Documents

Both documents are from (Section 7B) Schedule 3 National Health Act 61 Of 2003 of South Africa

Guideline For A Durable Power Of Attorney For Health Care (Section 7A)

 I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (full name), in granting this Durable Power of Attorney for Health Care, wish to confirm that I

• am 18 years or older;
• am of sound mind;
• act of my own free will, free from duress induced by others; and
• have carefully considered my own values, beliefs and preferences, as well as misfortunes of body and/or mind that may befall me.

Hence, should I, as a result of illness, injury or any other trauma, at a future date, develop any condition as a consequence of which I lack the requisite competence to have or communicate any rational preferences regarding my future health care,

I wish to appoint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (full name) as my agent (proxy) health care decision-maker, mandating him/her to act as my substitute for any and all of my health care and medical decisions, and instructing any person or institution to act on the directives of this duly appointed health care agent.

Should my first choice as health care agent be unable to assume this responsibility,

I wish to appoint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (full name) as my alternative agent (proxy) health care decision-maker, mandating him/her to act as my substitute for any and all of my health care and medical decisions, and instructing any person or institution to act on the directives of this duly appointed health care agent.

I understand that this Durable Power of Attorney for Health Care mandates my health care agent to make health care and medical decisions on my behalf for the duration of my biological life, thus enduring while I am no longer competent to revoke it. Should I, however, regain the requisite competence, I understand that I would have the authority to revoke this health care mandate.

In making health care and medical decisions on my behalf, my health care agent should give due recognition to my known values, beliefs, principles and personal preferences. Should it be impossible or difficult to know the practical implications of these considerations in particular circumstances, my health care agent should act in my objectively determined best interest.

In particular, I authorise my health care agent (proxy) decision-maker to make any and all of my health care and medical decisions on my behalf, that is, any and all decisions I would have made while still competent. In this mandate to my health care agent decision-maker,

I specifically include decision-making directives that would be routinely included in a Living Will, that is, directives relating to refraining from life-sustaining medication, treatment or procedures that would otherwise prolong life, thus impeding a natural death. [This clause may be excluded.]

In addition, I mandate my health care agent to make decisions on my behalf regarding the donation of my organs or tissue for any legitimate medical or scientific purpose. [This clause may be excluded.] [The grantor/maker of a Durable Power of Attorney for Health Care is free to issue specific instructions or directives to his/her health care agent about any medical intervention that the grantor/maker chooses to include in or exclude from the mandate.

WITNESS 1 to the signing of this Durable Power of Attorney for Health Care I declare that I have witnessed the signing of this Durable Power of Attorney for Health Care by (i) its grantor/maker and (ii) witness 2.

WITNESS 2 to the signing of this Durable Power of Attorney for Health Care I declare that I have witnessed the signing of this Durable Power of Attorney for Health Care by (i) its grantor/maker and (ii) witness 1.