DURABLE POWER OF ATTORNEY State of Florida County of ___

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 an d
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
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
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
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/declar ation-on-life-and-death
https://flaccb.org/

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.
• DURABLE POA: EVEN WHEN PERSON IS MENTALLY
INCAPACITATED
• RECORD IT IN THE COUNTY COURT
Do not resuscitate (DNR) order
Request to not have cardiopulmonary resuscitation
(CPR) if your heart stops or if you stop breathing.
Advance directives do not have to include a DNR order,
and you don't have to have an advance directive to have
a DNR order.
Your doctor can put a DNR order in your medical chart.
PHYSICIAN ORDERS for LIFE-SUSTAINING TREATMENTS
(POLST)

MEDICAL ORDERS for LIFE-SUSTAINING TREATMENTS
(MOLST)
END OF LIFE��CONSENT��ADVANCE
DIRECTIVES��POWER OF ATTORNEY��DO NOT
RESUSCITATE��POLST��MOLSTSlide Number 2Slide
Number 3Slide Number 4Slide Number 5Slide Number 6Slide
Number 7Slide Number 8Slide Number 9Slide Number 10Slide
Number 11Slide Number 12Slide Number 13Slide Number 14

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:
be expected to prolong my life; or
excessively burdensome and do not
offer sufficient benefit or would cause me significant physical
discomfort; or
e 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
http://www.flaccb.org/
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)
vickerykd

Text Box
Important!
In order to be legally valid this form MUST be printed on
yellow paper prior to being completed. EMS and medical
personnel are only required to honor the form if it is printed on
yellow paper.
This box will not show up when the form is printed.

DURABLE POWER OF ATTORNEY State of Florida County of ___

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