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Healthcare Proxy Form

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Quality of Life Initiative - Advance Care Planning

Like planning for a wedding, to start a family or for any life change, planning for your future healthcare, in the event of a medical crisis or end-of-life, is important.

Plan for care to the end of your life.

What is Advance Care Planning?

At any age, a medical crisis could leave someone too ill to make his or her own healthcare decisions. Making a clear healthcare plan for the future is an important step toward ensuring the medical care you would want, even when doctors and family members are making the decisions for you.

Completing an Advance Directive (Health Care Proxy)

Advance Care Planning involves learning about the types of decisions that might need to be made, considering those decisions ahead of time, and letting others know about your preferences, often by putting them into a document known as an advance directive.

An advance directive:

  • Is a simple legal document, also known as the Massachusetts Health Care Proxy in this state, that goes into effect only if you are incapacitated and unable to speak for yourself.
  • Can be used in the event of disease or severe injury for an adult of any age, 18 years and older, to help others know the type of medical care desired.
  • Allows you to appoint your Healthcare Agent, someone you know and trust to make decisions about your medical care when you are unable to communicate. Your agent cannot act for you until your doctor determines, in writing, that you lack the ability to make health care decisions. It will be important to discuss your wishes and values regarding medical treatments and end-of-life care, including life-sustaining measures, with the person you intend to be your Healthcare Agent, as that person will be expected to follow your directives in making decisions on your behalf. If your agent does not have this information, your agent is to make decisions based on his or her assessment of your best interest. Information about who can serve as a Healthcare Agent.
  • Is a living document that you can adjust as your situation changes because of new information or a change in your health.

Where can I obtain a Health Care Proxy?

Things to consider

You may wish to discuss medical treatment options with your physician prior to completing a Health Care Proxy.

A copy of your Health Care Proxy will be filed in your Cape Cod Hospital or Falmouth Hospital Medical Record. Your physician, your agent and a family member should also have a copy of your Health Care Proxy.

Massachusetts's law does not require that you have a Health Care Proxy. Completing one will assure you and our hospital staff that you will receive medical treatment in accordance with your wishes. Medical care is not conditioned, nor will any discrimination occur, based on whether you have a Health Care Proxy.

Additional planning tools

The Quality of Life Initiative

The Quality of Life Initiative, a group of more than 50 community organizations, is a resource for patients and healthcare providers that provides guest speakers, materials and helpful tools to guide people to make a clear plan for their end-of-life care.

The Quality of Life Initiative’s goal is for every competent adult age 18 or older to fill out a Health Care Proxy and plan for their future with other advance care directive tools.

Guest Speakers from The Quality of Life Initiative are available to meet with your civic or community group to discuss the importance of Advance Care Planning. Contact Tina Soares at tsoares@capecodhealth.org to schedule a presentation.

Learn more