Completing a Health Care Proxy Form

Individuals can use the proxy form prepared by the Department of Health, but are not required to do so. All health care proxies must contain the basic information described in the box on the next page. When a patient signs a proxy in a facility, lie or she should be given a copy of the completed form.

A proxy may, but need not, include wishes or instructions about treatment or statements about the agent's decision–making authority. For example, the proxy can include instructions about when a treatment should be provided or withdrawn, or it may clarify that the agent has the authority to decide about some treatments and not others. An agent can decide about artificial nutrition and hydration only if he or she has reasonable knowledge of the patient's wishes, as presented on the proxy form or as otherwise known to him or her.