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: IF:
[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 absent:
[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 ineffective:
[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illness or condition, and the likely risks and burdens associated with the medical intervention to be withheld or withdrawn may reasonably be judged to outweigh likely benefits to me from such intervention,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. ---Then: 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. --
MY HEALTH CARE AGENT (aka Health Care Proxy) HAS ALL OF THE FOLLOWING POWERS SUBJECT TO THIS DIRECTIVE 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 requested. 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 consents.
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 Association.
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.
--definitions: ------------------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 POA.
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 necessary.
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.
There is also a paper called a MOLST paper. I had to fill it out at the nursing home, at hospice and at the Day Care facility. It has a DNR (Do not resusitate) order on it and if that is your choice, then you keep that in a public place in your home and is the office of those caring for your loved one. My husband and I both chose the DNR because we do not want to be kept alive by artificial means. We both feel that when God calls you, you go home. I have watched too many old people kept alive by artificial means. I feel you lose your dignity in that situation and you are never the same after you do wake up, if you wake up! It has to be a personal choice and you need to discuss it while the patient understands what you are deciding. If you are his Health Care POA, then you have the right to make this decision for him or her. It has to be a legal paper! The MOLST is a Maryland requirement, but I understand it is coming to almost every state very soon. Several other states already have this paper.
I also live in Massachusetts. There is way too much in this document. I gave up reading it. I am a nurse and just lost my mother to Dementia and MDS 3 years ago Unfortunately, my mother never knew what she wanted until the last four days when her dementia cleared for a few moments and she told me to let her go. She had enough. Which was a big relief to me. Because for the past 12 years she was comfort care, no heroics. I was my mother's HCP. But, when a patient dies the HCP also dies. You need a POA- excutor/ executrix. The POA take care of the estate if you are incompetent. But,at death a simple POA dies too. You need a POA-executor/executrix for burials and wishes after death. I suggest you have two separate people you trust. My sister was the POA-executrix and wanted to sell my mother's home and put my mother in a nursing home. I being the HCP refused and my mother went no where. Brain donations, I have been involved with at death you still will need the permission of your executor/executrix. An executor/executrix would be the one person to give permission. If you don't have one and you have children. Each one would have to consent. If one says no then it won't happen. It is the law in MA. Brain donation. You need to sign on with a facility that does research on the brain. Massachusetts General Hospital in Boston is one facility I can think of, Dr. Louis Perls was last in charge. But, you could call them. They would need to do this while you are alive it is a little involved with paper work. There no time to start the process when you die because it would take too long and plans need to be made while you are alive so when you die. They can make one phone call. Living wills are not legal in MA. But, they are useful to your Primary Care Physician they can guide in your care. I put one in my chart. Your HCP needs to in force your wishes. I am a big believer in Comfort Care for the elderly or anyone at any age who has a terminal illness.
I am going through this right now. My mother had a simpler version but her intent was clear. She is now in Hospice. The above could not be clearer. Thanks for that!
The forms that you can download for free from the Compassion and Choices website are not "generic" -- this is the organization that is at the forefront of the movement, and their documents are researched state by state.
I never thought in this day and age. We tie people to chairs and force feed. This cruel to do to anyone. The long term care facility I worked in. This was never allowed. Yes, if a patient was will to eat and needed assistance. Even in Dementia when a person stops and medically unknown. Then it is believed a person was giving up. ""Failure to Thrive"" Force feeds and syringe feeding are unethical. Any institution that practices this should be shut down.
In addition, mental impairment aka mental illness poor judgement. You can have dementia also considered impaired judgement. The woman has instructed very clearly in a sound mind. No artificial hydration or feeding. I would assume that would include force feeding. Her HCP would in force no force feed. But, any facility has to follow the laws of the state. I can't imagine a facility doing this alone. If so they need to be reported to DPH.
Dr. Stanley Terman is a physician with a special interest in helping people plan for advanced dementia. He has a website called Caring Advocates.org.
POLST/MOLST is a good option, but doesn't walk you through a detailed advance plan for dementia. However, it can be completed by a family member, on behalf of someone with dementia.
Forms are nice, but if the patient has dementia and cannot sign the laws of that particular state take over. Most states will not allow the MD to with hold any thing. Very Scary.
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: IF:
[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 absent:
[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 ineffective:
[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. ---Then: 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. --
MY HEALTH CARE AGENT (aka Health Care Proxy) HAS ALL OF THE FOLLOWING POWERS SUBJECT TO THIS DIRECTIVE
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 requested.
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 consents.
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 Association.
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.
--definitions: ------------------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 POA.
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 necessary.
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.
POLST/MOLST is a good option, but doesn't walk you through a detailed advance plan for dementia. However, it can be completed by a family member, on behalf of someone with dementia.