Massachusetts Health Care Proxy - PDF document

Massachusetts Health Care Proxy Information, Instructions and Form Rev 7/7/2022 Health Care Proxy Instruction page 1 of 2 Massachusetts Health Care Proxy An O verview of t he Massachusetts Health Care Proxy Law The Massachus etts Health Care Proxy l aw ( M a ssachusetts General Laws, Chapter 201D) authorizes a competent adult who is a ge e ighteen or older t o appo int a Health Care Agent. Your a gen t will h ave f ull a uthority to m ake any h ealthcare d e cisions , when you are u na b le t o make or communicate t hose decisions. Boston Children ’ s Hospital ( B CH) h as developed the attached legal document a nd instructions f o r o u r pa t ients and their f amilies that m eets the r equire m ents of the Mass a chusetts law a s w e l l a s r e l e v a n t c o u r t c a s e s r e g a r d i n g h e a l t h c a r e p r o x i e s . This l eg al form can b e used t hroughout you r c are at B CH or another healthcare f acility / provider . R espons i bilities of the Health C are A gen t Y ou , the p rincipal, can appoint anyone , with the e x c e p t i o n o f a h e a l t h c a r e c l i n i c i a n o r s t a f f a t a health care facility ( i n c l u d i n g b u t n o t l i m i t e d t o a h ospital , c o m m u n i t y h e a l t h c e n t e r , o r l o n g t e r m c a r e f a c i l i t y ) . Please n o t e , a clinician o r s t a f f w h o i s related to you by blood, marriage, or adoption m a y b e a p p o i n t e d a s t h e H e a l t h C a r e A g e n t . U s i n g t h e B o s t o n C h i l d r e n ’ s f o r m , y o u r a g e n t w i l l b e a u t h o r i z e d t o m a k e decisions about y our medical a n d / or mental health care , a u t h o r i z e a d m i s s i o n o r d i s c h a r g e , a n d a c c e s s confidential m e d i c a l information only when you are, for some reason, unable to do that yourself. This w i l l i n c l u d e t h e a b i l i t y t o c o n s e n t t o o r r e f u s e a n y m e d i c a l t r e a t m e n t , i n c l u d i n g d e c i s i o n s a b o u t l i f e s u s t a i n i n g m e d i c a l t r e a t m e n t . T he p u rpose o f the BCH form is to a l low y our agent t o act o n y o u r b e h a l f i f y o u a r e temporarily u nconscious, in a coma, or have some other medical or mental health condition in which you cannot make or communicate health care decisions. T h e r e m u s t b e a determination b y y o u r t r e a t i n g health c a r e p r o v i d e r , i n w r i t i n g , t h a t you lack the c a p a c i t y o r ability to make health care decisions . P l ease note t hat a cou r t m ay also determine t hat you l ack capacity and a llow the H ealth C are A gen t to make d ecisions. Y o u r a g e n t w i l l m a k e d e c i s i o n s r e g a r d i n g c a r e a n d t r e a t m e n t b a s e d o n t h e i r determination o f w h a t i s i n y o u r b e s t i n t e r e s t . S o i t i s s t r o n g l y a d v i s e d that y o u communicate w i t h y o u r H e a l t h C a r e A g e n t i n a d v a n c e s o t h e y a r e a w a r e o f y o u r w i s h e s regarding a n y u p c o m i n g o r f u t u r e medical a n d / o r m e n t a l h e a l t h c a r e a n d t r e a t m e n t . U n d e r M a s s a c h u s e t t s l a w , y o u r c l i n i c i a n s w i l l h o n o r y o u r w i s h e s i f y o u d i s a g r e e w i t h a n y c a r e a n d t r e a t m e n t r e c o m m e n d e d b y y o u r health c a r e a g e n t – p r o v i d e d t h a t y o u r clinician h a s determined t h a t y o u h a v e c a p a c i t y t o m a k e s u c h d e c i s i o n s . T

h e H e a l t h c a r e P r o x y w i l l r e m a i n i n e f f e c t u n t i l e i t h e r y o u ( t h e principal ) r e g a i n s c a p a c i t y a s determined b y t h e t r e a t i n g clinician , o r a c o u r t o f c o m p e t e n t j u r i s d i c t i o n h a s determined t h e H e a l t h C a r e P r o x y s h o u l d b e t e r m i n a t e d . DO NOT SEND THIS PAGE TO MEDICAL RECORDS Massachusetts Health Care Proxy Information, Instructions and Form Rev 7/7/2022 Health Care Proxy Instruction page 2 of 2 I n s t r u c t i o n s t o C o m p l e t e t h e F o r m Section ( 1 ) T h e P r i n c i p a l s h o u l d p r i n t o u t t h e i r n a m e , a n d t h e n p r o v i d e t h e f u l l n a m e , a d d r e s s , telephone a n d e m a i l o f y o u r c h o s e n H ealth C are Agent. You may , but are not required, also name an alternat e a gent if your primary Health Care Agent is not able o r u n w i l l i n g to serve . Section ( 2 ) T h e B o s t o n C h i l d r e n ’ s H o s p i t a l p r o p o s e d l e g a l d o c u m e n t p r o v i d e s a d e t a i l e d a u t h o r i z a t i o n f o r y o u r H e a l t h C a r e A g e n t . W i t h i n t h i s s e c t i o n , y o u m a y a l s o s e t a n y l i m i t a t i o n s o n c e r t a i n h e a l t h c a r e services o r d e c i s i o n s b y y o u r a g e n t . T h i s i s n o t r e q u i r e d , s o i f y o u r Agent s h o u l d h a v e full authority to act for you, p l e a s e leave t h i s a r e a blank. Section ( 3 ) T h e p r i n c i p a l should t h e n s i g n t h e f o r m a c k n o w l e d g i n g t h a t t h e y have c h o s e n a n d a u t h o r i z e d t h e i r a g e n t t o s o a c t . P l e a s e n o t e , i f t h e p r i n c i p a l i s u n a b l e t o s i g n t h e f o r m , a n o t h e r p e r s o n ( w h o i s n o t t h e a g e n t a n d n o t o n e o f t h e t w o witnesses ) s h o u l d sign t h e p r i n c i p a l ’ s n a m e a s w e l l a s s i g n t h e f o r m . Y o u r t w o w i t n e s s e s m u s t t h e n s i g n t h e f o r m w i t h t h e i r c o n t a c t information . W i t n e s s e s a r e required t o s i g n v e r i f y i n g t h a t t h e p r i n c i p a l d o e s n o t a p p e a r t o b e u n d e r a n y c onstraint or undue influence t o s i g n t h e form . U n d e r t h e M a s s a c h u s e t t s l a w , t h e witnesses cannot be related to t h e p r i n c i p a l by blood or marriage, a n d s h o u l d n o t b e e n t i t l e d t o o r h a v e a n y c l a i m s o n t h e e s t a t e o f t h e p r i n c i p a l . B C H c l i n i c i a n s a n d / o r o t h e r s t a f f a r e a l l o w e d t o s i g n a s w i t n e s s e s i f t h e r e a r e n o o t h e r p a r t i e s a v a i l a b l e . W h e r e s h o u l d t h e H e a l t h C a r e P r o x y b e K e p t ? T h e principal s h o u l d a l w a y s k e e p t h e o r i g i n a l s i g n e d f o r m . C o p i e s o f t h e f o r m s h o u l d b e p r o v i d e d t o a l l m e d i c a l p r o v i d e r s ( i n c l u d i n g b u t n o t l i m i t e d t o a n y h o s p i t a l , community h e a l t h c e n t e r , l o n g t e r m c a r e f a c i l i t y , a n d y o u r p r o v i d e r ’ s o f f i c e / c l i n i c ) t o b e m a i n t a i n e d i n t h e p r i n c i p a l ’ s m e d i c a l r e c o r d . A c o p y should a l s o b e p r o v i d e d t o y o u r H e a l t h C a r e A g e n t t o u s e w i t h a n y o t h e r p r o v i d e r s t h a t w i l l

b e involved i n t h e p r i n c i p a l ’ s f u t u r e c a r e a n d t r e a t m e n t . C a n c e l l i n g t h e H e a l t h C a r e P r o x y ? T h e f o l l o w i n g m a y b e u s e d t o c a n c e l o r r e v o k e t h e H e a l t h C a r e P r o x y : 1. T h e principal sign s another Health Care Proxy a t a l a t e r d a t e ; 2. T h e principal notifies t h e i r a g e n t , c l i n i c i a n , o r o t h e r h e a l t h c a r e p r o v i d e r s t a f f t h a t t h e y want to revoke t h e p roxy , p r o v i d e d t h e pri ncipal h a s c a p a c i t y . T h i s c a n b e d o n e o r a l l y , i n w r i t i n g , o r o t h e r a c t i o n ( i n c l u d i n g d e s t r o y i n g t h e o r i g i n a l ) ; 3. A c o u r t o f c o m p e t e n t j u r i s d i c t i o n d e c l a r e s t h e H e a l t h C a r e P r o x y t o b e t e r m i n a t e d ; o r 4. T h e p r i n c i p a l c h a n g e s t h e a g e n t , b e c o m e s l e g a l l y s e p a r a t e d f r o m , o r d i v o r c e s t h e n a m e d h e a l t h c a r e a g e n t . DO N OT SEND THIS PAGE TO MEDICAL RECORDS MASSACHUSETTS HEALTH CARE PROXY Use Plate, Label, or Print: Name: BCH MRN#: DOB: Gender: Rev 7/7/2022 Health Care Proxy Form (1) I, ______________________________________, appoint as my principal Health Care Agent (print name, home address, telephone , a n d email of health care agent ) If my agent is u n a b l e o r unwilling to serve, I appoint as an alternate health ca r e agent : (print name, home address, telephone , a n d email of health care agent ) (2) I hereby direct my Agent to so act as my healthcare proxy to have full power, authority and discretion to r e v i e w a n y h e a l t h i n f o r m a t i o n a s w e l l a s make any and all health care consultation, treatment, and/or care coordinating decisions for me regarding my own medical and/or mental health care, including decisions about life sustaining medical treatment, without any limitations. T his declaration shall be honored by my family and my health ca re providers as the final expression of my desires regarding my future care. I further expressly revoke any and all Health Care Proxies that may have been signed prior to this Proxy. The determination regarding my ability to make health care decis ions is to be made by my treating healthcare provider . Furthermore, I hereby agree that any third party receiving a copy of this instrument via mail, fa x, or other electronic means, shall so act hereunder. I agree to hold harmless any such third party from and against any and all claims that may arise by reason of having relied on the provisions of this instrument. Unless so listed here, limitations on my Agent’s authority shall include: ( 3 ) Principal Signature : Date : I n t h e c a s e t h e Principal is unable to sign, I am sign ing this proxy form on behalf of the Principal (including writing their name above) in the presence of the Principal and two witn esses. Name: Signature: Date: Witness Statement I hereby witness this declaration and attest that I have met Principal and believe they are of sound mind , at least eighteen years of age, and under no constraint or u n d u e influence . I declare under penalty of perjury of l a w that the foregoing is true and correct in our presence this _________day of ________________, 20____. Witness #1 N a m e : S i g n a t u r e : A d d r e s s : Witness # 2 N a m e : S i g n a t u r e : A d d r e s s :