A Nebraska advance directive is a form used to designate a person to make healthcare-related decisions for another person. This can be used if the principal, also known as the declarant, lapses into a vegetative state or develops an incurable and irreversible condition that, without the administration of life-sustaining treatment, will cause death within a relatively short time. The document is used to give decision-making authority to a trusted individual in the unfortunate chance of serious injury or illness.
Statutory Form
POWER OF ATTORNEY FOR HEALTH CARE
I appoint [NAME], whose address is [ADDRESS, STREET, CITY, STATE, ZIP CODE], and whose telephone number is [PHONE NUMBER], as my attorney in fact for health care. I appoint [NAME], whose address is [ADDRESS, STREET, CITY, STATE, ZIP CODE], and whose telephone number is [PHONE NUMBER], as my successor attorney in fact for health care. I authorize my attorney in fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions. I have read the warning which accompanies this document and understand the consequences of executing a power of attorney for health care.
I direct that my attorney in fact comply with the following instructions or limitations:
[INSTRUCTIONS OR LIMITATIONS]
I direct that my attorney in fact comply with the following instructions on life-sustaining treatment (optional):
[INSTRUCTIONS]
I direct that my attorney in fact comply with the following instructions on artificially administered nutrition and hydration (optional):
[INSTRUCTIONS]
I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY ATTORNEY IN FACT, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN.
Signature of person making designation/date:
____________________________________________ [DAY] day of [MONTH], 20[XX]
DECLARATION OF WITNESSES
We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care in our presence, that the principal appears to be of sound mind and not under duress or undue influence, and that neither of us nor the principal’s attending physician is the person appointed as attorney in fact by this document.
Witnessed By:
Signature of Witness/Date: _____________________ [DAY] day of [MONTH], 20[XX]
Printed Name of Witness: [NAME]
Signature of Witness/Date: _____________________ [DAY] day of [MONTH], 20[XX]
Printed Name of Witness: [NAME]
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