Health Care Proxy

A health-care proxy form is an extremely important document that every patient should have in order to serve as protection of his or her wishes at a time when he or she might be incapacitated. A health-care proxy is a person who is appointed to make decisions on behalf of the patient if the patient is unable to do so. This health-care proxy is anyone whom the patient designates as someone he or she trusts: for example, a family member or close friend. Once this health-care proxy is designated, that person is authorized to make health-care decisions for the patient should the patient lose the ability to make decisions for himself or herself. It is not necessary to have a lawyer fill out this health-care proxy form;it is a form that can be completed by the patient with understanding on the part of the health-care proxy of this designation and the signatures of two witnesses. This becomes hospital record and can be used in the future as necessary. Any adult, 18 years of age or older, may be the health-care proxy. It is important that once the proxy is designated, the patient discuss wishes about advanced directives if such a situation should arise: the desire to be maintained on artificial nutrition, mechanical ventilation, renal replacement, or organ/tissue donation. Knowledge of the patient's viewpoints of these measures will help improve the ability of the health-care proxy to make decisions that best reflect the patient's wishes. The patient may even give the healthcare proxy specific instructions to follow, and this may be documented in the health-care proxy form, but this is not required.

Even though the patient has signed this health-care proxy form, he or she still has the right to make health-care decisions for himself or herself as long as he or she is able to do so. Treatment cannot be given to the patient or stopped if the patient objects, and the proxy has no power to object. The patient may also cancel the authority given to the health-care proxy by telling him or her orally or in writing.

Appointing a health-care proxy is voluntary. No one can require a patient to appoint one. Copies of the health-care proxy form should be given to the proxy, the physician, family members, an attorney, and close friends. A copy should also be kept in the patient's wallet. If the patient is hospitalized, the form should be brought in and included in the medical record.

It is important to understand the difference between a living will and a health-care proxy form. A living will is a document that provides specific instructions about health-care decisions. A patient may put such instructions on his or her health-care proxy form. Unlike a living will, a health-care proxy form does not require that a patient knows in advance all the decisions that may arise. Instead, the health-care proxy can interpret a patient's wishes as medical circumstances change and can make decisions that a patient could not have known would have to be made.

Health Care Proxy Form


, residing at

(PRINT your name)

appoint of


(City or Town)


(Name of person you choose as Agent/Proxy)





as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect only when and if I become unable to make my own health care decisions.

(2) Optional: Alternate Agent/Proxy

If my Agent is unwilling or unable to serve, then I appoint as my Alternate Agent:

(Name of person you choose as Alternate Agent)

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.

Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall remain in effect indefinitely. (Optional: If you want this proxy to expire, state the date or conditions here.) This proxy shall expire (specify date or conditions) :

I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows or as stated below. (If you want to limit your agent's authority to make health care decisions for you or to give specific instructions, you may state your wishes or limitations here.) I direct my health care agent to make health care decisions in accordance with the following limitations and/or instructions (attach additional pages as necessary) :

In order for your agent to make health care decisions for you about artificial nutrition and hydration (nourishment and water provided by feeding tube and intravenous line), your agent must reasonably know your wishes. You can either tell your agent what your wishes are or include them in this section.

(5) Your Identification (please print)

Your Name_

Your Signature_Date_

Your Address_

(6) Optional: Organ and/or Tissue Donation

I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply)

□ Any needed organs and/or tissues

□ The following organs and/or tissues_

If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.

Your signature_Date_

(7) Statement by Witnesses

(Witnesses must be 18 years of age or older and cannot be the health care agent or alternate.)

I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence.

Name of Witness 1 (print ) Name of Witness 2 (print )

Signature Signature

Address_ Address

Adapted from the New York State Health Proxy Form.

The structure of the health-care proxy form may differ from state to state, but the common elements all include the following:

• Name and address of the agent/proxy

# Name and address of an alternative agent

• Duration of the proxy (not indicating a duration means it is valid unless stated otherwise)

# Special instructions: these can broaden or limit the powers of the agent. If the patient does not want to be sustained by feeding tubes no matter what, this can be stated here. If there are certain treatments that the patient does not want to receive, such as blood transfusion, then they must be indicated. However, if the patient wants to give the agent more flexibility with some or no restriction, this too must be written. Name, date, and signature of the primary individual

Instructions about tissue or organ donation

Signatures of two adult witnesses, stating that they have witnessed this agreement and that both parties appear to be competent. The witnesses must be 18 years of age or older. The agent and primary individual do not qualify as witnesses.

A copy of a sample proxy form is shown on the previous page. You should copy this form and give it to all your patients if they have not already designated a health-care proxy.

Health-care proxy forms have become increasingly important today as a result of conflicts among relatives of the primary individual. The Terri Schiavo case is a famous modern-day example that lasted for 15 years of court battles (1990-2005). The patient was an American woman who suffered brain damage and became dependent for survival on a feeding tube. Her husband wanted to remove her feeding tube, but her parents opposed this action. This resulted in lengthy court battles that raised many moral, political, and medical issues. The whole controversy may have been avoided had the patient designated either her parents or her husband as her health-care proxy. Without a health-care proxy, a surrogate that follows next of kin becomes designated;however, the decision-making capacity of a surrogate is much more limited and varies by state. Therefore, if any individual can designate a health-care proxy while he or she is in good health, much agonizing and conflict can be avoided if a situation warrants this need in the future.

The reader should review the DVD-ROM included with this book for an example of discussing a health-care proxy with a patient.

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