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The Health Care Proxy is a legal document that allows you to name someone you know and trust to make healthcare decisions for you if, for any reason and at any time, you become unable to make or communicate those decisions. Under the Health Care Proxy Law (Massachusetts General Laws, Chapter 20 ID), any competent adult 18 years of age and over may use this form to appoint a Health Care Agent. You (the Principle) can appoint anyone EXCEPT the administrator, operator, or employee of a health care facility such as a hospital or nursing home where you are a patient or resident UNLESS that person is also related to you by blood, marriage, or adoption.

Your agent will make decisions about your health care only when you are unable to do so for yourself. This means that your agent can act for you if you are temporarily unconscious, in a coma, or have some other condition in which you cannot make or communicate health care decisions. Your agent cannot act for you until your doctor determines in writing that you lack the ability to make health care decisions. Your doctor will tell you of this if there is any sign that you will understand it. Acting with your authority, your agent can make any health care decision that you would if you were able. If you give your agent full authority to act for you, (s)he can refuse any medical treatment, including treatment that will keep you alive. Your agent will make decisions for you only after talking with your doctor or health care provider, and only after fully considering all of the options regarding diagnosis, prognosis, and treatment for your illness or condition. Your agent has the legal right to get any information including confidential medical information necessary to make informed decisions for you.

Your agent will make health care decisions for you according to your wishes or according to his or her assessment of your wishes, including religious and moral beliefs. You may wish to talk to your doctor, religious advisors, or other persons whose opinion you value before giving instructions to your agent. It is very important you talk with your agent so that (s) he knows what is important to you. If your agent does not know what your wishes would be in a particular situation, your agent will decide based on what (s)he thinks would be in your best interests. After your doctor has determined that you lack the ability to make health care decisions, if you still object to any decisions made by your agent, your own decisions will be honored unless a Court determines that you lack capability to make health care decisions. Your agents decision will have the same authority as you would if you were able and would be honored over those of any other person, except for any limitations you yourself made, or except for a court order specifically overriding the proxy.

1. At the top of the form, print your name and address. Print the name, address, and phone number of the person you choose as your Health Care Agent. (Optional: You may name a second person as an alternate. Your alternate will be called if your agent is unable or unwilling to serve

2. Setting limits on your agent’s authority might make it difficult for your agent to act for you in an unexpected situation. If you want an agent to have full authority to act for you, leave the limitations space blank.

3. BEFORE you sign, be sure you have two adults present who can witness you signing the document. The only people who cannot serve as witnesses are your Agent and Alternate. Then sign the document yourself (or if you are physically unable, have someone else sign at your direction The person who signs your name for you should put his or her name and address in the spaces provided.

4.Have your witness fill in the date, sign their names, and print their names and addresses.

5.OPTIONAL: On the back of the form are statements to be signed by your Agent and any alternate. This is not required by law but is recommended to ensure that you have talked with the person or persons who may have to make important decisions about your care and that each of them realizes the importance of the task they may have to do.

After you have filled in the form, make at least five (5) photocopies of the form. Keep the original yourself. Give one copy to your doctor, and send one copy to the medical records department of your hospital to be placed in your medical record. Give copies to your Agent and Alternate, your family members, clergy, and lawyer and anyone else who may be involved in your health care decision making.

• Your Health Care Proxy is revoked when any of the f ollowing four things happen:
• You sign another Health Care Proxy
• You legally separate or divorce your spouse and your spouse is named in the Proxy as your agent.
• You notify your Agent, doctor, or other health care provider orally or in writing that you want to revoke your Health Care Proxy.
• You do anything else that clearly shows that you want to revoke the Proxy, for example tearing up or destroying the Proxy, crossing it out, telling other people, etc.

I appoint as my Health Care Agent:

OPTIONAL: If my agent is unable or unwilling to serve, then I appoint as my alternate:

My agent shall have the authority to make all health care decisions for me including decisions about life sustaining treatment, subject to any limitations I state below, if I am unable to make health care decisions myself. My agent’s authority becomes effective if my attending physician determines in writing that I lack the capacity to make or to communicate health care decisions. My agent is then to have the same authority to make health care decisions as I would if I have the capacity to make them.

I direct my agent to make health care decisions based on my agent’s assessment of my personal wishes. If my personal wishes are unknown, my agent is to make health care decisions based on my agent’s assessment of my best interests. Photocopies of the Health Care Proxy shall have the same force and effect as the original.

Complete only if principle is unable to sign: I have signed the Principal’s name above at his/her direction in the presence of two witnesses:

 

Witness Statement:  We, the undersigned, each witnessed the signing of the Healthcare Prozy by the Principal, and that the Principal appears to be at least 18 years of age, of sound mind, and under no constraint or undue influence.  Neither of us is named the health care agent or alternate in this document.

HEALTH CARE AGENT: I have been named by the Principal as the Health Care Agent by this Health Care Proxy. I have read this document carefully and have personally discussed with the principal his or her health care wishes at the time of possible incapacity. I know the principal and accept this appointment freely. I am not an operator, administrator or employee of a hospital, clinic, nursing home, rest home, Soldiers Home or other health care facility where the principal is presently a patient or resident or has applied for admission. Or, if I am a person so described, I am also related to the principal by blood, marriage, or adoption. If called upon and to the best of my ability, I will try to carry out the principals wishes.

ALTERNATE: I have been named by the Principal as the Alternate by this Health Care Proxy. I have read this document carefully and have personally discussed with the principal his or her health care wishes at the time of possible incapacity. I know the principal and accept this appointment freely. I am not an operator, administrator or employee of a hospital, clinic, nursing home, rest home, Soldiers Home or other health care facility where the principal is presently a patient or resident or has applied for admission. Or, if I am a person so described, I am also related to the principal by blood, marriage, or adoption. If called upon and to the best of my ability, I will try to carry out the principals wishes.