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Massachusetts ___________________________________ Address: ______________________________________ Phone: _______________________________________ 2 ________________________ Address: ______________________________________ Phone: _______________________________________ _____________________________________________ (Witness Signa ture) Print Name: or undue influence. He or she signed (or asked another to sign for him or her) this document in my presence. _____________________________________________ (Witness Signature) Print Name: ___________ Dated: ______________________________ Statement by Witnesses I declare that the person who signed this document appears to be at least 18 years of age, of sound mind, and under no duress, constraintly indicating that I ha ve changed my mind. Signed: ____________________________________________________________________ Address: _____________________________________________________________________________ 1 These directions express my legal right to refuse treatment under federal and state law. I intend my instructions to be carried out, unless I have revoked them in a new writing or by clear_____________________________________________________ ____________________________________________________________________________ ___________________________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _______________________want maximum pain relief, even if it may hasten my death. Additional Instructions (optional - insert personal instructions or cross out if none): ______________________________________________________trongly about the following forms of treatment: · I do not want cardiac resuscitation. · I do not want mechanical respiration. · I do not want tube feeding. · I do not want antibiotics. However, I do ht occur by withholding or withdrawing treatment. Although I understand that I am not legally required to be specific about future treatments, if I am in the condition(s) described above I feel very sondition in which I am permanently unable to make decisions or express my wishes. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that migmental or physical condition with no reasonable expectation of recovery, including but not limited to: (1) a terminal condition; (2) a permanently unconscious condition; or (3) a minimally conscious cical treatment under the circumstances indicated below: I direct my attending physician to withhold or withdraw treatment that merely prolongs my dying, if I should be in an incurable or irreversible s statement as a directive to be followed if I become permanently unable to participate in decisions regarding my medical care. These instructions reflect my firm and settled commitment to decline med is subject to the Disclaimers and Terms of Use found at findlegalforms.com Choice In Dying / Living Will I, ___________________________________________________________, being of sound mind, make this recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these formsorms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is alway purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These fly notify the attending physician of such revocation. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specifice involved in the principal's care of the revocation. Any agent or member of the nursing staff informed of or provided with a revocation of a health care proxy pursuant to this section shall immediateon of a health care proxy shall immediately record the revocation in the principal's medical record and notify orally and in writing the agent and any health care providers known by the physician to br (ii) the divorce or legal separation of the principal and his spouse, where the spouse is the principal's agent under a health care proxy. A physician who is informed of or provided with a revocatiotherwise pursuant to court order. Living Will Information & Instructions ­ Page 5 A health care proxy shall also be revoked upon: (i) execution by the principal of a subsequent health care proxy, ony other act evidencing a specific intent to revoke the proxy. For the purposes of this section, every principal shall be presumed to have the capacity to revoke a health care proxy unless determined E PROXIES. Section 7. Revocation of health care proxy; notification. Section 7. A principal may revoke a health care proxy by notifying the agent or a health care provider orally or in writing or by a) the authority of the agent shall cease, but shall recommence if the principal subsequently loses capacity; and (ii) the principal's consent for treatment shall be required. CHAPTER 201D. HEALTH CARl prevail unless the principal is determined to lack capacity to make health care decisions by court order. In the event the attending physician determines that the principal has regained capacity: (iion that the principal lacks capacity to make health care decisions, where a principal objects to a health care decision made by an agent pursuant to a health care proxy the principal's decisions shalcity to make health care decisions is solely for the purpose of empowering an agent to make health care decisions pursuant to a health care proxy. Notwithstanding a determination pursuant to this sect; (ii) to the agent; and (iii) if the patient is in or is transferred from a mental health facility, to the facility director. A determination made pursuant to this section that a principal lacks capapal lacks capacity to make health care decisions shall promptly be given orally and in writing: (i) to the principal, where there is any indication of the principal's ability to comprehend such noticedetermination. A physician who has been appointed as a patient's agent shall not make the determination of the patient's capacity to make health care decisions. Notice of a determination that a princiconsult with a health care professional who has, specialized training or experience in diagnosing or treating mental illness or developmental disabilities of the same or similar nature in making such cord. If the attending physician determines that a patient lacks capacity because of mental illness or developmental disability, the attending physician who makes the determination must have, or must opinion regarding the cause and nature of the principal's incapacity as well as its extent and probable duration. This written determination shall be entered into the principal's permanent medical reions. Such determination shall be made by the attending physician according to accepted standards of medical judgment. The determination shall be in writing and shall contain the attending physician'sa determination is made, pursuant to the provisions of this section, that the principal lacks the capacity to make or to Living Will Information & Instructions ­ Page 4 communicate health care deciscapacity to make or to communicate health care decisions; notice; objections to agent's decision; determination of regained capacity. Section 6. The authority of a health care agent shall begin after have been made by the principal, subject to any limitations in the health care proxy, or in any specific court order. CHAPTER 201D. HEALTH CARE PROXIES. Section 6. Determination that principal lacks eof to be inserted in the principal's medical record. A health care provider shall comply with health care decisions made by an agent under a health care proxy to the same extent as if such decisions , except as otherwise provided in the health care proxy or by specific court order overriding the proxy. A physician who is provided with a health care proxy shall arrange for the proxy or a copy therrincipal's behalf shall have the same priority over decisions by any other person, including a person acting pursuant to a durable power of attorney as would decisions by the principal, when competentincipal's health care, including any and all confidential medical informa tion that the principal would be entitled to receive. Health care decisions by an agent pursuant to a health care proxy on a pt interests. Notwithstanding any general or special law to the contrary, the agent shall have the right to receive any and all medical information necessary to make informed decisions regarding the prssment of the principal's wishes, including the principal's religious and moral beliefs, or (ii) if the principal's wishes are unknown, in accordance with the agent's assessment of the principal's bes consideration of acceptable medical alternatives regarding diagnosis, prognosis, treatments and their side effects, the agent shall make health care decisions: (i) in accordance with the agent's asseal could make, including decisions about life-sustaining treatment, subject, however, to any express limitations in the health care proxy. After consultation with health care providers, and after full agents's right to medical information; priority of agent's decisions. Section 5. An agent shall have the authority to make any and all health care decisions on the principal's behalf that the principhall become effective if it is determined pursuant to section six that the principal lacks capacity to make health care decisions. CHAPTER 201D. HEALTH CARE PROXIES. Section 5. Health care decisions; Living Will Information & Instructions ­ Page 3 (iii) describe the limitation, if any, that the principal intends to impose upon the agent's authority; and (iv) indicate that the agent's authority sh care proxy shall: (i) identify the principal and the health care agent; (ii) indicate that the principal intends the agent to have authority to make health care decisions on the principal's behalf; ss said operator, administrator or employee is related to the principal by blood, marriage or adoption. CHAPTER 201D. HEALTH CARE PROXIES. Section 4. Duties of health care proxy. Section 4. The healtlity may be appointed as health care agent by an adult, who, at the time of executing the health care proxy is a patient or resident of such facility or has applied for admission to such facility unleER 201D. HEALTH CARE PROXIES. Section 3. Operators, administrators or employees of facilities; limitations on appointments. Section 3. No person who is an operator, administrator or employee of a facimake a timely decision given the patient's medical circumstances; or, the health care agent is disqualified from acting on the principal's behalf pursuant to other requirements of this chapter. CHAPTrnate may serve when the designated health care agent is not available, willing or competent to serve and the designated health care agent is not expected to become available, willing or competent to care proxy shall be presumed to be properly executed unless a court determines otherwise. A competent adult may designate an alternate health care agent as part of a valid health care proxy. Said altemed as health care agent in a health care proxy shall act as a witness to the execution of such proxy. For the purposes of this section, every adult shall be presumed to be competent and every health h signature. The witnesses shall affirm in writing that the principal appeared to be at least eighteen years of age, of sound mind and under no constraint or undue influence. No person who has been nath care proxy. Said health care proxy shall be in writing signed by such adult or at the direction of such adult in the presence of two other adults who shall subscribe their names as witnesses to sucE PROXIES. Section 2. Appointment of health care agents; health care proxies; alternate agents. Section 2. Every competent adult shall have the right to appoint a health care agent by executing a heal executed in accordance with the requirements of this chapter. Living Will Information & Instructions ­ Page 2 ""Principal'', a person who has executed a health care proxy. CHAPTER 201D. HEALTH CARitted by law to administer health care in the ordinary course of business or professional practice. "Health care proxy'', a document delegating to an agent the authority to make health care decisions, any limitations in the health care proxy, and is consistent with responsible medical practice. ""Health care provider'', an individual or facility licensed, certified, or otherwise authorized or permlegated under a health care proxy. ""Health care decision made by an agent under a health care proxy'', a decision which is made in accordance with the requirements of this chapter, is consistent withy treatment, service or procedure to diagnose or treat the physical or mental condition of a patient. ""Health care agent'' or ""agent'', an adult to whom authority to make health care decisions is des of and alternatives to any proposed health care, and to reach an informed decision. ""Facility'', any facility as defined in section seventy E of chapter one hundred and eleven. ""Health care'', ant as the attending physician. ""Capacity to make health care decisions'', the ability to understand and appreciate the nature and consequences of health care decisions, including the benefits and risknsibility for the treatment and care of the patient, in whatever setting medical diagnosis or treatment is rendered. Where more than one physician shares such responsibility, any such physician may ache following words shall, unless the context clearly requires otherwise, have the following meanings:""Attending physician'', the physician, selected by or assigned to a patient, who has primary responce, we have included useful excerpts from the General Laws of Massachusetts relating to Living Wills. CHAPTER 201D. HEALTH CARE PROXIES. Section 1. Definitions . Section 1. As used in this chapter ttion and Instruction for Massachusetts Living Will; (2) Massachusetts Living Will. This Massachusetts Living Will is based on the General Laws of Massachusetts Title II Chapter 201D. For your convenie_________ Address: ______________________________________ Date: _________________________________________ -2- Information and Instructions Massachusetts Living Will This package contains (1) Informaress: ______________________________________ Date: _________________________________________ _____________________________________________ (Witness 2 Signature) Print Name: __________________________ce. I am not the person appointed as agent or alternate agent by this document. _____________________________________________ (Witness 1 Signature) Print Name: ___________________________________ Addocument appears to be at least 18 years of age, of sound mind, and under no duress, constraint or undue influence. He or she signed (or asked another to sign for him or her) this document in my presen_________ Address: ______________________________________________________________________ Dated: ______________________________ -1- Statement by Witnesses I declare that the person who signed this d_________________________________________________ _____________________________________________________________________________ (5) Signed: ___________________________________________________________ she determines to be my best interests. (4) Other directions (optional ­ cross out if none): _____________________________________________________________________________ ____________________________in accord with my wishes and limitations as as may be stated below, or as he or she otherwise knows. If my wishes are unknown, I direct my agent to make health care decisions in accord with what he orternate agent) _____________________________________________________________________________ (home address and telephone number of alternate agent) (3) I direct my agent to make health care decisions t if the person I appoint above is unable, unwilling or unavailable to act as my health care agent (optional): _____________________________________________________________________________ (name of alexcept to the extent that I state otherwise below. This Health Care Proxy shall take effect in the event I become unable to make or communicate my own health care decisions. (2) Name of alternate agent) _____________________________________________________________________________ (home address and telephone number of agent) as my health care agent to make any and all health care decisions for me, Health Care Proxy (1) I, ____________________________________________________________, hereby appoint (name) _____________________________________________________________________________ (name of agenut of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -5- Massachusetts an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising oime and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should haveo their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to tuant to this section shall immediately notify the attending physician of such revocation. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as troviders known by the physician to be involved in the principal's care of the revocation. Any agent or member of the nursing staff informed of or provided with a revocation of a health care proxy pursormed of or provided with a revocation of a health care proxy shall immediately record the revocation in the principal's medical record and notify orally and in writing the agent and any health care pof a subsequent health care proxy, or (ii) the divorce or legal separation of the principal and his spouse, where the spouse is the principal's agent under a health care proxy. A physician who is infhall be presumed to have the capacity to revoke a health care proxy unless determined otherwise pursuant to court order. A health care proxy shall also be revoked upon: (i) execution by the principal xy by notifying the agent or a health care provider orally or in writing or by any other act evidencing a specific intent to revoke the proxy. -4- For the purposes of this section, every principal se principal's consent for treatment shall be required. CHAPTER 201D. HEALTH CARE PROXIES. Section 7. Revocation of health care proxy; notification. Section 7. A principal may revoke a health care pro the attending physician determines that the principal has regained capacity: (i) the authority of the agent shall cease, but shall recommence if the principal subsequently loses capacity; and (ii) th made by an agent pursuant to a health care proxy the principal's decisions shall prevail unless the principal is determined to lack capacity to make health care decisions by court order. In the eventnt to a health care proxy. Notwithstanding a determination pursuant to this section that the principal lacks capacity to make health care decisions, where a principal objects to a health care decisionector. A determination made pursuant to this section that a principal lacks capacity to make health care decisions is solely for the purpose of empowering an agent to make health care decisions pursuaere there is any indication of the principal's ability to comprehend such notice; (ii) to the agent; and (iii) if the patient is in or is transferred from a mental health facility, to the facility dir capacity to make health care decisions. Notice of a determination that a principal lacks capacity to make health care decisions shall promptly be given orally and in writing: (i) to the principal, whness or developmental disabilities of the same or similar nature in making such determination. A physician who has been appointed as a patient's agent shall not make the determination of the patient'sability, the attending physician who makes the determination must have, or must consult with a health care professional who has, specialized training or experience in diagnosing or treating mental illwritten determination shall be entered into the principal's permanent medical record. If the attending physician determines that a patient lacks capacity because of mental illness or developmental dishe determination shall be in writing and shall contain the attending physician's opinion regarding the cause and nature of the principal's incapacity as well as its extent and probable duration. This hat the principal lacks the capacity to make or to communicate health care decisions. Such determination shall be made by the attending physician according to accepted standards of medical judgment. T to agent's decision; determination of regained capacity. -3- Section 6. The authority of a health care agent shall begin after a determination is made, pursuant to the provisions of this section, tre proxy, or in any specific court order. CHAPTER 201D. HEALTH CARE PROXIES. Section 6. Determination that principal lacks capacity to make or to communicate health care decisions; notice; objections shall comply with health care decisions made by an agent under a health care proxy to the same extent as if such decisions have been made by the principal, subject to any limitations in the health ca order overriding the proxy. A physician who is provided with a health care proxy shall arrange for the proxy or a copy thereof to be inserted in the principal's medical record. A health care providererson, including a person acting pursuant to a durable power of attorney as would decisions by the principal, when competent, except as otherwise provided in the health care proxy or by specific courton that the principal would be entitled to receive. Health care decisions by an agent pursuant to a health care proxy on a principal's behalf shall have the same priority over decisions by any other pe agent shall have the right to receive any and all medical information necessary to make informed decisions regarding the principal's health care, including any and all confidential medical informatioral beliefs, or (ii) if the principal's wishes are unknown, in accordance with the agent's assessment of the principal's best interests. Notwithstanding any general or special law to the contrary, thnosis, treatments and their side effects, the agent shall make health care decisions: (i) in accordance with the agent's assessment of the principal's wishes, including the principal's religious and m, however, to any express limitations in the health care proxy. After consultation with health care providers, and after full consideration of acceptable medical alternatives regarding diagnosis, progion 5. An agent shall have the authority to make any and all health care decisions on the principal's behalf that the principal could make, including decisions about life-sustaining treatment, subjectprincipal lacks capacity to make health care decisions. CHAPTER 201D. HEALTH CARE PROXIES. Section 5. Health care decisions; agents's right to medical information; priority of agent's decisions. Secttion, if any, that the principal intends to impose upon the agent's authority; and (iv) indicate that the agent's authority shall become effective if it is determined pursuant to section six that the y the principal and the health care agent; -2- (ii) indicate that the principal intends the agent to have authority to make health care decisions on the principal's behalf; (iii) describe the limita or employee is related to the principal by blood, marriage or adoption. CHAPTER 201D. HEALTH CARE PROXIES. Section 4. Duties of health care proxy. Section 4. The health care proxy shall: (i) identif care agent by an adult, who, at the time of executing the health care proxy is a patient or resident of such facility or has applied for admission to such facility unless said operator, administratorection 3. Operators, administrators or employees of facilities; limitations on appointments. Section 3. No person who is an operator, administrator or employee of a facility may be appointed as healthe patient's medical circumstances; or, the health care agent is disqualified from acting on the principal's behalf pursuant to other requirements of this chapter. CHAPTER 201D. HEALTH CARE PROXIES. Sated health care agent is not available, willing or competent to serve and the designated health care agent is not expected to become available, willing or competent to make a timely decision given th be properly executed unless a court determines otherwise. A competent adult may designate an alternate health care agent as part of a valid health care proxy. Said alternate may serve when the designealth care proxy shall act as a witness to the execution of such proxy. For the purposes of this section, every adult shall be presumed to be competent and every health care proxy shall be presumed tol affirm in writing that the principal appeared to be at least eighteen years of age, of sound mind and under no constraint or undue influence. No person who has been named as health care agent in a h proxy shall be in writing signed by such adult or at the direction of such adult in the presence of two other adults who shall subscribe their names as witnesses to such signature. The witnesses shalnt of health care agents; health care proxies; alternate agents. Section 2. Every competent adult shall have the right to appoint a health care agent by executing a health care proxy. Said health carelth care decisions, executed in accordance with the requirements of this chapter. ""Principal'', a person who has executed a health care proxy. CHAPTER 201D. HEALTH CARE PROXIES. Section 2. Appointmerized or permitted by law to administer health care in the ordinary course of business or professional practice. -1- "Health care proxy'', a document delegating to an agent the authority to make heansistent with any limitations in the health care proxy, and is consistent with responsible medical practice. ""Health care provider'', an individual or facility licensed, certified, or otherwise authoisio ns is delegated under a health care proxy. ""Health care decision made by an agent under a health care proxy'', a decision which is made in accordance with the requirements of this chapter, is coh care'', any treatment, service or procedure to diagnose or treat the physical or mental condition of a patient. ""Health care agent'' or ""agent'', an adult to whom authority to make health care decits and risks of and alternatives to any proposed health care, and to reach an informed decision. ""Facility'', any facility as defined in section seventy E of chapter one hundred and eleven. ""Healtician may act as the attending physician. ""Capacity to make health care decisions'', the ability to understand and appreciate the nature and consequences of health care decisions, including the benefrimary responsibility for the treatment and care of the patient, in whatever setting medical diagnosis or treatment is rendered. Where more than one physician shares such responsibility, any such physis chapter the following words shall, unless the context clearly requires otherwise, have the following meanings:""Attending physician'', the physician, selected by or assigned to a patient, who has p. The following are useful excerpts from the General Laws of Massachusetts relating to the Health Care Proxy Form. CHAPTER 201D. HEALTH CARE PROXIES. Section 1. Definitions . Section 1. As used in thHealth Care Proxy (Power of Attorney for Health Care) Form. This Massachusetts Health Care Proxy (Power of Attorney for Health Care) is based on the General Laws of Massachusetts Title II Chapter 201DHealth Care Proxy (Power of Attorney for Health Care) This package contains (1) Information and Instruction for Massachusetts Health Care Proxy (Power of Attorney for Health Care) ; (2) Massachusetts ld be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Massachusetts ke sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document shou and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to marranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal as an Advance Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express waMassachusetts Advance Health Care Directive This package contains both a Massachusetts Power of Attorney for Health Care and a Massachusetts Living Will. Together these forms are also sometimes known Massachusetts