This is an important legal document before signing you should understand the following facts:
- This form gives the person you choose as your agent the authority to make all health care decisions for you, including the decision to remove or provide life-sustaining treatment, unless you say otherwise in this form. “Health Care” means any treatment, service or procedure to diagnose or treat your physical or mental condition.
- Unless your agent reasonably knows your wishes about artificial nutrition and hydration (nourishment and water provided by a feeding tube or intravenous line), he or she will not be allowed to refuse or consent to those measures for you.
- Your agent will start making decisions for you when your doctor determines that you are not able to make health care decisions for yourself.
- You may write on this form example of the types of treatments that you would not desire and/or those treatments that you want to make sure you receive. The instructions may be used to limit the decision-making power of the agent. Your agent must follow your instructions when making decisions for you.
- You do not need a lawyer to fill out this form.
- You may choose any adult (18 years of age or older), including a family member or close friend, to be your agent. If you select a doctor as your agent, he or she will have to choose between acting as your agent or as your attending doctor, because a doctor cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. Ask staff at the facility to explain those restrictions.
- Before appointing someone as your heath care agent, discuss it with him or her to make sure that he or she is willing to act as your agent. Tell the person you choose that he or she will be your health care agent. Discuss your health care wishes and this form with your agent. Be sure to give him or her, a signed copy. Your agent cannot be sued for health care decisions made in good faith.
- If you have named your spouse as your health care agent and you later become divorced or legally separated, your former spouse will no longer be your agent by law, unless you state otherwise. If you would like your former spouse to remain your agent, you may note this on your current form and date it or complete a new form naming your former spouse.
- Even though you have signed this form, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped if you object, nor will your agent have any power to object.
- You may cancel the authority given to your agent by telling him or her or your health care provider orally or in writing.
- Appointing a health care agent is voluntary. No one can require you to appoint one.
- You may express your wishes or instructions regarding organ and/or tissue donation on the form.
Write the name, home address and telephone number of the person you are selecting as your agent.
If you want to appoint an alternate agent, write the name, home address and telephone number of the person you are selecting as your alternate agent.
Your Health Care Proxy will remain valid indefinitely unless you set an expiration date or condition for its expiration. This section is optional and should be filled in only if you want your Health Care Proxy to expire.
If you have special instructions for your agent, write them here. Also, if you wish to limit your agent’s authority in any way, you may say so here, or discuss them with your health care agent. If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decision to consent to or refuse life-sustaining treatment.
If you want to give your agent broad authority, you may do so right on the form. Simply write: I have discussed my wishes with my health care agent and they know my wishes, including those about artificial nutrition and hydration.
If you wish to make more specific instruction, you could say: If I become terminally ill, I do/do not want to receive the following types of treatments: …if I am in a coma or have little conscious understanding, with no hope of recovery, then I do/do not want the following treatments: …If I have brain damage or a brain disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, I do/do not want the following types of treatments: … I have discussed with my agent my wishes about _________________________ and I want my agent to make all decisions about these measures.
Examples of medical treatments about which you may wish to give your agent special instructions are listed below. This is not a complete list:
- Artificial respiration
- Artificial nutrition and hydration (nourishment and water provided by feeding tube)
- Cardiopulmonary resuscitation (CPR)
- Antipsychotic medication
- Electric shock therapy
- Surgical procedures
- Blood transfusions
You must date and sign this Health Care Proxy form. If you are unable to sign yourself, you may direct someone else to sign in your presence. Be sure to include your address.
You may state wishes or instructions about organ and/or tissue donation on this form. A health care agent cannot make a decision about organ and/or tissue donation because the agent’s authority ends upon your death. The law does provide for certain individuals, in order of priority, to consent to an organ and/or tissue donation on your behalf; your spouse, a son or daughter 18 years of age or older, either of your parents, a brother or sister 18 years of age or older, a guardian appointed by a court prior to the donor’s death or any other legally authorized person.
Two witnesses 18 years of age or older must sign this Health Care Proxy form. The person who is appointed your agent or alternate agent cannot sign as a witness.