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Wednesday, November 7, 2012

Attachment to __ Health Care Proxy documents

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Attachment to __ Health Care Proxy documents
I, ______________________________________being of sound
mind, hereby make the following declaration of my carefully
deliberated wishes and intentions for the purpose of
offering health care proxy, my physician, family and
friends guidance. All end-of-life decisions should respect
my values and wishes while maintaining comfort and dignity.
I want to be pain free and comfortable at the end of life.

It is not my intent to authorize affirmative or deliberate
acts or omissions to shorten my life, rather only to permit
the natural process of dying.

I want to avoid life-prolonging interventions such as
cardiopulmonary resuscitation (CPR), kidney dialysis, or
breathing machines. My health care proxy is to direct my
physician or hospitalist to sign a do not resuscitate (DNR)
order and place it in my medical chart.

The following are my six (6) wishes:

[1] If I have a terminal condition as determined by my
attending physician and confirmed by a second qualified
physician it is my desire that my dying not be prolonged by
administration of death-prolonging procedures. My attending
physician is to withhold or withdraw medical procedures
that merely prolong the dying process

[2] If my terminal condition is, an incurable and
irreversible condition that even with the administration of
life-sustaining treatment will, in the opinion of the
attending physician and another physician, result in death
within six (6) months. Or I am persistently unconscious in
which thought and awareness of self and environment are

[3] If I have an end-stage condition, that is, a condition
caused by injury, disease, or illness, which results in
severe and permanent deterioration indicated by
incompetency and complete physical dependency for which
treatment of the irreversible condition would be medically

[4] If I am permanently unconscious and there is no
reasonable possibility that I will return to a cognitive or
sapient life, and shall include, but not be limited to, a
persistent vegetative state), as determined by my attending
physician and confirmed by a second qualified physician:

[5]If I have a serious irreversible illness or condition,
and the likely risks and burdens associated with the
medical intervention to be withheld or withdrawn may
reasonably be judged to outweigh likely benefits to me from
such intervention,

[6] If my quality of life is unacceptable to me because of
the following conditions {a, b, & c}.
{a} Permanent unconscious condition: I become totally
unaware of people or surroundings with little chance of
ever waking up from the coma.
{b} Permanent confusion: I become unable to remember,
understand, or make decisions. I don't recognize loved ones
or can't have a clear conversation with them.
[c} Dependent in all activities of daily living: I am no
longer able to talk clearly or move by myself, feed, bath,
dress, and walk and Rehabilitation or any other restorative
treatment will not help.

I DO NOT want treatment of new conditions including
resulting in unacceptable quality of life.
I direct that I be given health care treatment to relieve
pain or provide comfort even if such treatment might
shorten my life, suppress my appetite or my breathing, or
be habit forming.

I direct that all medical treatment be limited to measures
to provide comfort and to relieve pain and authorize the
administration of pain relieving drugs, even if their
administration may hasten the moment of my death.

I direct if the Life Sustaining Treatment is experimental
and not a proven therapy, or is likely to be ineffective or
futile in prolonging life, or is likely to merely prolong
an imminent dying process including use of surgery, blood
transfusions, or antibiotics that will deal with a new
condition but will not help the main illness; such therapy
and treatment shall not be used.

I direct that my life NOT be extended by artificially
administered nutrition and hydration. I DO NOT want tube
feedings to be given.

I direct my health care proxy person(s) to make health
care decisions for me, including: decisions to accept or
refuse any treatment, service, or procedure; decisions to
provide, withhold, or withdraw life-sustaining treatments
and artificial nutrition and hydration; and decisions
regarding organ donation, burial arrangements, and autopsy:

If any of the above conditions exist my attending
physician is to withhold or withdraw medical procedures
that merely prolong the dying process

This statement is made after careful consideration and is
in accordance with my strong convictions and beliefs. I
want the wishes and directions here expressed carried out
to the fullest extent. If there is a conflict between the
directions contained in this instrument and the
instructions given by my Health Care Proxy, the
instructions given by my Health Care Proxy shall control.

It is my intention this instrument shall amend any prior
Living Will or similar instrument, which I have executed.

I wish to live out my last days at home rather than in a
hospital, if it does not jeopardize the chance of my
recovery to a meaningful and conscious life and does not
impose an undue burden on my family.

Burial arrangements, hospice care, etc.: To my health care
proxy, my family, my physicians, my attorney, any medical
facility in whose care I may hereafter be, any individual
who may become responsible for my health, welfare or
affairs, and to any court having jurisdiction over my
person or property: I hereby direct that, after my death,
may bodily remains be cremated. I further request that no
formal wake or funeral ceremony be held, and that all
matters related to the disposition of my body at my death
be dealt with as simply and economically as possible.

1. To authorize, withhold or withdraw medical care and
surgical procedures.
2. To authorize, withhold or withdraw nutrition (food) or
hydration (water) medically supplied by tube through my
nose, stomach, intestines, arteries or veins.
3. To authorize my admission to or discharge from a
medical, nursing, residential or similar facility and to
make agreements for my care and health insurance for my
care, including hospice and/or palliative care.
4. To hire and fire medical, social service and other
support personnel responsible for my care.
5. To take any legal action necessary to do what I have
6. To request that a physician responsible for my care
issue a do-not-resuscitate (DNR) order, including an out-of-
hospital DNR order, and sign any required documents and

I direct my health care agent(aka Health Care Proxy) to
follow ALZ brain autopsy instructions if practical: Arrange
for a brain autopsy A brain autopsy involves a researcher
or physician to examine the brain after death to look for
the plaques and tangles found in Alzheimer's-affected
brains. It is the definitive way to confirm a diagnosis of
Alzheimer's. And, it may provide information researchers
can use to better understand the disease. A brain autopsy
may involve cost and special arrangements. To learn more
about getting a brain autopsy, contact the Alzheimer's

It is my intention that this directive shall be honored by
my family, physicians, health care proxy as the final
expression of my right to refuse medical or surgical
treatment and accept the consequences from such refusal.

My Health Care Agent (Health Care Proxy ) shall have
authority to act on my behalf only if, when and for so long
as a determination has been made that I lack the capacity
to make or to communicate health care decisions for myself.
This determination shall be made in writing by my attending
physician according to accepted standards of medical
judgment and the requirements of Chapter 201D of the
General Laws of Massachusetts.

My Health Care Agent (Health Care Proxy ) shall make
health care decisions for me only after consultation with
my health care providers and after full consideration of
acceptable medical alternatives regarding diagnosis,
prognosis, treatments and their side effects.

My Health Care Agent (Health Care Proxy ) shall make
health care decisions for me only in accordance with my
Health Care Proxy 's assessment of my wishes in accordance
with my Health Care Proxy's assessment of my best interests.

My Health Care Agent (Health Care Proxy ) shall have the
right to receive any and all medical information necessary
to make informed decisions regarding my health care,
including any and all confidential medical information that
I would be entitled to receive. I intend for my Health Care
Proxy to be treated as I would be with respect to my rights
regarding the use and disclosure of my individually
identifiable health information or other medical records.
This release authority applies to any information governed
by the Health Insurance Portability and Accountability Act
of 1996 (HIPAA), 42 USC 1320d and 45 CFR 160-164.

I execute this directive with the understanding that any
person, hospital, or medical institution which acts or
refrains from acting in reliance on and in compliance with
this directive shall be immune from liability otherwise
arising out of such failure to use or apply artificial,
extraordinary, extreme or radical medical or surgical means
or procedures calculated to prolong my life.

I understand the full impact of this directive and I am
emotionally and mentally competent to make this ....


This posting and any articles referred to in this posting
are not legal advice and are not intended as legal advice.
This posting and any articles referred to in this posting
are intended to provide only general information for
discussion of advance care planning.

Please remember This a copy of a personal health care
proxy prepared by an individual who is NOT a lawyer.

The contents of this posting have not been reviewed by any
attorney and may or may not be filled with errors. It is
contributed to this forum for members to discuss and
debate. You should discuss contents with your attorney
before adapting to your own requirements.

Health care proxy: An advance medical directive in the
form of a legal document that designates another person (a
proxy) to make health care decisions in case a person is
rendered incapable of making his or her wishes known. The
health care proxy has, in essence, the same rights to
request or refuse treatment that the person would have if
he or she were capable of making and communicating decisions.

While it is possible to download generic forms from the
internet, you have to be very careful that what you get is
in a current and acceptable for your particular state. Each
state has its own laws concerning acceptable language on a

I was more comfortable using hte services of an Elder Law
attorney. In addition to ensuring I had the correct
documents properly completed, she was also very helpful in
advising on how best to handle my parent's financial
affairs to ensure I did not jeopardize qualifying for
Medicaid assistance in the future, should it become

There are acutally four documents you should have completed:
Durable Power of Attorney - Gives you authority to handle
financial and legal affairs. Do NOT get a general POA -
this becomes invalid if your LO is delcared incompetent.
Make sure it is Durable. There are also two types of DPOA.
One type takes effect as soon as it is signed. The other
(called a "springing" DPOA) does not become effective until
the LO is officially declared incompetent. Avoid the
springing type if at all possible. If you have to act
quickly, trying to get two doctors and/or the court system
to declare incompetency is a nuisance. Having the type that
is immediately effective does not mean the LO must give
over control immediately, but it does allow you to step in
immediately when the need arises.

Medical Power of Attorney ( aka Health Care Proxy)- Gives
you the authority to make medical decisions on behalf of
your LO.

Living Will (aka Health Care Directive) - States your LO's
wishes concerning end-of-life medical decisions and care.
Guides the POA in making medical decisions in a manner that
is in agreement with LO's wishes.

Last Will and Testament - Appoints someone to handle
affairs after LO is deceased. The POAs become invalid at
the moment of death, so you need the will to appoint an
Executor, no matter how much or little is left in the form
of an estate.
Many Elder Law Attorneys will give an initial consultation
free of charge. I called several and spoke over the phone
with them to discuss my needs and their fees. I then
selected the one I had the most confidence in to proceed to
do futher business with.
The grantor (your ./... ) must have the requisite mental
capacity to sign a POA. If after signing the grantor
becomes incompacitated the document becomes void UNLESS
there are provisions in said document which makes the
document a Durable Power of Attorney. A DPOA continues to
be legal.

The document must be witnessed and notorized. The notory,
by signing, says that the grantor had the capacity to sign
said document.