Instructions for Using the Durable Power of Attorney (DP A) 
With Clinical Center Patients 
1. The DPA is a document which provides in advance for the appointment of a 
surrogate decision-maker for a Clinical Center (CC) patient. In the event that the 
patient becomes cognitively impaired, the surrogate will have the right to be 
consulted and make decisions about the continued course of research and clinical care 
at the CC. 
2. The physician responsible for completing the appropriate informed consent process 
shall, also, be responsible for completing the DPA, with the help of those who assist 
in the admission and access of new patients to protocols. 
3. This DPA form is to be used with patients who are in danger of becoming impaired 
during their care at the CC, and who are capable of understanding the meaning of 
appointing a surrogate decision-maker. If the patient is too impaired to understand 
the DPA, consultation with the CC Bioethicist or designate is required before 
appointment of a surrogate. This DPA form is not to be used in cases of serious 
impairment. Refer to the Medical Administrative Series Publication #87-4, “Consent 
Process in Research Involving Impaired Human Subjects,” or call the Bioethics 
Program office for assistance (496-2429). 
4. Before asking the patient to appoint another person to hold a DPA, the physician 
should: 
a) be assured that the patient understands the meaning of a DPA; 
b) be assured that the patient appoints someone of his/her choice; and 
c) be assured that the person to receive the DPA is willing to do so and knows the 
responsibilities involved when the patient becomes too impaired to act in his/her 
own interests; i.e., if the surrogate is in another location when consent is needed, 
the consent documents must be read, understood and signed before consent is 
valid. 
i 
5. The DPA form has an original and 4 copies. The original should be entered in the 
Medical Record, after it is signed and witnessed. Copies should be given to (1) the 
person who is appointed to hold the DPA, (2) Institute Clinical Director, (3) Chair, 
ICRS, and (4) CC Bioethicist. v . 
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