Covid-19 - Butcher Elder Law

We are here to help our clients at this critical time, that’s why we are offering to complete a complimentary Healthcare Power of Attorney and/or Living Will for anyone in need. Please complete the short contact form below, and someone from our office will be in touch with you. CLICK HERE to learn more about how Butcher Elder Law is responding to the COVID-19 pandemic in Northeast Ohio.

Healthcare Power of Attorney Living Will

Please answer the questions on this form to help us prepare your Healthcare Power of Attorney and Living Will. All information you provide will be kept in strict confidence.

Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Primary Healthcare Agent*
We encourage our clients first to choose agents who will follow their wishes even if their wishes do not align with the agent’s philosophy or wishes for the principal, and, next, to discuss their wishes with their agents beyond just terminal illness and permanent unconsciousness so that the agents know how their principals feel about certain healthcare measure as the principals grow older and face the need for other interventions. If you could not make your own healthcare decisions, even if just temporarily, who would you trust to make those decisions for you? Please provide their full legal name:
Relationship*
Address & Phone of your Primary Healthcare Agent*
Please list the full address and phone number for your Primary Healthcare Agent, the person you designated above.
First Alternative Healthcare Agent*
If the person you designate predeceased you or was otherwise unable to act in the capacity as your healthcare agent, who would be the backup? Please provide their full legal name below.
Relationship*
Address & Phone of Altnernative Healthcare Agent*
Please list the full address and phone number for your Primary Healthcare Agent, the person you designated above.
Would you like to name a second Alternate Healthcare Agent?*
- Yes
- No
Second Alternative Healthcare Agent
List the name of your second alternative healthcare agent (optional):
Relationship
Address & Phone of Second Altnernative Healthcare Agent
Please list the full address and phone number for your Primary Healthcare Agent, the person you designated above.
Guardian of Estate*
Are the agents the same as noted above for healthcare?
- Yes - Please ignore the next two questions
- No - Please answer the next two questions
If No:
Please list the full legal name of your Guardian below:
Address & Phone of your Guardian
Please list the full address and phone number for your Guardian, the person you designated above.
Do you wish to be an organ donor?*
- Yes
- No
If yes, you must also complete Donor Registry Enrollment. You would have completed this if you are designated as an organ donor on your drivers license.
About Living Wills*
A Living Will (sometimes also referred to as an advance directive) considers two end-of-life situations; one in which you are terminally ill, and one in which you are permanently unconscious. Terminal illness is defined as a condition that is irreversible, incurable, and untreatable. Permanent unconsciousness is defined as a condition in which you are irreversibly unaware of yourself and your surroundings and you have a total loss of cerebral cortical functioning so that you can’t even feel pain. The decision as to whether you are terminally ill or permanently unconscious is a decision that has to be made by your attending physician and at least one other physician who has examined you, and to a reasonable degree of medical certainty in accordance with reasonable medical standards. By executing a Living Will, you are instructing your healthcare providers that if you are terminally ill or permanently unconscious, you do not want life sustaining treatment, you want it withdrawn if it has been started, and you want to be allowed to die naturally and provided only that care that relieves your pain and makes you comfortable but does not postpone your death. Life sustaining treatment is also defined as treatment, including artificially or technologically supplied nutrition and hydration, that serves mainly to prolong the process of dying. Before a physician can act to withhold or withdraw life sustaining treatment, he or she must first make a good faith effort and use reasonable diligence to notify at least one of the individuals named as one of your healthcare agents.
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