Massachusetts Health Care Proy Assignment printable pdf download

Massachusetts Health Care Proxy Assignment

Instructions

— Authorized by the Massachusetts General Laws, Title II, Chapter 201D, 2005 —

I. What is a Health Care Proxy?

Every adult age 18 or older and of sound mind has the right to name a Health Care Proxy. A

Health Care Proxy is a person you choose to make medical decisions on your behalf if you

should become incapacitated and unable to communicate your wishes about what medical

treatment you do or do not want. You may give your proxy the authority to make any and all

medical decisions, or you may limit his or her authority. You may also designate an alternate

proxy in the event that your original proxy is unable or unwilling to serve in that capacity.

Your proxy has the authority to make medical decisions on your behalf only if your attending

doctor determines that you are unable to communicate your wishes. Your proxy’s orders about

your medical care shall override any objections by your next of kin (if your proxy is different

from your next of kin). If you should recover and become able again to communicate your

wishes about medical treatment, your proxy’s authority immediately ends.

II. Who Can Serve as Your Health Care Proxy

You may choose anyone you wish (subject to the exceptions listed below in Section III) to serve

as your Health Care Proxy. Your proxy may be, but does not have to be, your legal next of kin

or a family member. You should choose a proxy who understands what decisions you would

make about your medical care if you could speak, and whom you trust to carry those wishes

out.

III. Who Cannot Serve as Your Health Care Proxy

The following people cannot serve as your proxy:

a. An operator, administrator, or employee of any health care facility providing you care at the

time you execute this assignment form. EXCEPTION — such a person can serve as your proxy

if he or she is related to you by blood, marriage, or adoption.

IV. Physician/Facility Refusal to Honor Proxy’s Directions

Massachusetts law allows a physician, private facility, or other individual health care provider

to refuse to honor the directions of your proxy if those directions conflict with the moral or

religious views of the physician, private facility, or other individual health care provider.

HOWEVER, if a physician or other provider refuses to honor your proxy’s directions, the

physician or provider must transfer your care to a provider who will honor your proxy’s

Massachusetts Health Care Proy Assignment