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Health Care Proxy

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Massachusetts Health Care Proxy

Information and Instructions

What does the Health Care Proxy Law allow?
The 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 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 appropriate form to appoint a Health Care Agent. You (known as the "Principal") 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 related to you by blood, marriage or adoption.

What can my agent do?
Your agent will make decisions about your health care only when you are, for some reason, unable to do so. This means 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 make decisions on your behalf until your doctor determines, in writing, that you lack the ability to make health care decisions.

Your agent will make decisions for you only after talking with your doctor or health care provider, and after fully considering all of the options regarding diagnosis 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 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 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 yours 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 form?

  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 might not be available at any future time, you may name a second person as an Alternate. Your alternate 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 to make for you, include them in the 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. If you are physically unable, have someone other than either witness sign your name at your direction. The person who signs for you should put his/her own name and address in the spaces provided. The date should be designated at the time of signature.
  4. Have your witnesses fill in the date, sign their names and print their names and addresses.
  5. On the back of the form are statements to be signed and dated 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.

Who should have the original and copies?
After you have completed the form, make at least four photocopies of the form. Keep the original yourself where it can be easily found (not in your safe deposit box). Give one copy to your doctor and one to your hospital for your medical record. Give copies to your agent and any alternate. 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 if the following occurs:

  • You sign another Health Care Proxy later on.
  • You legally separate from or divorce your spouse who is named in the Proxy as your agent.
  • You notify your agent, your 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 you want to revoke the Proxy, for example, tearing up or destroying the Proxy, crossing it out, telling other people, etc.

How often should the document be reviewed?
The Health Care Proxy should be reviewed periodically by the Principal to ensure that the information is accurate.

Points to Consider
The following are some life-supporting and life-sustaining measures commonly used today that should be considered and discussed with your agent (and alternate, if appropriate). Your agent should be aware of what is important to you and treatments you wish to have carried out.

  • CPR (Cardiopulmonary Resuscitation): Chest compressions, drugs and heart defibrillation
  • Mechanical Breathing: Air is pumped into the lungs by a machine called a ventilator (respirator)
  • Renal Dialysis: A type of life-sustaining treatment that performs the work of the kidneys and eliminates toxins from the blood by a machine
  • Tube Feeding: Nutrition and hydration is provided through a tube to a person who cannot swallow, digest, or absorb food or liquids taken by mouth
  • Cultural and Religious Beliefs: Your beliefs that may or may not influence decisions regarding your diagnosis, prognosis and treatment

Your physician should also be aware of your wishes, and any additional questions should be referred to your physician for discussion as well.