MASSACHUSETTS ADVANCE DIRECTIVE
(Health Care Proxy & Personal Directive/Living Will)
[// GUIDANCE: This template combines a statutorily-recognized Health Care Proxy under Mass. Gen. Laws ch. 201D with a non-statutory “Living Will” (Personal Directive). Massachusetts does not legislate living wills, but such instructions are routinely honored. Delete or tailor bracketed text as needed.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Appointment of Health Care Agent
3.2 Scope of Authority
3.3 Personal Health Care Instructions (Living Will)
3.4 Organ & Tissue Donation
3.5 HIPAA Authorization
3.6 Access to Medical Records & Protected Information
3.7 Nomination of Guardian/Conservator - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
This Massachusetts Advance Directive (“Directive”) is executed as a sealed instrument on this ___ day of _, 20 (“Effective Date”) by [PRINCIPAL FULL LEGAL NAME], residing at [ADDRESS] (“Principal”), pursuant to Mass. Gen. Laws ch. 201D, § 1 et seq., and any other applicable law.
WHEREAS, Principal desires (a) to appoint a trusted individual to make health-care decisions on Principal’s behalf if Principal lacks capacity, and (b) to provide written instructions regarding end-of-life and other medical treatment preferences;
NOW, THEREFORE, Principal executes this Directive on the terms set forth below.
2. DEFINITIONS
For purposes of this Directive, the following terms have the meanings indicated:
“Advance Directive” or “Directive” – This document, inclusive of the Health Care Proxy and the Personal Directive/Living Will sections.
“Agent” – The individual designated in § 3.1(a) to make health-care decisions for Principal if Principal is determined to lack capacity.
“Alternate Agent” – The individual designated in § 3.1(b) to act if the Agent is unavailable, unwilling, or ineligible.
“Attending Physician” – The physician or nurse practitioner who has primary responsibility for Principal’s care.
“Good Faith Standard” – Honesty in fact in the conduct or transaction concerned.
“Health-Care Decision” – Any decision regarding the diagnosis, treatment, or care of Principal, including withdrawal or withholding of life-sustaining treatment.
“HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, 45 C.F.R. Parts 160 & 164.
“Principal” – The individual executing this Directive.
“Provider” – Any health-care professional, institution, or facility that provides medical services to Principal.
3. OPERATIVE PROVISIONS
3.1 Appointment of Health Care Agent
(a) Primary Agent. Principal designates [AGENT FULL LEGAL NAME], residing at [ADDRESS], telephone: [PHONE], as Agent.
(b) Alternate Agent. If the Agent is unable or unwilling to serve, Principal designates [ALTERNATE AGENT FULL LEGAL NAME], residing at [ADDRESS], telephone: [PHONE], as Alternate Agent.
(c) Qualification Restrictions. No person currently serving as Principal’s health-care provider, or related to such provider, may serve as Agent unless that person is related to Principal by blood, marriage, or adoption.
3.2 Scope of Authority
(a) Agent may make any and all Health-Care Decisions on Principal’s behalf that Principal could make if capable, including but not limited to:
i. consenting to, refusing, or withdrawing treatment;
ii. approving admission to or discharge from medical facilities;
iii. accessing medical records;
iv. employing or discharging health-care personnel.
(b) Limitations or Special Instructions:
[INSERT ANY LIMITATIONS, e.g., “Agent shall not authorize electroconvulsive therapy”].
(c) Agent’s decisions are binding on all Providers who, in Good Faith, rely on this Directive.
3.3 Personal Health Care Instructions (Living Will)
[// GUIDANCE: Complete, modify, or delete subsections as desired.]
(a) End-of-Life Care. If I am in a terminal condition and lack capacity, I prefer:
[ ] Life-prolonging treatment
[ ] Comfort measures only
[ ] Other: ______
(b) Permanent Unconsciousness. If I am in a persistent vegetative state or irreversible coma:
[ ] Continue artificial nutrition/hydration
[ ] Discontinue artificial nutrition/hydration
[ ] Agent to decide
(c) Pain Management. I desire adequate pain relief even if it may hasten death.
(d) Religious/Personal Values. [INSERT].
Agent shall honor these instructions unless they are medically impracticable or inconsistent with the Good Faith Standard.
3.4 Organ & Tissue Donation
[ ] I give all organs/tissues.
[ ] I give only the following: ________
[ ] I refuse to donate.
3.5 HIPAA Authorization
Principal authorizes any Provider to disclose protected health information to Agent, Alternate Agent, and to any court of competent jurisdiction as necessary to enforce this Directive, pursuant to 45 C.F.R. §§ 164.502 & 164.524.
3.6 Access to Medical Records & Protected Information
Agent may execute any release forms, receive copies, and instruct addenda to Principal’s records.
3.7 Nomination of Guardian/Conservator
Should a court determine a guardian or conservator is necessary, Principal nominates the Agent (or Alternate Agent, if applicable) for such role.
4. REPRESENTATIONS & WARRANTIES
4.1 Principal affirms capacity to execute this Directive.
4.2 Principal warrants that all information herein is accurate and complete.
4.3 Agent and Alternate Agent represent they are willing and able to serve and will act pursuant to the Good Faith Standard.
5. COVENANTS & RESTRICTIONS
5.1 Agent shall:
(a) act in accordance with Principal’s expressed wishes;
(b) consult available medical personnel and family members where appropriate;
(c) maintain confidentiality of medical information, subject to law.
5.2 Agent shall not:
(a) receive compensation beyond reimbursement of reasonable expenses;
(b) make decisions resulting in self-dealing or conflict of interest.
6. DEFAULT & REMEDIES
6.1 If Agent and Alternate Agent are unavailable, Providers shall follow Principal’s written instructions herein as if they were decisions of an acting Agent.
6.2 Any person aggrieved by non-compliance may petition the [COUNTY] Probate & Family Court for injunctive relief compelling adherence to this Directive.
6.3 Prevailing parties in enforcement actions are entitled to reasonable attorneys’ fees and costs.
7. RISK ALLOCATION
7.1 Indemnification (Provider Protection)
Principal agrees to indemnify and hold harmless any Provider who, in Good Faith, relies on this Directive or on the direction of an acting Agent, from civil or criminal liability except for gross negligence or willful misconduct.
7.2 Limitation of Liability
No Agent, Alternate Agent, or Provider acting in Good Faith pursuant to this Directive shall be liable for acts or omissions that conform to the Good Faith Standard.
7.3 Insurance
[OPTIONAL] Agent shall maintain personal liability insurance with limits of not less than $[AMOUNT].
7.4 Force Majeure
No party shall be liable for failure to fulfill obligations hereunder where performance is prevented by acts of God, war, epidemic, or other circumstance beyond reasonable control.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Directive shall be governed by and construed under the laws of the Commonwealth of Massachusetts (“state_healthcare_law”).
8.2 Forum Selection. All actions arising under this Directive shall be brought in a court of competent jurisdiction within Massachusetts.
8.3 Arbitration & Jury Waiver. Not applicable.
8.4 Injunctive Relief. Nothing herein limits the right to seek injunctive relief to enforce the terms of this Directive.
9. GENERAL PROVISIONS
9.1 Amendment & Revocation.
(a) Principal may amend or revoke this Directive at any time by (i) executing a subsequent written directive, (ii) providing written or oral notice to Agent or Provider, or (iii) any act evidencing intent to revoke, consistent with Mass. Gen. Laws ch. 201D, § 7.
(b) Divorce or legal separation revokes any designation of a former spouse as Agent.
9.2 Assignment. Rights and obligations hereunder are personal and non-assignable.
9.3 Severability. If any provision is held invalid, the remaining provisions shall continue in full force.
9.4 Integration. This Directive constitutes the entire understanding of the parties concerning the subject matter and supersedes all prior directives.
9.5 Copies & Electronic Signatures. Photocopies, facsimile, and electronically-signed counterparts shall be deemed originals.
10. EXECUTION BLOCK
PRINCIPAL
[PRINCIPAL NAME]
Date: _______
WITNESS ATTESTATION
We, the undersigned witnesses, affirm that (i) the Principal voluntarily signed this Directive in our presence or expressly directed another to sign on Principal’s behalf, (ii) the Principal appears to be of sound mind, and (iii) neither of us is named as Agent, Alternate Agent, or a health-care provider for the Principal.
Witness #1: ____
Printed Name: ___
Address: ____
Date: _______
Witness #2: ____
Printed Name: ___
Address: ____
Date: _______
NOTARY ACKNOWLEDGMENT (Optional but recommended)
State/Commonwealth of Massachusetts
County of __
On this ___ day of _, 20, before me, the undersigned notary public, personally appeared [PRINCIPAL NAME], proved to me through satisfactory evidence of identification to be the person whose name is signed on this document, and acknowledged to me that he/she executed it voluntarily for its stated purpose.
Notary Public
My Commission Expires: _____
[// GUIDANCE:
1. Verify all personal information and preferences.
2. Provide signed copies to the Agent, Alternate Agent, primary care physician, and local hospital.
3. Consider registering the Directive with any statewide health-care proxy registry, if available.
4. Review annually and after major life changes.]