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Massachusetts s Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ 2 e) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ _____________________________________________ (Witnesunder no duress, constraint or undue influence. He or she signed (or asked another to sign for him or her) this document in my presence. _____________________________________________ (Witness Signatur___________________________ 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 in a new writing or by clearly indicating that I have 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 ____ ____________________________________________________________________________ ____________________________________________________________________________ ___________________________________________________________________________________________ ____________________________________________________________________________ ________________________________________________________________________ antibiotics. However, I do want maximum pain relief, even if it may hasten my death. Additional Instructions (optional - insert personal instructions or cross out if none): __________________________escribed above I feel very strongly 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 including any pain that might 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) d (3) a minimally conscious condition 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,n incurable or irreversible mental or physical condition with no reasonable expectation of recovery, including but not limited to: (1) a terminal condition; (2) a permanently unconscious condition; ored commitment to decline medical 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 aeing of sound mind, make this 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 settlchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Choice In Dying / Living Will I, ___________________________________________________________, bom a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purfrom 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 make sure it fits your particular situation. Advice frsuitability 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 time and 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 to their s 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 pursuant tof 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 providerubsequent 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 informed ooke a health care proxy unless determined otherwise pursuant to court order. Information & Instructions ­ Page 5 A health care proxy shall also be revoked upon: (i) execution by the principal of a scare provider orally or in writing or by any 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 revhall be required. CHAPTER 201D. HEALTH CARE 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 hat the principal has regained capacity: (i) the authority of the agent shall cease, but shall recommence if the principal subsequently loses capacity; and (ii) the principal's consent for treatment sh 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 event the attending physician determines tnding a determination pursuant to this section 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 healtto 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 pursuant to a health care proxy. Notwithstaincipal'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 director. A determination made pursuant ns. 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, where there is any indication of the pr 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's capacity to make health care decisiomakes the determination must have, or must consult with a health care professional who has, specialized training or experience in diagnosing or treating mental illness or developmental disabilities ofd into the principal's permanent medical record. If the attending physician determines that a patient lacks capacity because of mental illness or developmental disability, the attending physician who 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 written determination shall be entereons ­ Page 4 communicate health care decisions. Such determination shall be made by the attending physician according to accepted standards of medical judgment. The determination shall be in writing The authority of a health care agent shall begin after a determination is made, pursuant to the provisions of this section, that the principal lacks the capacity to make or to Information & InstructiPROXIES. Section 6. Determination that principal lacks capacity to make or to communicate health care decisions; notice; objections to agent's decision; determination of regained capacity. Section 6. alth care proxy to the same extent as if such decisions 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 th care proxy shall arrange for the proxy or a copy thereof 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 herney as would decisions by the principal, when competent, except as otherwise provided in the health care proxy or by specific court order overriding the proxy. A physician who is provided with a healsions by an agent pursuant to a health care proxy on a principal's behalf shall have the same priority over decisions by any other person, including a person acting pursuant to a durable power of attoion necessary to make informed decisions regarding the principal's health care, including any and all confidential medical information that the principal would be entitled to receive. Health care decirdance with the agent's assessment of the principal's best interests. Notwithstanding any general or special law to the contrary, the agent shall have the right to receive any and all medical informath care decisions: (i) in accordance with the agent's assessment of the principal's wishes, including the principal's religious and moral beliefs, or (ii) if the principal's wishes are unknown, in accor consultation with health care providers, and after full consideration of acceptable medical alternatives regarding diagnosis, prognosis, treatments and their side effects, the agent shall make healtcare decisions on the principal's behalf that the principal could make, including decisions about life-sustaining treatment, subject, however, to any express limitations in the health care proxy. AfteD. HEALTH CARE PROXIES. Section 5. Health care decisions; 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 authority; and (iv) indicate that the agent's authority shall become effective if it is determined pursuant to section six that the principal lacks capacity to make health care decisions. CHAPTER 201ve authority to make health care decisions on the principal's behalf; Information & Instructions ­ Page 3 (iii) describe the limitation, if any, that the principal intends to impose upon the agent's PROXIES. Section 4. Duties of health care proxy. Section 4. The health care proxy shall: (i) identify the principal and the health care agent; (ii) indicate that the principal intends the agent to haent of such facility or has applied for admission to such facility unless said operator, administrator or employee is related to the principal by blood, marriage or adoption. CHAPTER 201D. HEALTH CAREon 3. No person who is an operator, administrator or employee of a facility may be appointed as health care agent by an adult, who, at the time of executing the health care proxy is a patient or residrincipal's behalf pursuant to other requirements of this chapter. CHAPTER 201D. HEALTH CARE PROXIES. Section 3. Operators, administrators or employees of facilities; limitations on appointments. Secticare agent is not expected to become available, willing or competent to make a timely decision given the patient's medical circumstances; or, the health care agent is disqualified from acting on the pernate health care agent as part of a valid health care proxy. Said alternate may serve when the designated health care agent is not available, willing or competent to serve and the designated health section, every adult shall be presumed to be competent and every health care proxy shall be presumed to be properly executed unless a court determines otherwise. A competent adult may designate an altnd and under no constraint or undue influence. No person who has been named 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 of two other adults who shall subscribe their names as witnesses to such signature. The witnesses shall affirm in writing that the principal appeared to be at least eighteen years of age, of sound mi shall have the right to appoint a health care agent by executing a health care proxy. Said health care proxy shall be in writing signed by such adult or at the direction of such adult in the presence a person who has executed a health care proxy. CHAPTER 201D. HEALTH CARE PROXIES. Section 2. Appointment of health care agents; health care proxies; alternate agents. Section 2. Every competent adultoxy'', a document delegating to an agent the authority to make health care decisions, executed in accordance with the requirements of this chapter. Information & Instructions ­ Page 2 ""Principal'',der'', an individual or facility licensed, certified, or otherwise authorized or permitted by law to administer health care in the ordinary course of business or professional practice. "Health care prwhich is made in accordance with the requirements of this chapter, is consistent with any limitations in the health care proxy, and is consistent with responsible medical practice. ""Health care provi agent'' or ""agent'', an adult to whom authority to make health care decisions is delegated under a health care proxy. ""Health care decision made by an agent under a health care proxy'', a decision s defined in section seventy E of chapter one hundred and eleven. ""Health care'', any treatment, service or procedure to diagnose or treat the physical or mental condition of a patient. ""Health care the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and to reach an informed decision. ""Facility'', any facility ad. Where more than one physician shares such responsibility, any such physician may act as the attending physician. ""Capacity to make health care decisions'', the ability to understand and appreciatehysician'', the physician, selected by or assigned to a patient, who has primary responsibility for the treatment and care of the patient, in whatever setting medical diagnosis or treatment is rendere01D. HEALTH CARE PROXIES. Section 1. Definitions. Section 1. As used in this chapter the following words shall, unless the context clearly requires otherwise, have the following meanings:""Attending pl is based on the General Laws of Massachusetts Title II Chapter 201D. For your convenience, we have included useful excerpts from the General Laws of Massachusetts relating to Living Wills. CHAPTER 2Information and Instructions Massachusetts Living Will This package contains (1) Information and Instruction for Massachusetts Living Will; (2) Massachusetts Living Will. This Massachusetts Living Wil Massachusetts