This is an important legal form. Before signing this form, you should
understand the following facts:
- This forms 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.
- 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.
- 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 measure for you.
- Your agent will start making decisions for you when doctors decide
that you are not able to make health care decisions for yourself.
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 can 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 or 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 staff at the facility to
explain those restrictions.
You should tell the person you choose that he or 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. You 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 or her or your health care
provider orally or in writing.