Massachusetts Advance Directive Form

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A Massachusetts advance directive is a document that allows a person to select an agent to carry out their health care wishes. The document outlines a person’s medical preferences in the event they become permanently incapacitated. After completing, the form needs to be signed by the principal and at least two (2) witnesses to be legal.

Advance Directive Includes

Table of Contents

Laws

StatuteGL Chapter 201D (Health Care Proxies)

Signing Requirements (§ 201D-2) – Two (2) witnesses.

Versions (3)


AARP

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Massachusetts Medical Society

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Spanish (Español) Version

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How to Write

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Step 1 – Obtain The Massachusetts Advance Health Care Directive

The Massachusetts Advance Health Care Directives are available in the “PDF” format available through the button presented with the feature image or the “Adobe PDF” link displayed on this page.

Step 2 – Review The Introduction For Appointing A Massachusetts Health Care Proxy

The beginning of the Massachusetts template package presents several instructions that will aid in understanding some of the definitions presented in your Health Care Proxy’s appointment. Anyone intending to name a Health Care Proxy or Agent to wield principal decision-making authority with Massachusetts Medical Staff is encouraged to familiarize themselves with the entirety of this packet including the introductions. 

 

Step 3 – Document The Massachusetts Principal’s Name And Place Of Residence

The Massachusetts Health Care Proxy template seeks some introductory information to this act of appointment with a request for the Principal’s full name and address. These items should be reported separately so the first line in the first article will seek the full name of the Principal while the line labeled “Address” will seek a production of the Principal’s home address. In this paperwork, it will be the Principal who grants his or her decision-making powers and authority over his or her medical treatment to a trusted family member or friend.

 

Step 4 – Submit The Formal Appointment Of The Massachusetts Health Care Proxy

The second article of this document begins with Article “2. My Health Care Agent Is” as its title. This statement will be completed when you fill in the information requested by the labeled lines beneath it. The “Name” line and “Address” line refer to the Massachusetts Health Care Agent or Proxy that the Principal authorizes as his or her Representative.  Directly below the identity and residential address you reported for the Massachusetts Health Care Proxy, one label shall enable several entries. It is imperative that any Massachusetts Physician or Medical Personnel reviewing this document to seek your medical preferences because you are unconscious be able to reach your Health Care Proxy or Agent. Furnish the telephone number(s) where the Massachusetts Health Care Proxy named above can be reliably reached. Naturally, this may require that the home number and the work number be entered on the first two lines, however, if the Health Care Proxy has a cell phone that is usually on his or her person, then include this phone number as well.  

 

Step 5 – Name The Alternate Choice To The Massachusetts Health Care Proxy

This paperwork shall seek to ensure that you have constant medical representation when you are unconscious even if the Health Care Agent or Health Care Proxy you named above is unavailable, has had his or her ability to represent you revoked, or is unwilling to carry out your directives. Naturally, you shall make an effort to select a Health Care Agent or Proxy who will be available and willing at all times, however, sometimes events or unforeseen circumstances may provide one or more significant obstacles. With this in mind, turn to the third article, titled with the words “3. My Alternate Health Care Agent.” Use the first two lines (labeled “Name” and “Address”) to set the name of a reserve Health Care Proxy that will not be given the right to represent the Massachusetts Principal (Patient) unless the First Health Care Agent or Proxy is unwilling or unable to act in this role. His or her full “Name” should be presented on the first line then report his or her home “Address” on the second line.  The lines labeled “Phone” are especially important. In a scenario where authorization for your treatment must be secured quickly and your First Health Care Proxy is unreachable or does not have the power to represent you, then Massachusetts Physicians relying on this paperwork must be able to use it to contact the Alternate Health Care Agent or Proxy. Supply his or her home telephone number, work telephone number, and cell phone number on the lines following the word “Phone(s)” under the title “3. My Alternate Health Care Agent.”  

 

Step 6 – Attach Principal Directives To The Designation Of The Health Care Agent

Article “4. My Health Care Agent’s Authority” will grant the access to the Principal’s medical records “As Governed By The Health Insurance Portability And Accountability Act” and the right to make the decisions needed to determine the Principal’s health care or treatment plans to the Massachusetts Health Care Proxy or Health Care Agent through its language. Additionally, this article can be used to limit or restrict some topics or authority from the scope of the Massachusetts Health Care Proxy’s principal powers. The blank lines included in this section expect the direct report on all limitations and restrictions the Principal wishes placed on the Massachusetts Health Care Proxy’s representational powers. The Principal is encouraged to directly address Massachusetts Medical Staff as well as the Health Care Proxy being appointed in this section.  

 

Step 7 – A Production Of the Massachusetts Principal’s Signature Is Required

The Principal issuing this paperwork should betake a moment to review the designation being made above as well as the information that was supplied to complete this document. Once satisfied with the accuracy of the paperwork, the Principal must locate Article “5. Signature And Date,” sign his or her name to the empty line attached to the word “Signed” then input the current “Date” on the empty line to the right.

 

Step 8 – Witnesses Must Present Written Testimony To Support The Principal’s Signature

This appointment seeks evidence that the Principal issuing it has signed it to effect. This task will be handled by Article “6. Witness Statement And Signature” The paragraph presented in this area will act as a verification statement for the Principal’s act of signing. To achieve this goal each Witness must read the paragraph starting with the words “We, The Undersigned, Have Witness…” Once done, Witness One and Witness Two must furnish their respective signature to the line labeled “Signed.”  After the signature is complete, each Witness must deliver his or her printed name on the blank line underneath his or her signature that is labeled “Print Name.”  The “Date” when Witness One and Witness Two have signed this document should be dispensed as well by each Party in his or her respective sections on the line labeled “Date.”  

 

Step 9 – If Possible, Obtain The Massachusetts Health Care Agent’s Acknowledgment

Article “7. Health Care Agent Statement” displays a statement where the Health Care Proxy or Health Care Agent can formally acknowledge and accept the role(s) being appointed. The Massachusetts Health Care Proxy must sign the line labeled “Health Care Agent” and document his or her “Date” of signature after reading and agreeing to the statement in this article. 

The “Alternate Health Care Agent” line should be signed by the Successor Health Care Proxy who will only accept and use the principal powers delivered to the Agent above if that Agent is unwilling or unable to fill the role of the Principal’s Health Care Proxy. To complete this section the “Alternate Health Care Agent” line must be signed by the Alternate or Successor Health Care Proxy and the “Date” of this signature should be furnished to the adjacent area. 

 

Step 10 – Complete The Massachusetts Medical Orders For Life-Sustaining Treatment

If the Principal issuing this advance directive package has opted to include the Massachusetts Medical Order For Life-Sustaining Treatment form, then the next template must be tended to with the cooperation of a Physician licensed to practice in the State of Massachusetts. It should be mentioned that this form should not be altered, and it should be printed on bright pink two-sided paper as this will follow a format that EMT and other First Responders have been trained to recognize in a Patient’s files. In addition to this format, locate the first box on this page. Three blank lines will seek the identity of the Principal or Patient making the MOLST declaration. The “Patient’s Name” must be submitted to the first of these lines. 

The Principal or Massachusetts Patient issuing this form must also have his or her “Date Of Birth” presented in this area on the appropriately labeled line. 

If the Principal or Patient behind this form has a “Medical Record Number” with the Massachusetts Physician’s Medical Facility, it is strongly recommended that this be furnished on the final blank line. 

 

Step 11 – Discuss Then Record The Patient’s Directives On Cardiopulmonary Resuscitation

Section A of this paperwork will be the first area where the results of a discussion between the Massachusetts Physician and the Principal or Patient setting his or her directives in motion. If the Patient has determined that he or she does not wish to be resuscitated with the use of “Cardiopulmonary Resuscitation” then select the box in Section A labeled with the directive “Do Not Resuscitate.” If the Patient has indicated that he or she approves of “Cardiopulmonary Resuscitation” used to “Attempt Resuscitation” then select the second checkbox in Section A.

 

Step 12 – Establish The Patient’s Willingness To Receive Relief For Respiratory Distress

The Patient’s preferable response by Massachusetts Medical Personal to his or her respiratory distress should be documented in Section “B Ventilation.” Four choices are presented here. If the Patient does not approve of intubation and other methods of aiding his or her breathing process then the first checkbox (“Do Not Intubate And Ventilate”). If the Patient will submit to help in breathing, even though invasive techniques, then select the box labeled “Intubate And Ventilate.” A discussion on non-invasive respiratory aid must be had between the Massachusetts Physician and the Patient. If the Patient will not approve of “Non-Invasive Ventilation” then place a mark in the checkbox labeled “Do Not Use Non-Invasive Ventilation (E.G. CPAP).  Conversely, if the Patient authorizes the “Use Of Non-Invasive Ventilation” then select the second checkbox on this row. 

 

Step 13 – Produce The Patient’s Approval For Hospital Transfers Or Disapproval

Section “C Transfer To Hospital” will seek the Patient’s authorization to be transferred to a hospital or his or her solid refusal. If the only reason the Patient would agree to be transferred to a Hospital for care is to receive comfort care and does not wish to be transferred solely for the purpose of treatment or to be revived, then select the first checkbox in Section C. If the Patient agrees to be transferred to a Hospital for treatment upon the decision of Massachusetts Health Care Personnel, then select the “Transfer To Hospital” checkbox in Section C.

 

Step 14 – Present The Massachusetts Issuer’s Status In This Document

Section D is dedicated to the Patient’s identity. Four circles have each been made available with a label defining the type of Entity issuing this form at the beginning of Section D. If the MOLST being completed is being tended to directly by the Patient issuing it then mark the first circle. If not and the Patient’s Health Care Agent or Proxy is completed this form on his or her behalf (according to the Principal’s directives) then select the second circle. It Patient is a minor and the MOLST is being completed by either his or her Guardian (i.e., court-appointed) or his or her “Parent/Guardian then select either the third or fourth circle. The example on display below has indicated the Patient is issuing this directly with the Massachusetts Physician.

 

Step 15 – The Massachusetts POLST Issuer Must Sign This Document

Section D makes a final request. The Patient issuing this form has engaged in a discussion regarding the appropriate response for Massachusetts Medical Personnel to take when finding you in cardiac arrest, unable to breathe, or unconscious. The next task this Party must complete is the execution of this paperwork by signing his or her full name on the “Signature Of Patient (Or Person Representing The Patient)” line.

 

Step 16 – Furnish Additional Signature Items For This Execution

After the signing, the Signature Party (Patient or Proxy) must print his or her name on the line labeled “Legible Printed Name Of Signer” then disclose his or her telephone number on the next blank line.

 

Step 17 – Signature Authorization From The Overseeing Massachusetts Physician Must Be Provided

Section E of this paperwork is for the Massachusetts Clinician act of verifying the authenticity of this form. This paperwork can also be signed by a Nurse Practitioner or Physician Assistant employed by the Massachusetts Doctor overseeing the MOLST. The blank line labeled “Signature Of Physician, Nurse Practitioner, Or Physician Assistant” expects the Massachusetts Health Professional’s signature supplied to it while the “Date And Time Of Signature” should be produced on the next line.  The “Legible Printed Name of the Signer” must be included with the Massachusetts Physician’s signature in Section E along with the “Telephone Number Of Signer”

 

Step 18 – Set An Expiration Date To This Form If Desired

An “Optional” area in Section E allows the Patient and Massachusetts Clinician to set an expiration date to the MOLST being completed. To do so, seek the blank line following the words “Expiration Date (If Any) Of This Form” then furnish the requested Date.  In addition to the expiration date, the full name of the Health Care Agent or Proxy should be produced on the line “Health Care Agent Printed Name” then his or her “Telephone Number” should be displayed to the right where it is requested. The Patient’s “Primary Care Provider Printed Name” should also be submitted to this section if possible. In addition, the “Telephone number” of the Primary Care Provider should be dispensed if it is available.  

 

Step 19 – Report Patient Preferences To Treatment Responses Of Massachusetts Medical Personnel

While the Patient’s preferences for cardiac or pulmonary failure and unconsciousness has been documented then executed as a directive, the discussion between the Patient and the Massachusetts Physician should cover some additional topics. Section F shall discuss these scenarios so that the Patient’s authorization can be documented properly. If the Patient has already indicated his or her feelings on “Intubation And Ventilation” on Page 1 then mark the first checkbox on in this row but if he or she has indicated that intubation and ventilation may be used but only for a short time, then select the second checkbox. A third and fourth box will allow the Patient to be defined as “Undecided” or that the Patient “Did Not Discuss” this matter. Mark the checkbox that best defines the result of the Patient conversation with the Massachusetts Doctor. Notice that below the Patient has indicated he or she will authorize the use of intubation and ventilation techniques that he or she approved of on the first page but only for a short amount of time because the second checkbox is selected. The next area of discussion, “Non-Invasive Ventilation” allows you to indicate the Patient’s level of authorization for CPAP treatment has been adequately discussed on the previous page by selecting the first checkbox, that he or she will only approve of the non-invasive techniques for ventilation but only for a short time by marking the second checkbox, if he or she was “Undecided” by selecting the third checkbox, or if this topic was not fully discussed by selecting the last checkbox (labeled “Did Not Discuss”). Notice in the example below the Patient’s feelings on non-invasive ventilation intervention can be used to the full extent he or she has indicated on the first page of the MOLST form. If the Patient has indicated he or she wishes to refuse “Dialysis” when it was needed, then mark the “No Dialysis” checkbox in the next section. If the Patient authorizes the use of dialysis, then select the second checkbox of this section. The third checkbox “Use Dialysis, But Short-term Only” allows the Patient to indicate that he or she will only authorize dialysis administered for a short time while the “Undecided” and “Did Not Discuss” boxes will indicate that the Patient has not ventured an opinion. Notice below, that since the Massachusetts Declarant has not made a decision regarding dialysis, the “Undecided” box has been marked.  The topic of “Artificial Nutrition” is usually of concern to Patients when discussing their possible incapacitation. The checkbox “No Artificial Nutrition” should be selected if the Patient has flatly refused to authorize the administration of nutrients when he or she cannot feed himself or herself. If the Patient has decided to authorize being fed (even intravenously) then select the second checkbox or, if he or she will only accept artificial nutrition for a short time, mark the third checkbox. Lastly, the final set of boxes allows documentation of the Patient’s indecision on this matter (see the checkbox “Undecided”) or if this topic was not discussed (indicated by the “Did Not Discuss” checkbox). The example provided below indicates the Declarant does not authorize Massachusetts Medical Staff to administer artificial nutrition. The final area of Section F, wishes a discussion on the subject of “Artificial Hydration.” If “No Artificial Hydration” is preferred by the Patient when he or she is unconscious or unable to drink on his or her own, then select the first checkbox underneath the “Artificial Hydration” heading. The second checkbox should be selected if the Patient has indicated that the use of artificial Hydration is full authorized by him or her or the “Use Artificial Hydration, But Short Term Only” box if the Patient only approves of short term artificial hydration. The final two boxes can be used to show that the Patient is either “undecided” or the Patient and Doctor “Did Not Discuss” this subject.  If the Patient has additional instructions such as how long he or she will accept artificial hydration, artificial nutrition, or dialysis then Section F can also be used to document such directives. For this task, use the blank lines following the statement “Other Treatment Preferences Specific To The Patient’s Medical Condition And Care” to present such information.

 

Step 20 – Verify The Signature Patient’s Identity

After completing this page, the Patient’s status must be reiterated. Thus, located Section G where a description of the Issuer should be dispensed. If the Signature Party is the Patient, then select the first checkbox (as in the example below). If not then select either the second box to document that the Signature Party is the Patient’s “Health Care Agent,” the third box to indicate the issuing Party is the Patient’s “Guardian,” or the final checkbox if the Signature Party is the “Parent/Guardian Of Minor” 

 

Step 21 – The Patient Must Authorize The Second Page By Signature

The Signature Party, whether it is the Patient, the Patient’s Health Care Agent, or the Patient’s Guardian or Parent must sign the blank line labeled “Signature Of Patient (Or Person Representing The Patient)” then input the current date on the “Date Of Signature” line.   The Issuing Party of the MOLST must now print his or her name and submit his or her phone number on the blank lines holding the labels “Legible Printed Name Of Signer” and “Telephone Number Of Signer” respectively.

 

Step 22 – Obtain The Massachusetts Physician’s Signature And Professional Information

Section H’s first blank line (labeled as “Signature Of Physician, Nurse Practitioner, Or Physician Assistant”) requires the signature of the Massachusetts Medical Professional completing this paperwork while the “Date And Time Of Signature” line will seek the exact calendar date and time of day when this signature was dispensed.

Finally, the printed name of the Signature Massachusetts Medical Professional behind this paperwork and the telephone number where this Party can be reached should be dispensed to the final two lines of Section H.

 

Step 23 – Complete The Personal Directive For The Massachusetts Declarant

The Personal Directive portion of this package is not a formal declaration as no one is legally required to follow it however it can act as a personal guide to the Principal’s Health Care Agent, family members, and Health Care Providers when you cannot represent yourself. Read through the introduction on page six of the Massachusetts Advance Directive package. While this is not a legal form, your signature will carry some weight especially if you have discussed this subject matter with your support network (i.e., family, friends) and your Massachusetts Physician prior to a medical event that leaves you incapacitated. 

 

Step 24 – Identify The Massachusetts Declarant

You as the Declarant are the only one who should determine exactly what should be placed on this work form. Identify yourself on the first blank line under the title “Personal Directive” (see page seven). Since this is not an official form, make sure to use your exact name as it appears on your government ID such as your birth certificate, social security card, or State Issued Driver’s License then record your residential address between the phrase “…Residing At” and the term “Write This Directive”

 

Step 25 – Dispense The Status Of The Declarant’s Health Care Proxy Or Agent

The first task of this document is to solidify whether the Declarant has issued a Health Care Proxy to act in his or her name. If so, then select the first checkbox presented in this document (attached to the term “I Have Chosen…”) and furnish the Massachusetts Health Care Agent or Proxy’s first, middle, and last name along with his or her residential address and telephone numbers.  If you have not appointed a Health Care Representative, then select the second checkbox (“I Have Not Chosen…”). In our example below, the Patient has not selected this option, thus, it will be understood that he or she has named a Massachusetts Health Care Agent or Proxy.

 

Step 26 – Document Your Personal Preferences, Thoughts And Beliefs

As mentioned earlier, Massachusetts Health Providers are not required to formally recognize this form. The purpose is to present your own viewpoints and medical preferences to paper so that such information is available to anyone making medical decisions on your behalf. It will be assumed that this paperwork can support the formal declarations and appointments made earlier but cannot act as a legal standalone document that demands by declaration certain treatments or officially denies them. The first section “I My Personal Preferences, Thoughts, And Beliefs seeks to organize such a presentation beginning with the first item (labeled by the number 1) where a few blank lines will accept what you consider the minimum quality of life that you require to continue living even when struck with a debilitating medical condition that is long term and may or will result in death. For instance, the ability to work, think clearly, or speak clearly can all be documented in this section. 

 

Step 27 – Submit Principal Directives To Maintain A Quality Of Life When Injured

Define the minimum actions that you wish to engage in to make life worth living in the second item (number 2). For example, being able to feed yourself or go to the bathroom independently of machines, and other actions may be discussed here.

 

Step 28 – Document The Personal Values Of The Principal That Should Bear On Medical Decisions

If you have any personal values, religious/spiritual beliefs, or cultural considerations to be made when treatment is determined then discuss them in the third item.

 

Step 29 – Furnish The Principal’s Thoughts On Prolonging Life When Fatally Ill Or Injured

Address your concerns regarding a long-term injury or illness and what you believe would alleviate such concerns using the space provided in item 4 to do so.

 

Step 30 – Present the Principal’s Post-Life Preferences

The fifth item allows a direct report on the treatments that you find acceptable and nonacceptable when you are unable to represent yourself and suffering from a serious (and possibly fatal) illness or are in a permanently vegetative state. Use the sixth item to present your end-of-life preferences such as the hospice care facility you would prefer to be in.

 

Step 31 – Deliver A List Of The Principal’s Personal Support Network

Utilize the lines provided in Section “II. People To Inform About My Choices And Preferences” to list the name, phone number, email address, and (recommended) home address of the people you wish contacted and informed of this document and any directive it is attached to. If there no one other than the people involved need to be informed then you may type in the word “None.”

 

Step 32 – Discuss the Principal’s Mental Health Treatment Preferences

Section “III. My Medical Care: My Choices And Treatment Preferences” requests that your current medical condition and treatments (if any) be documented on the blank lines presented. This section will also accept any preferences you have regarding treatment for these pre-existing medical conditions should you be rendered in a persistent vegetative state or cannot represent yourself during an end-of-life event. 

 

Step 33 – Establish The Life-Sustaining Treatments Approved By The Principal

Notice that Section III has two items in “B. Life-Sustaining Treatments.” To best use these items to convey your preferences read through each one then place a mark in the box that corresponds to the statement that best defines your belief or preference. For instance, if you wish to die naturally when in cardiac arrest or pulmonary failure and intend to refuse CPR place a mark in the first checkbox of item 1. This option begins with the words “I Do Not Want CPR…” 

If you wish CPR attempted to resuscitate you when in cardiac arrest/pulmonary failure but only under the condition that you will be able to regain your quality of life and it is not a medical event that will result in death soon then select the second checkbox in item one. If you want CPR administered under any circumstances when your heart or lungs stop then select the third checkbox.  You may not be sure of the stance you should take regarding cardiopulmonary resuscitation. If so and you will rely on your Health Care Proxy to make this decision, then mark the fourth checkbox. Notice several lines are provided so that you may continue your wishes on paper directly. 

Step 34 – Produce The Principal’s Level Of Authorization For Life Support Techniques

When your medical condition is considered permanent with no hope of recovery leaving you unconscious or incognizant until death, then you may wish to deliver a declaration on treatments that may be used to prolong your life. If you intend to experience a natural death by denying life support or life-prolonging treatment, then select the first checkbox in item number two. If you authorize the use of life support techniques to keep you alive so long as there is a chance to recover, then you may opt then select the second checkbox. This option will mean that life support and life-prolonging machines and medicine will be used to keep you alive until you Massachusetts “Doctor And Agent Agree That Such Treatments Are No Longer Helpful.” You can approve of all “Appropriate Life-Sustaining Treatments Recommended By” your Massachusetts Physician by selecting the third checkbox. Select the fourth checkbox if do not wish to document any preferences regarding life-prolonging techniques. This will default this decision to the hands of your Massachusetts Health Care Proxy. You may also directly address the Reviewer of this paperwork on the blank lines furnished in item “2. Treatments To Prolong My Life” 

Step 35 – Additional Principal Instructions Or Personal Messages Can Be Included

If you wish to include more instructions or provisions to your declarations regarding medical care and treatment, then locate the blank lines in Section “IV. Other Instructions, Information And Personal Messages” to present them. 

 

Step 36 – Only the Massachusetts Declarant Can Sign And Execute This Paperwork

As discussed earlier, this document is not a standalone document that can be used on its own with a legal need to be accepted however, it still should be signed. Especially, if you plan on attaching it to one of the previous documents in the Massachusetts Advance Directive packet. To this end, sign your name on the blank line labeled “Signed” in Section “V. Signature And Date” then record the official date of your signature on the next line over (labeled “Date”). 

 

Step 37 – The Declaring Principal May Review, Reassess, And Reaffirm This Issue At Will

If desired, you may edit this in the future although, it is strongly recommended that you officially show such action was personally attended by signing your name on the “Reviewed And Reaffirmed” line then supplying an updated “Date” of the signature on the blank line provided to the right. 

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