HEALTH CARE PROXY
1. APPOINTMENT OF HEALTH CARE AGENT AND ALTERNATE
I, , of , Massachusetts, appoint my , , of , as my Health Care Agent ("Agent") to make health care decisions for me as authorized in this Health Care Proxy and under Chapter 201D of the General Laws of Massachusetts, including any future amendments. Capitalized terms used and not defined in this Health Care Proxy have the meaning specified in Chapter 201D.
2. AGENT'S AUTHORITY TO ACT
My Agent is authorized to act on my behalf only if my Attending Physician determines, as provided in Section 6 of Chapter 201D, that I lack Capacity to Make Health Care Decisions or to communicate my decisions. Notice that such a determination has been made must be given orally and in writing (a) to me, if there is any indication that I could comprehend the notice, (b) to my Agent and (c) if I am in or transferred from a mental health Facility, to the director of the Facility.
My Agent's authority will end if my Attending Physician determines that I have regained Capacity to Make Health Care Decisions and will resume if it is again determined that I lack such capacity.
Notwithstanding a determination that I lack Capacity to Make Health Care Decisions, if I object to any decision made by my Agent, my decision will prevail unless a court of competent jurisdiction determines that I lack Capacity to Make Health Care Decisions.
3. AGENT'S POWERS
My Agent has complete authority to make any Health Care decisions for me, including decisions about life-sustaining treatment. My Agent may make Health Care decisions for me (a) only after consultation with my Health Care Providers and consideration of all acceptable medical alternatives regarding diagnosis, prognosis, treatments and their side effects, and (b) according to my Agent's assessment of my wishes as stated in this Health Care Proxy, or as otherwise known to my Agent, including my religious and moral beliefs or, if my wishes are not known, according to what my Agent determines to be in my best interest.
I authorize my Agent
(a) to receive any medical information regarding me or my Health Care, including any confidential medical information that I would be entitled to receive, and to disclose the information to others;
(b) to arrange my admission to or discharge from any Facility, even if against medical advice;
(c) to contract for any Health Care for me at my expense, without incurring personal liability for the payment of any Health Care;
(d) to employ and discharge Health Care Providers and related support personnel; and
(e) to do all things necessary to carry out the intent of this Health Care Proxy, including granting any waiver or release from liability required by a Health Care Provider, signing any documents relating to a refusal of treatment and pursuing any legal action in my name and at my expense to force compliance with my wishes as determined by my Agent.
4. STATEMENT OF DESIRES
I desire that, in making decisions concerning any life-sustaining treatment, my Agent consider what relief from pain and suffering the treatment will give me, the expense involved and what quality of life I will have in the future. I do not want my life to be prolonged, nor do I want life-sustaining treatment to be provided or continued, if my Agent believes the burdens of the treatment outweigh the expected benefits.
It is my desire that if at any time I am suffering from one or more of the conditions described below, I not be given life-sustaining treatment, including, but not limited to,
cardiopulmonary resuscitation, mechanical breathing, artificial nutrition and hydration, major surgery, blood or blood products and antibiotics. I do, however, wish to be given any medication and/or any medical or surgical treatment which would relieve my pain, even though it may lead to physical damage, addiction or hasten the moment of (but not intentionally cause) my death.
(a) I am in a coma or persistent vegetative state which, in the opinion of my Attending Physician, is irreversible and there is no hope that I will regain awareness or higher mental functions no matter what medical or surgical treatment I may receive; or higher mental functions no matter what medical or surgical treatment I may receive; or
(b) I have brain damage or a brain disease which cannot be reversed and which makes me unable to recognize people or to communicate with them (whether or not I also have a terminal illness); or
(c) I have a terminal condition caused by injury, disease or illness and the application of life-sustaining procedures would serve only to delay artificially the moment of my death.
5. REVOCATION
This Health Care Proxy will be revoked if:
(a) I sign a subsequent Massachusetts Health Care Proxy; or
(b) I notify my Agent or one of my Health Care Providers orally or in writing or by any other act showing a specific intent to revoke this Health Care Proxy.
I, , by signing this Health Care Proxy declare that I understand its contents and the effect of this grant of authority to my Agent, that I sign it willingly in the presence of each of the undersigned witnesses, and that I sign it as my voluntary act for the purposes expressed, this day of , 20 .
___________________________________
Acceptance
I, , declare that I have read this instrument carefully and accept the appointment as Agent. I represent that I am eighteen years of age or older.
__________________________________
Address __________________________________________________ Telephone _____________________________
___________________________________
Alternate health care agent only in event health care agent is unable or unwilling to serve.
We, the witnesses who sign below, each declare in the presence of that neither of us has been named as Agent or alternate Agent in this Health Care Proxy and neither of us is related to her by blood or marriage. We further declare that she signed this instrument as her Health Care Proxy in the presence of each of us, that she signed it willingly, that each of us signs this Health Care Proxy as witness in her presence, and that to the best of our knowledge she is eighteen (18) years of age or over, of sound mind, and under no constraint or undue influence.
__________________________________ residing at_______________________________________________
(Witness) __________________________
__________________________________ residing at_______________________________________________
(Witness) __________________________
COMMONWEALTH OF MASSACHUSETTS County of Middlesex
Subscribed, sworn to and acknowledged before me by and the witnesses this day of , 20 .
_________________________________
Notary Public
My commission expires:
Photocopies will be deemed original.