Durable Power of Attorney Example - Massachusetts - Edit, Fill, Sign Online

-i-

SUGGESTIONS

FOR PREPARING WILL TO LIVE

DURABLE POWER OF ATTORNEY

(Please read the document itself before reading this.

It will help you better understand the suggestions.)

YOU ARE NOT REQUIRED TO FILL OUT ANY PART OF THIS "WILL TO LIVE" OR ANY

OTHER DOCUMENT SUCH AS A LIVING WILL OR DURABLE POWER OF ATTORNEY

FOR HEALTH CARE. NO ONE MAY FORCE YOU TO SIGN THIS DOCUMENT OR ANY

OTHER OF ITS KIND.

The Will to Live form starts from the principle that the presumption should be for life. If you

sign it without writing any "SPECIAL CONDITIONS," you are giving directions to your health care

provider(s) and health care agent

1

to do their best to preserve your life.

Some people may wish to continue certain types of medical treatment when they are

terminally ill and in the final stages of life. Others may not.

If you wish to refuse some specific medical treatment, the Will to Live form provides space

to do so ("SPECIAL CONDITIONS"). You may make special conditions for your treatment when

your death is imminent, meaning you will live no more than a week even if given all available

medical treatment; or when you are incurably terminally ill, meaning you will live no more than three

months even if given all available medical treatment. There is also space for you to write down

special conditions for circumstances you describe yourself.

The important thing for you to remember if you choose to fill out any part of the "SPECIAL

CONDITIONS" sections of the Will to Live is that you must be very specific in listing what

treatments you do not want. Some examples of how to be specific will be given shortly, or you may

ask your physician what types of treatment might be expected in your specific case.

Why is it important to be specific? Because, given the pro-euthanasia views widespread in

society and particularly among many (not all) health care providers, there is great danger that a vague

description of what you do not want will be misunderstood or distorted so as to deny you treatment

that you do want.

Many in the medical profession as well as in the courts are now so committed to the quality

of life ethic that they take as a given that patients with severe disabilities are better off dead and

would prefer not to receive either life-saving measures or nutrition and hydration. So pervasive is

this "consensus" that it is accurate to say that in practice it is no longer true that the "presumption is

1

Some states use the terms “attorney in fact,” “surrogate,” “designee,” and “representative” instead of “agent.”

They are synonymous for purposes of these suggestions.

-ii-

for life" but rather for death. In other words, instead of assuming that a now incompetent patient

would want to receive treatment and care in the absence of clear evidence to the contrary, the

assumption has virtually become that since any "reasonable" person would want to exercise a

"right to die," treatment and care should be withheld or withdrawn unless there is evidence to the

contrary. The Will to Live is intended to maximize the chance of providing that evidence.

It is important to remember that you are writing a legal document, not holding a

conversation, and not writing a moral textbook. The language you or a religious or moral leader

might use in discussing what is and is not moral to refuse is, from a legal standpoint, often much

too vague. Therefore, it is subject to misunderstanding or deliberate abuse.

The person you appoint as your health care agent may understand general terms in the

same way you do. But remember that the person you appoint may die, or become incapacitated,

or simply be unavailable when decisions must be made about your health care. If any of these

happens, a court might appoint someone else you don't know in that person's place. Also

remember that since the agent has to follow the instructions you write in this form, a health care

provider could try to persuade a court that the agent isn't really following your wishes. A court

could overrule your agent's insistence on treatment in cases in which the court interprets any

vague language you put in your "Will to Live" less protectively than you meant it.

So, for example, do not simply say you don't want "extraordinary treatment." Whatever

the value of that language in moral discussions, there is so much debate over what it means

legally that it could be interpreted very broadly by a doctor or a court. For instance, it might be

interpreted to require starving you to death when you have a disability, even if you are in no

danger of death if you are fed.

For the same reason, do not use language rejecting treatment which has a phrase like

"excessive pain, expense or other excessive burden." Doctors and courts may have a very

different definition of what is "excessive" or a "burden" than you do. Do not use language that

rejects treatment that "does not offer a reasonable hope of benefit." "Benefit" is a legally vague

term. If you had a significant disability, a health care provider or court might think you would

want no medical treatment at all, since many doctors and judges unfortunately believe there is no

"benefit" to life with a severe disability.

What sort of language is specific enough if you wish to write exclusions? Here are some

examples of things you might--or might not--want to list under one or more of the "Special

Conditions" described on the form. Remember that any of these will prevent treatment ONLY

under the circumstances--such as when death is imminent--described in the "Special Condition"

you list it under. (The examples are not meant to be all inclusive--just samples of the type of

thing you might want to write.)

-iii-

"Cardiopulmonary resuscitation (CPR)." (If you would like CPR in some but not all

circumstances when you are terminally ill, you should try to be still more specific: for example,

you might write "CPR if cardiopulmonary arrest has been caused by my terminal illness or a

complication of it." This would mean that you would still get CPR if, for example, you were the

victim of smoke inhalation in a fire.) "Organ transplants." (Again, you could be still more

specific, rejecting, for example, just a "heart transplant.")

"Surgery that would not cure me, would not improve either my mental or my physical

condition, would not make me more comfortable, and would not help me to have less pain, but

would only keep me alive longer."

"A treatment that will itself cause me severe, intractable, and long-lasting pain but will

not cure me."

Pain Relief

Under the "General Presumption for Life," of your Will to Live, you will be given

medication necessary to control any pain you may have "as long as the medication is not used in

order to cause my death." This means that you may be given pain medication that has the

secondary, but unintended, effect of shortening your life. If this is not your wish, you may want

to write something like one of the following under the third set of "Special Conditions" (the

section for conditions you describe yourself):

"I would like medication to relieve my pain but only to the extent the medication would

not seriously threaten to shorten my life." OR

"I would like medication to relieve my pain but only to the extent it is known, to a

reasonable medical certainty, that it will not shorten my life."

Think carefully about any special conditions you decide to write in your "Will to Live."

You may want to show them to your intended agent and a couple of other people to see if they

find them clear and if they mean the same thing to them as they mean to you. Remember that

how carefully you write may literally be a matter of life or death--your own.

AFTER WRITING DOWN YOUR SPECIAL CONDITIONS, IF ANY, YOU SHOULD MARK OUT

THE REST OF THE BLANK LINES LEFT ON THE FORM FOR THEM (JUST AS YOU DO AFTER

WRITING OUT THE AMOUNT ON A CHECK) TO PREVENT ANY DANGER THAT SOMEBODY OTHER

THAN YOU COULD WRITE IN SOMETHING ELSE.

IT IS WISE TO REVIEW YOUR WILL TO LIVE PERIODICALLY TO ENSURE THAT IT STILL

GIVES THE DIRECTIONS YOU WANT FOLLOWED.

Robert Powell Center for Medical Ethics

National Right to Life

www.nrlc.org ~ (202) 378-8862

-iv-

How to use the Massachusetts Will to Live Form

SUGGESTIONS AND REQUIREMENTS

1. This document allows you to designate (name) a health care agent who will make health

care decisions for you whenever you are unable to make them for yourself. It also allows

you to give instructions about medical treatment decisions that the health care agent must

follow. Any competent person who is at least 18 years old may designate a health care

agent through this document.

2. To properly designate a health care agent through this document, you must sign and date

this document in the presence of two adult witnesses. (If you are unable to sign and date

the document yourself, you may direct someone to do it for you in your presence. The

person who signs your name for you should put his/her name and address in the spaces

provided on the form.) The two witnesses must sign the document in your presence and

in each other’s presence.

3. The witnesses cannot be named as a health care agent or alternate in your document.

4. Your health care agent cannot be an operator, administrator, or employee of your

hospital, nursing home, or other health care facility where you are currently a patient or

resident or have applied for admission. However, one of these may serve if related to you

by blood, marriage, or adoption.

5. It is helpful to designate alternate health care agent(s), to take over if your first choice is

unable to serve. There is space on the form for you to designate two alternate health care

agents.

6. You should tell your doctor about this document. You should also ask your doctor to

keep a copy of this document as a part of your medical health record.

7. Your health care agent’s authority takes effect only when you no longer have the capacity

to make and communicate your own health care decisions. Under Massachusetts law this

is determined by your attending doctor, who must write it in your medical record,

describing the cause and nature of your incapacity, as well as its extent and probable

duration. However, if you object to a health care decision by your agent after your doctor

has determined you are incapable your wishes will prevail unless a court rules you are

incapable.

1 of 2

-v-

8. The document will remain in effect until you revoke (cancel) it. You may revoke this

document (in whole or in part) or limit your health care agent’s authority at any time by

notifying your agent or health care provider orally or in writing, or by doing anything else

showing your intent to revoke. You will also revoke this document if you sign a new

document naming a health care agent or if you legally separate from or divorce your

spouse and your spouse is named as your health care agent in the document.

9. You and your agent generally have the right to require the doctor and private facility

providing treatment and care for you to honor your health care decisions. If a treating

doctor considers it against his or her moral or religious beliefs to do so, the doctor may

refuse to comply but must transfer your care to another doctor willing to do so. A private

facility can refuse to honor your decisions only if it has a formally adopted policy based

on religious beliefs, and it informs you or your agent before or upon admission, if that is

reasonably possible. It must also allow your transfer to a facility willing to comply. If the

doctor or facility and your agent are unable to arrange a transfer, judicial guidance must

be sought or your or your agent’s health care decision must be honored.

10. This type of document has been authorized by Mass. Ann. Laws Ch. 201D, §§ 1 –17

(2011).

11. You should periodically review this document to be sure it complies with your wishes.

Before making any changes, be aware that it is possible that the statutes controlling this

document have changed since this form was prepared. Contact the Will to Live Project

by visiting www.nrlc.org (click on “Will to Live”) or an attorney to determine if this

form can still be used.

12. If you have any questions about this document or want assistance filling it out, please

consult an attorney.

For additional copies of the Will to Live, please visit www.nrlc.org

Form prepared 2001

Clerical changes made 01/09

Reviewed 2013

2 of 2

-vi-

Massachusetts Health Care Proxy

WILL TO LIVE FORM

I, (your name)__________________________________________________________________

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

designate:

(Name of agent)________________________________________________________________

(address of agent)_______________________________________________________________

(phone number(s) of agent)_______________________________________________________

as my health care agent to make any health care decisions for me as authorized in this document

consistent with the instructions below.

If the person I designate above is unavailable, unwilling, or incompetent to serve and is not

expected to become available, willing or competent to make a timely medical decision given my

medical circumstances, I designate the following persons (each to act alone and successively, in

the order named):

A. First Successor Agent

(successor agent’s name)_________________________________________________________

(successor agent’s address)________________________________________________________

_____________________________________________________________________________

(successor agent’s phone number)__________________________________________________

B. Second Successor Agent

(second successor agent’s name)___________________________________________________

(second successor agent’s address)__________________________________________________

______________________________________________________________________________

(second successor agent’s phone number)____________________________________________

as my health care agent(s) to make any health care decisions for me as authorized in this

document consistent with the instructions below. This designation shall become effective only

when I become incapable of making or communicating my own health care decisions, as

determined pursuant to Mass. Gen. L. ch. 201D, § 6.

Any earlier designation is revoked.

1 of 4

-vii-

GENERAL PRESUMPTION FOR LIFE

I direct my health care provider(s) and health care agent(s) to make health care decisions

consistent with my general desire for the use of medical treatment that would preserve my life, as

well as for the use of medical treatment that can cure, improve, reduce or prevent deterioration

in, any physical or mental condition.

Food and water are not medical treatment, but basic necessities. I direct my health care

provider(s) and health care agent(s) to provide me with food and fluids, orally, intravenously, by

tube, or by other means to the full extent necessary both to preserve my life and to assure me the

optimal health possible.

I direct that medication to alleviate my pain be provided, as long as the medication is not used in

order to cause my death.

I direct that the following be provided:

 the administration of medication;

 cardiopulmonary resuscitation (CPR); and

 the performance of all other medical procedures, techniques, and technologies, including

surgery,

–all to the full extent necessary to correct, reverse, or alleviate life-threatening or health

impairing conditions or complications arising from those conditions.

I also direct that I be provided basic nursing care and procedures to provide comfort care.

I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of

an unborn or newborn child, who has been subject to an induced abortion. This rejection does

not apply to the use of tissues or organs obtained in the course of the removal of an ectopic

pregnancy.

I also reject any treatments that use an organ or tissue of another person obtained in a manner

that causes, contributes to, or hastens that person’s death.

I request and direct that medical treatment and care be provided to me to preserve my life

without discrimination based on my age or physical or mental disability or the “quality” of my

life. I reject any action or omission that is intended to cause or hasten my death.

I direct my health care provider(s) and health care agent(s) to follow the policy above, even if I

am judged to be incompetent.

During the time I am incompetent, my agent, as named above, is authorized to make medical

decisions on my behalf, consistent with the above policy, after consultation with my health care

2 of 4

-viii-

provider(s), utilizing the most current diagnoses and/or prognosis of my medical condition, in the

following situations with the written special instructions.

WHEN MY DEATH IS IMMINENT

A. If I have an incurable terminal illness or injury, and I will die imminently – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only a week or less even

if lifesaving treatment or care is provided to me – the following may be withheld or withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

WHEN I AM TERMINALLY ILL

B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even

though death is not imminent I am in the final stage of that terminal condition – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only three months or less,

even if lifesaving treatment or care is provided to me – the following may be withheld or

withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

C. OTHER SPECIAL CONDITIONS:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

3 of 4

-ix-

IF I AM PREGNANT

D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and

health care agent(s) to use all lifesaving procedures for myself with none of the above special

conditions applying if there is a chance that prolonging my life might allow my child to be born

alive. I also direct that lifesaving procedures be used even I am legally determined to be brain

dead if there is a chance that doing so might allow my child to be born alive. Except as I specify

by writing my signature in the box below, no one is authorized to consent to any procedure for

me that would result in the death of my unborn child.

If I am pregnant, and I am not in the final stage of a terminal condition as defined above,

medical procedures required to prevent my death are authorized even if they may result in the

death of my unborn child provided every possible effort is made to preserve both my life and the

life of my unborn child.

____________________________________

Signature of Declarant

Signed this ____________________day of ___________________________, 20_______.

Signature______________________________________________________________________

Address_______________________________________________________________________

Complete only if principal is unable to sign:

I have signed the principal’s name above at his/her direction in the presence of the principal and

two witnesses.

Name

Address

In our joint presence, the principal, who appeared to be at least eighteen years of age, of sound

mind and under no constraint or undue influence, signed this Health Care Proxy this day of

, 20 .

First Witness Signature:__________________________________________________________

Residence Address:______________________________________________________________

Second Witness Signature:________________________________________________________

Residence Address:______________________________________________________________

Form prepared 2001

Clerical changes made 01/09

Reviewed 2013

4 of 4

Fillable Printable Durable Power of Attorney Example - Massachusetts

Fillable Printable Durable Power of Attorney Example - Massachusetts

Durable Power of Attorney Example - Massachusetts