such person of actual notice of revocation or amendment.

  3. (C) Reimbursement of costs. My Healthcare Representative shall be entitled to reimbursement for all reasonable costs and expenses actually incurred and paid by my Healthcare Representative on my behalf under any provision of this document but will not be entitled to compensation for services rendered hereunder.

DATED THIS______________DAY of _______________,200______.

___________________________________________ (p.401) is personally known to me and I believe her or him to be of sound mind. I am not a Healthcare Representative appointed by this document. I am competent and at least eighteen (18) years of age.

DATED THIS DAY__________ OF ____________v, 200_____,

____________________________________ Witness

STATE OFINDIANA

SS:

DELAWARE COUNTY

Before me, a Notary Public in and for said County and State, personally appeared _______, who acknowledged the execution of the foregoing Appointment of Healthcare Representative, and who, having been duly sworn, stated that any representations therein contained are true.

EXECUTED at Muncie, Indiana, this ___________ day of _____________, 200 ____

_____________________

Document 4

Funeral Preplanning Checklist

To be used as a guide and aid for my family upon my death. Please notify the church as soon as possible after death.

FULL NAME

____________________________________

ADDRESS

____________________________________

_________________________________

I have a Last Will, and Testament and it has been filed with:

_____________________________

(p.402) 1. Disposition of the Body

__Whole Body Burial

__Cremation

__Donation of body to medical research. Forms have been filed with:

______________________________

2. Pre-Funeral Preferences

My funeral wishes are on file with:

____Grace Episcopal Church

____Funeral Home _

and they are: ____ Prepaid ___ Not Prepaid

____Family Member

Other:

________________

Mortician

____Body to lie in state at the funeral home

____ Casket open

____Casket open to family, then closed

Casket closed

Casket

___Wood

___Cloth-covered wood

___Metal

Participation in Organ Donor Program

____My signed Uniform Donor Card can be found at:

____________________

___None

(p.403) Autopsy

___If it is helpful for research or needs of my survivors

___Decision to be made by:

___None, unless vital to medical research or required by law

3. Funeral Preferences

location of service:

____Grace Episcopal Church

Other: ________

Type of Resurrection liturgy

___Burial Office with Eucharist using:

Rite I

Rite II

___Burial Office only

Rite I

Rite II

Music

____ Organ and Hymn singing

___Hymns to be sung

___Other hymns of praise and faith

Hymn numbers from 1982 Hymnal:

_____________________________

________________________

___Organ only

____Other instruments, soloists, duet, etc.

(p.404) Scripture Readings (See Book of Common Prayer p. 470, 475, 480 or 494–495)

old Testament (Name of Reader optional)

____________________________v

Psalm (Name of Reader optional)

_________________________v

Epistle (Name of Reader optional)

_____________

Gospel

______________________

Homily (Name of Priest optional)

_________________________

Personal Tribute (Name optional)

___________________________

Additional Ceremonies

___Incense

___Asperges (Holy Water)

Suggested Pallbearers (minimum of 6:you may have honorary pallbearers)

___My family will arrange for pallbearers.

The following should be included:

Other:

Ushers:

The Parish Hall is available for fellowship and/or reception following the service.

4. Interment

Burial location:

___________________________________

____Cremation

(p.405) Committal Liturgy

For whole body burial

__At graveside, with family and friends, if possible

__Lowering of casket into ground at the words of committal

For interment after cremation

__Place to be arranged between family and priest

5. Additional Requests

If there is a choice and depending on circumstances, I would prefer to die:

____At home or present residence

_____In the hospital or nursing home

I request that no extraordinary means be used to keep me alive

_____If family, priest, and doctor agree, please remove my support equipment

I understand that I may change these requests at any time, by notifying those who are holding copies.

I authorize the person(s) named here to make any necessary changes in the above requests, in accordance with their best judgment and the circumstances which exist at the time of my death:

_____________________________________

______________________________________

_____________________________________

Other requests or instructions:

SIGNED:

______________________

Date:

_________________

WITNESS:

______________________

Date:

________________________ (p.406)