, a person of the full age of majority and a resident of the Parish of, State of Louisiana, and residing at

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1 SPECIAL LIMITED MEDICAL POWER OF ATTORNEY BY: TO: STATE OF LOUISIANA PARISH OF CITY OF BEFORE ME, the undersigned Notary Public, duly commissioned and qualified in and for the State of Louisiana, and in the presence of the undersigned competent witnesses, PERSONALLY CAME AND APPEARED:, a person of the full age of majority and a resident of the Parish of, State of Louisiana, and residing at (hereinafter referred to as the PRINCIPAL ), who declared that PRINCIPAL hereby names, deputes, constitutes, and appoints:, a person of the full age of majority and a resident of the Parish of, State of Louisiana, and residing at (hereinafter Agent or ), to be PRINCIPAL S AGENT and ATTORNEY-IN-FACT (the AGENT ) with full and complete authority to make any applicable decisions concerning any medical care on PRINCIPAL S behalf, including the right to give consent to or approval for the performance of any type of medical procedure or examination, including but not limited to medication of any type, surgical procedures, medical examinations, or physical or psychological therapy, despite any contrary feelings, beliefs, or opinions of other members of PRINCIPAL S family, relatives, friends, or curator, AGENT having sole and absolute discretion to exercise the powers granted herein relating to matters involving PRINCIPAL S health and medical care. In exercising such powers, AGENT should first try to discuss with PRINCIPAL the specifics of any proposed decision regarding PRINCIPAL S medical care and treatment if PRINCIPAL is able to communicate in any manner, however rudimentary. AGENT is further instructed that if PRINCIPAL is unable to give an informed consent to a proposed medical treatment, AGENT should give, withhold, withdraw, or modify such consent for PRINCIPAL based upon any treatment choices that PRINCIPAL expressed while competent, whether under this document or otherwise. If AGENT cannot determine the treatment choice PRINCIPAL would want made under the circumstances, if PRINCIPAL were Page 1 of 5

2 able to express himself/herself, then AGENT should make such choice based upon what AGENT believes to be in PRINCIPAL S best interests, being guided by any information given to AGENT by PRINCIPAL S treating physicians as to PRINCIPAL S medical diagnosis and prognosis, and the intrusiveness, pain, risks, and side effects associated with the treatment. Accordingly, without limiting the generality of the foregoing, AGENT S health care powers shall include the following powers: (1) The AGENT is authorized to give consent to and authorize or refuse, or to withhold or withdraw consent to, any and all types of medical care, treatment, tests, or procedures relating to the physical or mental health of the PRINCIPAL, including any medication program, surgical procedures, life-sustaining treatment, or provision of nourishment and hydration (including for example, all forms of intravenous and parenteral feeding, all forms of tube feeding and misting) for the PRINCIPAL, including but not limited to consent to and arrangement for the administration of pain-relieving drugs of any kind and/or other surgical or medical procedures calculated to relieve PRINCIPAL S pain, including unconventional pain-relief therapies which AGENT believes may be helpful, even though such drugs or procedures may have adverse side effects, may cause addiction, or may hasten the moment of (but not intentionally cause) PRINCIPAL S death, and to exercise PRINCIPAL S right of privacy and right to make decisions regarding PRINCIPAL S medical treatment even though the exercise of PRINCIPAL S rights might hasten the moment of death or be against conventional medical advice. (2) The AGENT is authorized to admit the PRINCIPAL to or discharge the PRINCIPAL from any and all types of hospitals, institutions, homes, residential or nursing facilities, hospice or home care, treatment centers, and other health care institutions providing personal care or treatment for any type of physical or mental condition of PRINCIPAL, and to summon paramedics or other emergency medical personnel and seek emergency treatment for PRINCIPAL. (3) The AGENT is authorized to contract for any and all types of health care services and facilities in the name of and on behalf of the PRINCIPAL and to employ and discharge medical personnel including physicians, psychiatrists, dentists, nurses, and therapists as AGENT shall deem necessary, and to provide for such companionship for PRINCIPAL as will meet PRINCIPAL S needs and preferences, and to bind the PRINCIPAL to pay for all such services and facilities; and the AGENT shall not be personally liable for any services or care contracted for on behalf of the PRINCIPAL. (4) At the PRINCIPAL S expense and subject to reasonable rules of the health care provider to prevent disruption of the PRINCIPAL S health care, the AGENT shall have the same right the PRINCIPAL has to request, receive, review, and examine and copy and consent to disclosure of all the PRINCIPAL S medical records, and any Page 2 of 5

3 written or verbal information that the AGENT deems relevant to the exercise of the AGENT S powers, whether the records relate to mental health or any other medical condition and whether they are in the possession of or maintained by any physician, psychiatrist, psychologist, therapist, hospital, nursing home, or other health care provider. (5) The AGENT is authorized to grant, in conjunction with any instructions given herein, releases to hospital staff, physicians, nurses, and other medical and hospital administrative personnel who act in reliance on instructions given by AGENT, or who render written opinions to AGENT in connection with any matter described herein, from all liability for damages suffered or to be suffered by PRINCIPAL, and to sign documents purporting to be a Refusal to Treatment and Leaving Hospital Against Medical Advice as well as any necessary waivers of or releases from liability required by a hospital or physician to implement PRINCIPAL S wishes regarding medical treatment or non-treatment. (6) The AGENT shall be entitled to reimbursement for all reasonable costs and expenses actually incurred and paid by AGENT on PRINCIPAL S behalf under any provision hereunder, but AGENT shall not be entitled to compensation for services rendered hereunder. (7) The AGENT is authorized to seek on PRINCIPAL S behalf and at PRINCIPAL S expense: (a) a declaratory judgment from any court of competent jurisdiction interpreting the validity of this document or any of the acts authorized by this document, but such declaratory judgment shall not be necessary in order for the AGENT to perform any act authorized by this document; or (b) a mandatory injunction requiring compliance with the AGENT S instructions by any person obligated to comply with instructions given by the AGENT; or (c) actual and punitive damages against any person obligated to comply with instructions given by the AGENT who negligently or willfully fails or refuses to follow such instructions. To further guide AGENT in exercising the health care powers described hereinabove, and without limiting any such powers, PRINCIPAL does hereby express the following: (8) If PRINCIPAL is in a coma, or any permanent vegetative state, and in the opinion of PRINCIPAL S physicians and several consultants there is no known hope of PRINCIPAL regaining awareness and higher mental functions, no matter what is done, Page 3 of 5

4 or if PRINCIPAL is in a coma and has a small likelihood of recovering fully or of surviving without permanent brain damage, or if PRINCIPAL has suffered brain damage or some brain disease which cannot be reversed and which makes PRINCIPAL unable to recognize people or to speak understandably, whether or not PRINCIPAL has any other terminal and incurable illness, it is PRINCIPAL S wish that all further medical care, diagnostic tests, mechanical breathing, artificial nutrition, or hydration be withheld. However it is PRINCIPAL S wish that under such circumstances, pain medications be administered even if they dull PRINCIPAL S consciousness and/or indirectly shorten PRINCIPAL S life. This Special Limited Medical Power of Attorney shall be effective immediately and shall not be affected by PRINCIPAL S subsequent incapacity or disability. If is not available and willing to make a health care decision for PRINCIPAL, then PRINCIPAL designates PRINCIPAL S,, to serve as alternate to the AGENT named above. PRINCIPAL hereby revokes any powers of attorney for health care previously granted by him, and he hereby retains the right to revoke or amend this document and to substitute other agents. Amendments to this document shall be made in writing personally by PRINCIPAL and shall be attached to the original of this document. No person who relies in good faith upon the authority of the AGENT under this document shall incur any liability to PRINCIPAL, his estate, heirs, successors, or assigns. Additionally, no person who relies in good faith upon any oral or written representation that the AGENT may make as to (a) the fact that this document and the AGENT S powers are then in effect, (b) the scope of the AGENT S authority granted under this document, (c) PRINCIPAL S competency at the time this document is executed, (d) the fact that this document has not been revoked, or (e) the fact that PRINCIPAL is alive and that the AGENT continues to serve as such shall incur any liability to PRINCIPAL, his estate, heirs, successors, or assigns for permitting the AGENT to exercise any such authority. Page 4 of 5

5 THUS DONE AND PASSED, in multiple originals, on the day of, 20, at the City and State aforesaid, and in the presence of the undersigned competent witnesses, who hereunto sign their names with the said PRINCIPAL and me, Notary, after due reading of the whole. WITNESSES: Print Name: Principal: Print Name: NOTARY NAME: NOTARY NUMBER: Page 5 of 5