What is a health care proxy?
The New York health care proxy law allows you to appoint someone you trust – for example, a family member or close friend – to decide about treatment if you lose the ability to decide for yourself. You can appoint someone by signing a form called a Health Care Proxy.
You can give the person you select, your “health care agent,” as little or as much authority as you want. You can allow your health care agent to decide about all health care or only about certain treatments. You may also give your agent instructions that he or she has to follow. Your agent can then make sure that health care professionals follow your wishes and can decide how your wishes apply as your medical condition changes. Hospital, doctors and other health care providers must follow your agent’s decisions as if they were your own.
Why should I choose a health care agent?
If you become too sick to make health care decisions, someone else must decide for you. Health care professionals often look to family members for guidance. But family members are not allowed to decide to stop treatment, even when they believe that is what you would choose or what is best for you under the circumstances. Appointing an agent lets you control your medical treatment by:
- Allowing your agent to stop treatment when he or she decides that is what you would want or what is best for you under the circumstances;
- Choosing one family member to decide about treatment because you think that person would make the best decisions or because you want to avoid conflict or confusion about who should decide; and
- Choosing someone outside your family to decide about treatment because no one in your family is available or because you prefer that someone other than a family member decides about your health care.
How can I appoint a health care agent?
All competent adults can appoint a health care agent by signing a form called a Health Care Proxy. You don’t need a lawyer, just two adult witnesses. You can use a pre-printed form or an original statement.
When would my health care agent begin to make treatment decisions for me?
Your health care agent would begin to make treatment decisions after doctors decide that you are not able to make health care decisions. As long as you are able to make treatment decisions for yourself, you will have the right to do so.
What decisions can my health care agent make?
Unless you limit your health care agent’s authority, your agent will be able to make any treatment decision that you could have made if you were able to decide for yourself. Your agent can agree that you should receive treatment, choose among different treatments, and decide that treatments should not be provided, consistent with your wishes and interests. If your health care agent is not aware of your wishes about artificial nutrition and hydration (nourishment and water provided by feeding tubes), he or she will not be able to make decisions about these measures. Artificial nutrition and hydration are used in many circumstances, and are often used to continue the life of patients who are in a permanent coma.
How can I give my agent written instructions?
See “Instructions for Filling Out a Health Care Proxy.”
How will my health care agent make decisions?
You can write instructions on the proxy form. Your agent must respect your oral and written instructions, as well as your moral and religious beliefs. If your agent does not know your wishes or beliefs, your agent is legally required to act in your best interests.
Who will pay attention to my agent?
All hospitals, doctors and other health care facilities are legally required to obey the decisions made by your agent. If a hospital objects to some treatment options (such as terminating certain treatment) they must tell you or your agent IN ADVANCE.
What if my health care agent is not available when decisions must be made?
You can appoint an alternate agent to decide for you if your health care agent is not available or able to act when decisions must be made. Otherwise, health care providers will make treatment decisions for you that follow instructions you gave while you were still able to do so. Any instructions that you write on your Health Care Proxy form will guide health care providers under these circumstances.
What if I change my mind?
It is easy to cancel the proxy, to change the person you have chosen as your health care agent, or to change any treatment instructions you have written on your Health Care Proxy form. Just fill out a new form. In addition, you can require that the Health Care Proxy expire on a specified date or if certain events occur. Otherwise, the Health Care Proxy will be valid indefinitely. If you choose your spouse as your health care agent and you get divorced or legally separated, the proxy is automatically cancelled.
Can my health care agent be legally liable for decisions made on my behalf?
No. Your health care agent will not be liable for treatment decisions made in good faith on your behalf. Also, he or she cannot be held liable for costs of your care, just because he or she is your agent.
Is a health care proxy the same as a living will?
No. A living will is a document that provides specific instructions about health care treatment. It is generally used to declare wishes to refuse life-sustaining
treatment under certain circumstances. In contrast, the health care proxy allows you to choose someone you trust to make treatment decisions on your behalf. Unlike a living will, a health care proxy does not require that you know in advance all the decisions that may arise. Instead, your health care agent can interpret your wishes as medical circumstance change and can make decisions you could not have known would have to be made. The health care proxy is just as useful for decisions to receive treatment as it is for decisions to stop treatment. If you complete a Health Care Proxy form, but also have a living will, the living will provides instructions for your health care agent, and will guide his or her decisions.
Where should I keep the proxy form after it is signed?
Give a copy to your agent, your doctor and any other family members or close friends you want. You can also keep a copy in your wallet or purse or with other important papers.
Appointing a Health Care Agent is a serious decision. Make sure you talk about it
with your family, clergy, attorney, close friends and doctor. Do it in advance, not just when you are planning to enter the hospital.
Health Care Proxy
(Be sure to read the all of this form before completing it.)
1. I, ____________________________________ hereby appoint ____________________________________ as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect when and if I become unable to make my own health care decisions.
2. Optional instructions: I direct my proxy to make health care decisions in accord with my wishes and limitations as stated below, or as he or she otherwise knows. (Attach additional pages if necessary.)
(Unless your agent knows your wishes about artificial nutrition and hydration (feeding tubes), your agent will not be allowed to make decisions about artificial nutrition and hydration. See instructions on reverse for samples of language you could use).
3. Name of substitute or fill-in proxy if the person I appoint is unable, unwilling or unavailable to act as my health care agent.
4. Unless I revoke it, this proxy shall remain in effect indefinitely, or until the date or conditions stated below.
This proxy shall expire (specific date or conditions, if desired):
5. Signature ______________________________________________________________________________
Statement by Witness (must be 18 or older)
I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence.
This is an important legal form. Before signing this form, you should understand the following facts:
(1) This form gives the person you choose as your agent the authority to make all health care decisions for you, except to the extent you say otherwise in this form. “Health Care” means any treatment, service or procedure to diagnose or treat your physical or mental condition.
(2) Unless you say otherwise, your agent will be allowed to make all health care decisions for you, including decisions to remove or withhold life-sustaining treatments.
(3) Unless your agent knows your wishes about artificial nutrition and hydration (nourishment and water provided by a feeding tube), he or she will not be allowed to refuse those measures for you.
(4) Your agent will start making decisions for you when doctors decide that you are not able to make health care decisions for yourself.
You may write any information on this form about treatment that you do not desire and/or those treatments that you want to make sure you receive. Your agent must follow your instructions (oral and written) when making decisions for you.
If you want to give your agent written instructions, do so right on the form. For example, you could say:
- If I become terminally ill, I do/don’t want to receive the following treatments…
- If I am in a coma or unconscious, with no hope of recovery, then I do/don’t want…
- If I have brain damage or a brain disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, I do/don’t want…
Examples of medical treatments about which you may wish to give your agent special instructions are listed below. This is not a complete list of treatment about which you may leave instructions:
- Artificial respiration
- Artificial nutrition and hydration (nourishment and
water provided by feeding tube)
- Cardiopulmonary resuscitation (CPR)
- Anti-psychotic medication
- Electric shock therapy
- Blood transfusion
Talk about choosing an agent with your family and/or close friends. You should discuss this form with a doctor or another health care professional, such as a nurse or social worker, before you sign it to make sure that you understand the types of decisions that may be made for you. You may also wish to give your doctor a signed copy. You do not need a lawyer to fill out this form.
You can choose any adult (over 18), including a family member, or close friend, to be your agent. If you select a doctor as your agent, he or she may have to choose between acting as your agent or as your attending doctor; a physician cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. You should ask staff at the facility to explain those restrictions.
You should tell the person you choose that he or she will be your health care agent. You should discuss your health care wishes and this form with your agent. Be sure to give him or her a signed copy. Your agent cannot be sued for health care decisions made in good faith.
Even after you have signed this form, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to your or stopped if you object. You can cancel the control given to your agent by telling him or her, or your health care provider, orally or in writing.
Filling out the Proxy Form
(1) Write your name and the name, home address and telephone number of the person you are selecting as your agent.
(2) If you have special instructions for your agent, you should write them here. Also, if you wish to limit your agent’s authority in any way, you should say so here. If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decision to consent to or refuse life-sustaining treatments.
(3) You may write the name, home address and telephone number of an alternate agent.
(4) This form will remain valid indefinitely unless you set an expiration day or condition for its expiration. This section is optional and should be filled in only if you want the health care proxy to expire.
(5) You must date and sign the proxy. If you are unable to sign yourself, you may direct someone else to sign in your presence. Be sure to include your address. Two witnesses at least 18 years of age must sign your proxy. The person who is appointed agent or alternate agent cannot sign as a witness.
(Be sure to read these instructions before completing the reverse side of this form)