Health Care Proxy Form Instructions - New York
Health
Care
Proxy Form Instructions
Item
(1)
Write the name, home address and telephone
number
of the
person you
are
selecting as
your
agent.
Item
(2)
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.
Item
(3)
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.
Item
(4)
If
you
have
special
instructions
for
your
aEient, 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 agient.
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
haue
discussed my wishes
uith my health care
agent
and
alternate and
they know my wishes
including those
about artificial nutrition
and hydration.
If
you
wish to
make more specific
instructions,
you
could say:
If I
become terminally
ill,
I
doldon't
want to
receiue
the following types of treatments....
If I am in a coma or haue
little conscious
understanding,
with no hope of
recot)eru, then
I
dol
don't want the
following types of treatments:....
If I
haue brain damage
or a brain disease
that
makes me unable to
recognize
people
or
speak and
there is no
hope that my condition
will improue,
I
doldon't want
the following types
of treatments:....
I haue
discussed
with mg agent
mg wishes
about and
I
want
mg agent
to
make
all decisions about these
measures.
30
Examples of medical treatments about which
you
may
wish
to
give
your
aEient special
instructions
are
listed
below.
This is not a complete list:
.
artificial
respiration
.
artificial nutrition and
hydration
(nourjshment
and water
provided
by
feeding
tube)
.
cardiopulmonary
resuscitation
(CPR)
.
antipsychotic medication
o
electric
shock therapy
o
antibiotics
.
surgical
procedures
.
dialysis
.
transplantation
.
blood transfusions
.
abortion
.
sterilization
Item
(5)
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.
Item
(6)
You may state wishes or
instructions about organ
and /or tissue
donation on this
form. New York
law does
provide
for
certain
individuals
in
order
of
priority
to consent to an
organ and/or tissue
donation
on
your
behalf:
your
health
care
agent,
your
decedent's agent,
your
spouse
,
if
you
are
not legally separated, or
your
domestic
partner,
a
son or daughter
18
years
of agie or older,
either of
your parents,
a brother or sister
18
years
ofage
or
older, a
guardian
appointed by a court
prior
to the
donor's
death.
Item
(7)
TVro witnesses
18
years
of age
or older must sign
this
Health Care
Proxy form.
The
person
who
is
appointed
your
agent or alternate
agient cannot
sign as a witness.
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