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Massachusetts Health Care Proxy Form 2

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Massachusetts Health Care Proxy Form 2
Massachusetts Health Care Proxy Form 2
Expressing your wishes regarding your care and treatment
450 Brookline Ave.
Boston, MA 02215
Health care decisions: Planning in advance
You have the right to make decisions about your own medical care. A serious illness or
accident, however, could prevent you from making or communicating those choices.
That’s why it is important to think about your wishes and share them with your health
care team and loved ones both in person and in writing.
A health care proxy form is a simple legal document that allows you, if you are age 18 or
older, to name someone you trust to speak for you if you cannot make medical decisions
on your own. In Massachusetts, the person you choose is called a health care agent.
At Dana-Farber, we believe that everyone should have a health care proxy, regardless of
their health status. We encourage you to fill out the attached health care proxy form.
Our goal is to have each adult patient identify a health care agent by his or her third visit
at Dana-Farber. You can decline to identify an agent, but you will be asked to do so in
writing. You do not need a signed health care proxy form to receive excellent care at
If you have already completed a similar health care proxy form, please give a copy to your
Dana-Farber physician, as well as to your primary care physician, so it can be included in
your medical record.
What role does a health care agent play
If you become unable to make decisions or to speak for yourself, your doctor will ask
your health care agent to speak on your behalf. Your agent will have full access to your
medical record, including personal health information necessary to make decisions about
your care. He or she will communicate your values and goals the things that are most
important to you and will try to imagine being in your place. Your agent will consider
the options based on your illness, prognosis, and available treatments. This person will be
responsible for presenting his or her best understanding of your wishes to the medical
team, and for making decisions on your behalf.
Your health care agent can make decisions for you only if your care team determines
that you cannot speak for yourself. If you can communicate and demonstrate an ability
to understand the treatment options available to you, your medical caregivers will
encourage you to make your own decisions about treatment.
A health care agent is involved in medical decisions only and does not have legal authority
to speak for you about financial or other matters.
Massachusetts Health Care Proxy Form 2