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F. Sample Letters

 

FIGURE 6.1 Sample Living Will/Health Proxy

 

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I, (name of individual), currently residing at (address), being of sound mind and health, hereby make known my directions to my family, friends, all physicians, hospitals and other health-care providers and any Court or Judge:

After thoughtful consideration, I have decided to forgo all life-sustaining treatment if I shall sustain substantial and irreversible loss of mental capacity and my attending physician is of the opinion that I am unable to eat and drink without medical assistance and it is highly unlikely that I will regain the ability to eat and drink without medical assistance; or my attending physician is of the opinion that I have an incurable or irreversible condition that is likely to cause my death within a relatively short time.

I shall be conclusively presumed to have sustained an irreversible loss of mental capacity upon a determination to such effect by my attending physician or when a Court determines that I have sustained such loss, whichever shall first occur.

As used herein, the term "an incurable or irreversible condition which is likely to cause my death within a relatively short time" is a condition which, without the administration of medical procedures, would serve only to prolong the process of dying and will, in my attending physician's opinion, result in my death within a relatively short period of time. The determination as to whether my death would occur in a relatively short period of time is to be made by my attending physician without considering the possibilities of extending my life with life-sustaining treatment.

I direct that this decision shall be carried into effect even if I am unable to personally reconfirm or communicate it, without seeking judicial approval or authority. Accordingly, if and when it is so determined that (1) I have sustained substantial and irreversible loss of mental capacity and (2) 1 am unable to eat and drink without medical assistance and it is highly unlikely that I will regain the capacity to eat and drink without medical assistance or I have an incurable or irreversible condition which is likely to cause my death within a relatively short time, all life-sustaining treatment (including without limitation, administration of nourishment and liquids intravenously or by tubes connected to my digestive tract) shall thereupon be withheld or withdrawn forthwith, whether or not I am conscious, alert, or free from pain, and no cardiopulmonary resuscitation shall thereafter be administered to me if I sustain cardiac or pulmonary arrest. In such circumstances I consent to an order not to resuscitate, as that term is defined in New York Public Health Law Section 296 1, and direct that such an order thereupon be placed in my medical record. I recognize that when life-sustaining treatment is withheld or withdrawn from me, I will surely die of dehydration and malnutrition within days or weeks. All available medication for the relief of pain and for my comfort shall be administered to me after life-sustaining treatment is withheld or withdrawn, even if I am rendered unconscious and my life is shortened thereby.

I wish to die at home and not in a hospital, and I do not want to be transfer-red to a hospital unless my condition makes it impractical for me to be treated at home, as may be the case during severe hemorrhage, or extreme restlessness, convulsions, or unmanageable pain; in which case, then as soon as possible, I want to be sent back home.

I recognize that there may be many instances besides those described above in which the compassionate practice of good medicine dictates that life-sustaining treatment be withheld or withdrawn, and I do not intend that this instrument be construed as an exclusive enumeration of the circumstances in which I have decided to forgo life-sustaining treatment. To the contrary, it is my express direction that whenever the compassionate practice of good medicine dictates that life-sustaining treatment should not be administered, such treatment shall be withheld or withdrawn from me. I similarly direct that in the event I am able to personally communicate a decision to forgo life-sustaining treatment in other circumstances than those described herein, such instructions shall be followed to the same extent as if originally included in this declaration.

This instrument and the instructions herein contained may be revoked by me at any time and in any manner. However, no physician, hospital, or other health-care provider who withholds or withdraws life-sustaining treatment in reliance upon this Living Will or upon my personally communicated instructions without actual knowledge that I have countermanded these instructions shall have any liability or responsibility to me, my estate, or any other person for having withheld such treatment.

I am in full command of my faculties. I make this Living Will declaration in order to furnish clear and convincing proof of the strength and durability of my determination to forgo life-sustaining treatment in the circumstances described above. I emphasize my firm and settled conviction that I am entitled to forgo such treatment in the exercise of my right to determine the course of my medical treatment. My right to forgo such treatment is paramount to any responsibility of any health-care provider or the authority of any Court or Judge to attempt to force unwanted medical care upon me.

I direct that my family, friends, all physicians, hospitals and other healthcare providers and any Court or Judge honor my decision that my life not be artificially extended by mechanical means and that if there is any doubt as to whether or not life-sustaining treatment is to be administered to me after I have sustained substantial and irreversible loss of mental capacity, such doubt is to be resolved in favor of withholding or withdrawing such treatment.

I have discussed this document with (names of witnesses), and I appoint said (name of individual) as my Surrogate and Health Proxy to act for me in any and all of the within premises, and if any interpretation of this document is ever necessary, my said Surrogate and Health Proxy is authorized to interpret it.

 

 

(Name)

Dated: (Place of execution), February ,              19__.

WITNESS: _______________________________________________________________________________________

ADDRESS:_______________________________________________________________________________________

WITNESS:_______________________________________________________________________________________

ADDRESS:_______________________________________________________________________________________

WITNESS:_______________________________________________________________________________________

ADDRESS:_______________________________________________________________________________________

STATE OF NEW YORK )

)SS.:

COUNTY OF NEW YORK )

On this (date), before me personally appeared (person's name), to me known to me to be the individual described in and who executed the foregoing instrument, and she acknowledged to me that she executed the same.

 

_________________________________________

Notary Public

 

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FIGURE 6.2 Sample Retainer Agreement

 

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Date

Jane Doe (Client)

Anyplace, U.S.A.

Re: Retainer Agreement Regarding Doe vs. Doe

Dear Jane Doe:

This letter confirms that you have retained me as your attorney to negotiate a settlement agreement with your husband, if that is reasonably possible; or, if not, to represent you in a divorce action. You agree to pay to me promptly an initial retainer of $1,500, which is my minimum fee in this matter. If I devote more than 10 hours to this case based upon my time records commencing from the initial conference, you shall pay an additional fee counted at the rate of $150/hour.

If you should decide to discontinue my services in this matter at any time, you shall be liable for my time computed at the rate of $ 150/hour.

These fees do not include any work in appellate courts, any other actions or proceedings, or out-of-pocket disbursements. Out-of-pocket disbursements include but are not limited to costs of filing papers, court fees, process servers, witness fees, court reporters, long-distance telephone calls, travel, parking, and photocopies normally made by me or requested by you, which disbursements shall be paid for or reimbursed to me upon my request.

You are aware of the hazards of litigation and that, despite my efforts on your behalf, there is no assurance or guarantee of the outcome of this matter.

Kindly indicate your understanding and acceptance of the above by signing this letter below where indicated. I look forward to serving you.

Sincerely yours,

(Signature)

 

I have read and understand the above letter, have received a copy, and accept all of its terms:

 

__________________________________

Jane Doe

 

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FIGURE 6.3 Sample Contingency Fee Arrangement

 

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Date

John Doe (Client)

Anyplace, U.S.A.

Re: Retainer Agreement Regarding Doe vs. Smith

 

Dear John Doe:

This letter confirms that we will represent you in the prosecution of your claim for personal injuries sustained by you on February 16, 19_, as a result of an auto accident with Mr. Smith in Cleveland. Ohio.

We will devote our efforts to this matter for a fee, the amount of which will depend upon the outcome of your claim:

1. If nothing is recovered, you will not be indebted to us for our services
2. If we are successful, we will receive 25 percent of the amount obtained for you if no suit is filed, and 33 1/3 percent of any amount recovered after suit is filed.
3. Actual costs expended in reaching a settlement, if any, are to be paid by you.
4. Proceeds, if any, recovered by way of settlement, judgment, or otherwise shall be disbursed as follows: All our costs which have not been reimbursed by you will be deducted; our fees, as set out in the percentage above, will be deducted and the balance will be paid to you.
5. Should you decide to discharge us and retain another law firm, we shall receive a reasonable percentage of the proceeds recovered by said firm as fees for our services.

   If this letter correctly states our understanding, will you please so indicate by signing this agreement in the space provided below and returning it to us.

Sincerely yours,

_________________________________________

John Doe

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FIGURE 6.4 Sample Monthly Billing Statement

 

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Date

Name of Client

Company

Address

Current statement for all services rendered in the matter of the contract negotiation between (name of client) and (name of employer) at the rate of $200 per hour per agreement:

1. 1/05/97	Tel. conv. with Employer's Attorney 9:40-9:45 a.m.	5 min.
	Tel. conv. with Client 9:15-9:20 a.m.	5 min.
	Tel. conv. with Client 12:10- 12:15 p.m.	5 min.
2. 1/04/97	Draft of revised Agreement including tel. conv. with Client 6:50-8:05 a.m.	75 min.
3. 1/03/97	Meeting with Client tel. conv. with Client 6:50-8:05 a.m.	70 min.
4. 12/19/96	Review of initial proposed Agreement 7:30-7:55 a.m.	25 min.
	Tel. conv. with Client 10 min. 9:35-9:40 a.m.; 3:40-3:45 p.m.	10 min.

Total time spent on Matter from December 19, 1996 through January 5, 1997 at standard rate of $200 per hour:

195 min. or 3.25 hours

Amount earned: $650.00