Cancer Care Of Western New York Health Care Proxy Form
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2CANCER CARE OF WESTERN NEW YORK
Health Care Proxy
About the Health Care Proxy
This is an important legal form. Before signing this form, you should understand the following facts:
1. This form gives the person you choose as your agent the authority to make all health care decisions for you, except to the extent you say
otherwise in this form. “Health care” means any treatment, service or procedure to diagnose or treat your physical or mental condition.
2. Unless you say otherwise, your agent will be allowed to make all health care decisions for you, including decisions to remove or provide life-
sustaining treatment.
3. Unless your agent knows your wishes about artificial nutrition and hydration (nourishment and water provided by a feeding tube), he or she
will not be allowed to refuse or consent to those measures for you.
4. Your agent will start making decisions for you when doctors decide that you are not able to make health care decisions for yourself. You may
write on this form any information about treatment that you do not desire and/or those treatments that you want to make sure you receive.
Your agent must follow your instructions (oral and written) when making decisions for you. If you want to give your agent written
instructions, do so right on the form. For example, you could say:
* If I become terminally ill, I do/don’t want to receive the following treatments...
* If I am in a coma or unconscious, with no hope of recovery, then I do/don’t want...
* 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/don’t want...
* 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 of
the treatments about which you may leave instructions:
* artificial respiration
* transplantation
* abortion
* psychosurgery
* cardiopulmonary resuscitation (CPR)
* electric shock therapy
* artificial nutrition and hydration
* blood transfusions
* sterilization
(nourishment provided by feeding tube)
* antipsychotic medication
* antibiotics
Talk about choosing an agent with your family and/or close friends. You should discuss this form with a doctor or another health care
professional, such as a nurse or social worker, before you sign it to make sure that you understand the types of decisions that may be made
for you. You may also wish to give your doctor a signed copy. You do not need a lawyer to fill out this form.
You may choose any adult (over 18), including a family member or close friend, to be your agent. If you select a doctor as your agent, he/she
may have to choose between acting as your agent or as your attending doctor; a physician 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. You should ask the staff at the facility to explain those restrictions.
You should tell the person you choose that he/she will be your health care agent. You should 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.
Even after 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. You can cancel the control given to your agent by telling him/her or your
health care provider orally or in writing.
Filling Out the Proxy Form
Item (1) Write your name and the name, home address, and telephone number of the person you select as your agent.
Item (2) If you have special instructions for your agent, you should write them here. Also, if you wish to limit your agent’s authority in any way,
you should say so here. 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.
Item (3) You may write the name, home address, and telephone number of an alternate agent.
Item (4) This form 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 the health care proxy to expire.
Item (5) You must date and sign the proxy. If you are unable to sign yourself, you may direct someone else to sign in your presence. Be sure to
include your address.
Two witnesses of at least 18 years of age must sign your proxy. The person who is appointed agent or alternate agent cannot sign as a witness.
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