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Advance Directives

What is an advance medical directive?

It is a legal document that allows you to name someone you know and trust to make your health care decisions, if, for any reason and at any time, you become unable to make or communicate those decisions.  This person is referred to as your “Health Care Agent.”

Types of advance medical directives:

  1. Health care proxy allows you to name someone you know and trust to be your agent and to make health care decisions for you.  It can be completed without an attorney or notary.
  2. Durable power of attorney designates a person to act on your behalf to make financial as well as medical decisions. This must be notarized.

Who can complete a health care proxy?

Any competent adult 18 years of age or over.

When should I execute a health care proxy?

Now. If you become unable to make decisions, your friends, family and health care providers should understand your choices.

Who can I name as my agent on a proxy?

A close family member or friend that 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.

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What should I do with the completed proxy?

Keep the original where it can be easily found (not in a safe deposit box).

Give copies of the completed proxy to:

  1. Your physician
  2. Your agent (a family member or close friend) and to an alternate if he or she is not available
  3. 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.
  • When you do anything that clearly shows that you want to revoke it, i.e., tear it up, destroy it, cross it out, tell other people that it is no longer valid.

What can my health care agent do?

  • 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 talk about with your agent:

You should be sure that he or she knows what is important to you.

You should tell your agent your beliefs and wishes regarding:

  • Where you want to be cared for
  • 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

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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 me?

When your physician decides, in writing, that you are unable to make decisions about your health care, and after fully considering all medical information about your condition.

When you are admitted to South Shore Hospital, you will be asked:

  1. If you have a health care proxy
  2. If you want information about the proxy
  3. If you want to complete a proxy

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.

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Where can I get a health care proxy form?

South Shore Hospital's Admitting Department at 781-624-8216.

Download a copy

You can also download a health care proxy form right now in Adobe Acrobat Reader format, together with instructions for filling out the forms. If you do not have Acrobat, you can download it for free at Adobe.com (Click on the button below.Adobe Acrobat Reader)


Health Care Proxy Form  View (11.65KB) health care proxy form (Print it after it appears.)

Who can answer my questions on this topic?

Pastoral Care Dept: 781-624-4784
Social Service Dept: 781-624-4791
You can also visit putitinwriting.org for help with advance medical directives.

For patients in the hospital:

For further information, view the in-hospital closed circuit TV Channel 23. Forms can be witnessed by the Concierge, ext. 4300.

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Copyright 2017 Dana-Farber/Cancer Center in clinical affiliation with South Shore Hospital, All Rights Reserved.

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