Hearing Date and Time: __________________
Virginia: Special Justice of City / County of _________________________________
Re ______________________________________, Patient
Order Authorizing Medical Treatment For Incapacitated Adult
The attached Petition to Authorize Medical Treatment For Incapacitated Adult was presented today before the undersigned Special Justice, who appointed the undersigned attorney at law to represent Patient in the proceeding.
The Court having duly considered the Petition and the medical evidence adduced in support thereof, finds on the basis of clear and convincing evidence that due notice of the proceeding has been given pursuant to Virginia Code § 37.1-134.21 (C), (E), and (F); that there is no legally authorized person available to consent to the treatment described in the Petition for which consent is sought; that the Patient is incapable of making an informed decision regarding the medical treatment or course of treatment described in the Petition, or is incapable of communicating such decision, and is unlikely to become capable of making an informed decision or of communicating an informed decision within the time required for decision; and that, having taken into consideration the right of the Patient to rely on non-medical and remedial treatment in the practice of religion, that the proposed treatment or course of treatment set forth in the Petition is in the best interest of the Patient. It is accordingly
ORDERED that (A) the health care providers named in the Petition, including when applicable the Petitioner, are and each is authorized to perform upon the person of the Patient the proposed treatment as described in the Petition, together with all examinations, tests, or services as are reasonably related to the treatment, and (B) the treating physician shall report to the court and the undersigned attorney for the Patient (1) any change in the condition of the Patient resulting in probable restoration or development of capacity to make and to communicate an informed decision prior to completion of the authorized treatment and related services, and (2) to report to the court and the attorney for the Patient any change in circumstances regarding the authorized treatment or related services which may indicate that such authorization is no longer in the best interest of the Patient.
This Order may be appealed de novo within ten days of entry to the circuit court for the jurisdiction where the order was entered, and any such order of a circuit court on appeal, may be appealed within ten days to the Virginia Court of Appeals.
Ordered this ______________________, at __________ a.m. / p.m.
___________________________, Special Justice
Seen ( [ ] and objected to):
___________________________, Attorney for Patient
___________________________, Petitioner
(Complete in quadruplicate)
Prepared and Copyrighted,2003, by R. Shawn Majette, VSB 19372