Sample Healthcare Proxy Form - Massachusetts

2
B. POWERS OF HEALTHCARE AGENT
1. I give my Healthcare Agent full authority to make any and all health-
care decisions for me, including decisions about life-sustaining treatment,
subject only to any limitations that I state below.
2. My Healthcare Agent shall have authority to act on my behalf only if,
when and for so long as a determination has been made that I lack the
capacity to make or to communicate healthcare decisions for myself. This
determination shall be made in writing by my attending physician accord-
ing to accepted standards of medical judgment and the requirements of
Chapter 201D of the General Laws of Massachusetts.
3. The authority of my Healthcare Agent shall cease if my attending
physician determines that I have regained capacity. The authority shall
recommence if I subsequently lose capacity and consent for treatment is
required.
4. I shall be notified of any determination that I lack capacity to make
or communicate healthcare decisions where there is any indication that I
am able to comprehend this notice.
5. My Healthcare Agent shall make healthcare decisions for me only
after consultation with my healthcare providers and after consideration of
acceptable medical alternatives regarding diagnosis, prognosis, treatments,
and their side effects.
6. My Healthcare Agent shall make healthcare decisions for me in accor-
dance with his/her assessment of my wishes, my moral or religious beliefs,
or, if such factors are unknown, then in accordance with my Healthcare
Agent’s assessment of my best interests.
7. My Healthcare Agent shall have the right to receive any and all med-
ical information necessary to make informed decisions regarding my
healthcare, including any and all confidential medical information that I
would be entitled to receive.
8. If I object to a healthcare decision made by my Healthcare Agent, my
decision shall prevail unless it is determined by court order that I lack
capacity to make healthcare decisions.
9. The decisions made by my Healthcare Agent on my behalf shall have
the same priority as my decisions would have if I were competent over
decisions by any other person, except for any limitation I state below or a
specific court order overriding this proxy.
10. Nothing in this proxy shall preclude any medical procedure deemed
necessary by my attending physician to provide comfort care or pain alle-
viation including but not limited to treatment with sedatives and pain-
killing drugs, non-artificial oral feeding, suction, and hygienic care.
C. COURT-APPOINTED GUARDIAN
If it is deemed necessary to seek the appointment by a probate court of a
guardian of my person, I hereby nominate the persons named herein as my
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Sample Healthcare Proxy Form - Massachusetts PDF

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