Who can make out
a health care proxy?
Any mentally competent adult 18 years of age
When should I complete a health care proxy?
Now. If you become unable to make decisions,
your friends, family and health care providers should understand
Whom can I name as my agent on a proxy?
You should choose a close family member or friend
who will be available to communicate with your caregivers.
This person can not be an employee, administrator, or operator
of a facility, such as a hospital or nursing home, where you
are a patient, unless that person is also related to you by
blood, marriage, or adoption.
What should I do with the completed proxy?
Keep the original where it can be found easily
(not in a safe deposit box).
Give copies of the completed proxy to:
- Your physician
- Your agent, and an alternate if your agent
is not available
- Other close friends or family members
When is my proxy revoked?
- When you make out another one
- If your spouse is your agent and you divorce
or legally separate
- When you notify your agent or physician, orally
or in writing, that you want to revoke it
What can my health care agent do?
When you do anything that shows clearly that
you want to revoke it, i.e., tear it up, destroy it, cross
it out, or tell other people that it is no longer valid
- Make decisions about your health care only
when you can't
- Consent to or refuse any medical treatment
- Get any medical information necessary to make
informed decisions for you
Things to discuss with
your agent, to be sure that he or she knows what is important
You should tell your agent your beliefs and
- Where you want to receive care
- What caretakers you want
- Your family involvement
- Your religious beliefs
- Financial concerns
- When or when not to prolong your life
- Pain or suffering
- Organ donations
You should let your agent know your feelings
about certain forms of medical treatments, such as:
- Life-sustaining treatment
- Cardiopulmonary resuscitation (CPR)
- The use of intravenous therapy and/or
feeding tubes to administer food, water or medicine
- Breathing machines
- Kidney dialysis
When can my agent make decisions for
When your physician decides, in writing,
that you are unable to make decisions about your health
care, and after considering fully all medical information
about your condition.
When you are admitted to Nantucket Cottage
Hospital, you will be asked:
If you have completed a health care proxy,
you should bring a copy of it to the hospital. It will be
placed in your hospital record. If you have made changes
to your proxy, you should bring the new copy.
- If you have a health care proxy
- If you want information about the proxy
- If you want to complete a proxy
Where can I get a health care proxy form?
Nantucket Cottage Hospital's Admitting Office.