Massachusetts Medical Society: Health Care Proxy Information and Forms

Health Care Proxy Information and Forms

The Health Care Proxy is a simple document, legally valid in Massachusetts, which allows you to name someone (an "agent") to make health care decisions on your behalf if you are unable to make or communicate those decisions.

This Health Care Proxy document, provided free of charge, gives a clear explanation of the responsibilities of a health care agent, and simple directions on how fill out and sign the form. There are also instructions on how to revoke or cancel the document at a later date, if you choose to do so.

Massachusetts Health Care Proxy Information, Instructions and Form  
Information, instructions, and form for naming someone you know and trust to make health care decisions for you if, for any reason and at any time, you become unable to make or communicate those decisions.

Discussion Questions

  1. First, think about what is most important to you in your life. What makes life meaningful or good for you now?
  2. Now, think about what is important to you in relation to your health. What, if any, religious or personal beliefs do you have about sickness, health care decision-making, or dying?
  3. Have you or other people you know faced difficult medical treatment decisions during times of serious illness? How did you feel about those situations and any choices that were made?
  4. Some people feel a time might come when their life would no longer be worth living. Can you imagine any circumstances in which life would be so unbearable for you that you would not want medical treatments used to keep you alive?
  5. If your spokesperson ever had to make a medical decision on your behalf, are there certain people you would want your spokesperson to talk to for advice or support (family members, friends, health care providers, clergy, other)?
  6. Is there anyone you specifically would NOT want involved in helping to make health care decisions on your behalf?
  7. How closely would you want your spokesperson to follow your instructions about care decisions, versus do what they think is best for you at the time decisions are made?
  8. Should financial or other family concerns enter into decisions about your medical care? Please explain.
  9. Are there other things you would like your spokesperson to know about you, if he or she were ever in a position to make medical treatment decisions on your behalf? 
Share on Facebook
270005MS_CARE_RR_300x250_0623_FINAL2 (1)

Find a Physician  

Three DoctorsSearch for Massachusetts Medical Society physicians by specialty or locality.

Find a Physician »

Facebook logoLinkedInYouTube logoInstagram

Copyright © 2024. Massachusetts Medical Society, 860 Winter Street, Waltham Woods Corporate Center, Waltham, MA 02451-1411

(781) 893-4610 | General Support: (617) 841-2925 or