Durable Power of Attorney Example - Massachusetts

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How to use the Massachusetts Will to Live Form
SUGGESTIONS AND REQUIREMENTS
1. This document allows you to designate (name) a health care agent who will make health
care decisions for you whenever you are unable to make them for yourself. It also allows
you to give instructions about medical treatment decisions that the health care agent must
follow. Any competent person who is at least 18 years old may designate a health care
agent through this document.
2. To properly designate a health care agent through this document, you must sign and date
this document in the presence of two adult witnesses. (If you are unable to sign and date
the document yourself, you may direct someone to do it for you in your presence. The
person who signs your name for you should put his/her name and address in the spaces
provided on the form.) The two witnesses must sign the document in your presence and
in each other’s presence.
3. The witnesses cannot be named as a health care agent or alternate in your document.
4. Your health care agent cannot be an operator, administrator, or employee of your
hospital, nursing home, or other health care facility where you are currently a patient or
resident or have applied for admission. However, one of these may serve if related to you
by blood, marriage, or adoption.
5. It is helpful to designate alternate health care agent(s), to take over if your first choice is
unable to serve. There is space on the form for you to designate two alternate health care
agents.
6. You should tell your doctor about this document. You should also ask your doctor to
keep a copy of this document as a part of your medical health record.
7. Your health care agent’s authority takes effect only when you no longer have the capacity
to make and communicate your own health care decisions. Under Massachusetts law this
is determined by your attending doctor, who must write it in your medical record,
describing the cause and nature of your incapacity, as well as its extent and probable
duration. However, if you object to a health care decision by your agent after your doctor
has determined you are incapable your wishes will prevail unless a court rules you are
incapable.
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