Roman Catholic Health Care Proxy - Saint Elizabeth Ann Seton Parish printable pdf download

ROMAN CATHOLIC HEALTH CARE PROXY

1. APPOINTMENT OF HEALTH CARE AGENT AND ALTERNATE

I, ______________________________, residing at ______________________________________, Massachusetts,

(name of principal)

(street)

(city)

appoint ____________________________________________________________________________________,

(

name of Health Care Agent)

area code and telephone number)

residing at _______________________________________________________, as my Health Care

(street)

(city/state)

Agent (“Agent”) to make health care decisions for me as authorized in this Health Care Proxy according to Chapter

201D of the General Laws of Massachusetts, including any future amendments (“Chapter 201D”). Capitalized terms

used and not defined in this Health Care Proxy have the meaning specified in Chapter 201D.

If for any reason ____________________________________________, is unavailable, unwilling, incompetent, or

(

name of Health Care Agent)

otherwise disqualified under Chapter 201D to act as my Agent and is not expected to become available, willing,

competent or qualified to make a timely decision given my medical circumstances, I appoint

___________________________________________________, residing at ______________________________,

(name of alternate agent)

(area code & telephone)

(street)

_____________________________________, as my Agent.

(city/state)

2. WHEN MY AGENT’S AUTHORITY TO MAKE HEALTH CARE DECISIONS ON MY BEHALF

BECOMES EFFECTIVE

My Agent is authorized to act on my behalf only if and when my Attending Physician determines, as provided in Sec-

tion 6 of Chapter 201D, that I lack the Capacity to Make Health Care Decisions or to communicate my decisions. A

notice that such a determination has been made must be given orally and in writing (a) to me, if there is any indica-

tion that I could comprehend the notice, (b) to my Agent and (c) if I am in or transferred from a mental health Facili-

ty, to the director of the Facility.

My Agent’s authority will end if and when my Attending Physician determines that I have regained the Capacity to

Make Health Care Decisions and will resume if it is again determined that I lack such capacity.

Notwithstanding my Attending Physician’s determination that I lack the Capacity to Make Health Care Decisions, if I

object to any decision made by my Agent, my decision will prevail unless a court of competent jurisdiction deter-

mines that I lack the Capacity to Make Health Care Decisions.

3. SCOPE OF MY AGENT’S AUTHORITY

My Agent is authorized to make any and all Health Care decisions for me that I could make on my own behalf, in-

cluding decisions about life-sustaining treatment, subject to any limitations described herein. My Agent may make

Health Care decisions for me (a) only after consultation with my Health Care Providers and consideration of ac-

ceptable medical alternatives regarding diagnosis, prognosis, treatments and their side effects, and (b) according to

my Agent’s assessment of my wishes as stated in this Health Care Proxy, or as otherwise known to my Agent, includ-

ing my religious and moral beliefs or, if my wishes are not known, according to what my Agent determines to be in

my best interest.

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Roman Catholic Health Care Proxy - Saint Elizabeth Ann Seton Parish

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