Advance Directives or Health Care Proxy

Health Care Proxy Form, click here

Advance Directives or Health Care Proxy

In Massachusetts, you can make legally valid decisions about your medical treatment through a health care proxy. A health care proxy is a simple legal document that allows you to name someone you know and trust to make health care decisions for you if, for any reason and at any time, you become unable to make or communicate those decisions. It is an important document, however because it concerns not only the choices you make about your health care, but also the relationships you have with your physician, family, and others who may be involved with your care. Under the Health Care Proxy Law (Massachusetts General Laws, Chapter 201D), any competent adult 18 years of age or over may use the form that is attached at the back of this booklet to appoint a health care agent. You can appoint any adult 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. Whether or not you live in Massachusetts, you can use this form if you receive your health care in Massachusetts.

What Can My Agent Do?

Your agent will make decisions about your health care only if you are, for some reason, unable to do that 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 would understand it.

Acting with your authority, your agent can make any health care decision that you could, if you were able.

If you give your agent full authority to act for you, he or she can consent to or refuse any medical treatment, including treatment that could keep you alive.

Your agent will make decisions for you only after talking with your doctor or health care provider, and after fully considering all the options regarding the diagnosis, prognosis and treatment of 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/her assessment of your wishes, including your religious or moral beliefs. You may wish to talk first with your doctor, religious advisor or other people before giving instructions to your agent. It is very important that you talk with your agent so that he or she 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 he or she 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 decision made by your agent, your own decisions will be honored unless a court determines that you lack capacity to make health care decisions.

Your agent’s decisions will have the same authority as your decisions would, if you were able, and will be honored over those of any other person, except for any limitation you yourself made, or except for a court order, specifically overriding the proxy.

How Do I Fill Out the Health Care Proxy Form?

A copy of the form is included in the back of this booklet for your convenience. If it is missing, please ask your nurse to contact social services. 1. At the top of the form, print your full name and address. Print the name, address and phone number of the person you choose as your Health Care Agent. (Optional: If you think your agent may not be available at any future time, you may name a second person as an alternate agent. Your alternate agent will be called if your agent is unwilling or unable 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 your agent to have full authority to act for you, leave the limitations space blank. However, if you want to limit the kinds of decisions you would want your agent or alternate agent to make for you, include them in the blank. 3. BEFORE you sign, be sure you have two adults present who will be witnesses as you sign the document. The only people who cannot serve as witnesses are your agent and alternate agent. With the witnesses present, sign the document. (Or, if you are physically unable, have someone other than either witness sign your name at your direction. The person who signs your name for you should put his/her own name and address in the spaces provided.) 4. Have your witnesses 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 agent. 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 realizes the importance of the task they may have to do.

Who Should Have the Original and Copies?

After you have filled in the form, remove it from the booklet and make at least four photocopies. Keep the original yourself where it can be found easily (not in your safe deposit box). Give copies to your doctor, hospital and/or health plan to put into your medical record. Give copies to your agent and any alternate agent. You can give additional copies to family members, your clergy and/or lawyer and other people who may be involved in your health care decision-making.

How Can I Revoke or Cancel the Document?

Your health care proxy is revoked when any of the following four things happens:

1. You sign another health care proxy at a later time. 
2. You legally separate from or divorce your spouse who is named in the proxy as your agent.
3. You notify your agent, your doctor or other health care provider orally or in writing that you want to revoke your health care proxy.
4. You do anything else that clearly shows you want to revoke the proxy, for example, tearing up or destroying the proxy, crossing it out, telling other people, etc.

If you already have a health care proxy, please tell your physician and your nurse. A copy of the documents must be included in your medical record to ensure that your wishes are honored. If you do not have an existing proxy and wish to create one, use the form that is attached in the back of this booklet or ask your nurse to contact social services. It is a policy of this hospital to honor a patient’s health care decision to the full extent required or allowed by law. You are not required to have an advance directive to receive care at Jordan Hospital.