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What You Should Know


This is an important legal form. Before signing this form, you should understand the following facts:

1. This form gives the person you choose as your agent the authority to make all health care decisions for you, except to the extent you say otherwise in this form. "Health care" means any treatment, service or procedure to diagnose or treat your physical or mental condition.

2. Unless you say otherwise, your agent will be allowed to make all health care decisions for you, including decisions to remove or withhold life-sustaining treatment.

3. Unless your agent knows your wishes about artificial nutrition and hydration (nourishment and water provided by a feeding tube), he or she will not be allowed to refuse those measures for you.

4. Your agent will start making decisions for you when doctors decide that your are not able to make health care decisions for yourself.


You may write on this form any information about treatment that you do not desire and/or those treatments that you want to make sure you receive. Your agent must follow your instructions (oral and written) when making decisions for you.

If you want to give your agent written instructions, do so right on the form. For example, you could say:

  • If I become terminally ill, I do/don't want to receive the following treatments...
  • If I am in a coma or unconscious, with no hope of recovery, then I do/don't want...
  • If I have brain damage or a brain disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, I do/don't want...

Examples of medical treatments about which you may wish to give your agent special instructions are listed below. This is not a complete list of the treatments about which you may leave instructions.

  • artificial respiration
  • artificial nutrition and hydration (nourishment and water provided by feeding tube)
  • cardiopulmonary resuscitation (CPR)
  • antipsychotic medication
  • electric shock therapy
  • antibiotics
  • psychosurgery
  • dialysis
  • transplantation
  • blood transfusions
  • abortion
  • sterilization

Talk about choosing an agent with your family and/or close friends. You should discuss this form with a doctor or another health care professional, such as a nurse or social worker, before you sign it to make sure that you understand the types of decisions that may be made for you. You may also wish to give your doctor a signed copy. You do not need a lawyer to fill out this form.

You can choose any adult (over 18), including a family member, or close friend, to be your agent. If you select a doctor as your agent, he or she may have to choose between acting as your agent or as your attending doctor; a physician cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. You should ask staff at the facility to explain those restrictions.

NOTE: Even after you have signed a Health Care Proxy form, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped if you object. You can cancel the control given to your agent by telling him or her or your health care provider orally or in writing.

You should tell the person you choose that he or she will be your health care agent. You should discuss your health care wishes and this form with your agent. Be sure to give him or her a signed copy. Your agent cannot be sued for health care decisions made in good faith.


What to Do with the Forms

If you are being admitted to the hospital or are having ambulatory surgery, bring a copy of the completed forms with you to provide to the admitting nurse.

Be sure to send copies of the forms to your doctor(s), the agent you appointed, family members or close friends, your clergyman, your hospital and your lawyer.

Keep a copy for your own records.



Medical issues should be discussed with your doctor.

Legal issues should be discussed with your lawyer, but neither legal consultation nor a notary public is necessary to complete these forms.


About Health Care Proxy, Advance Care Directive (Living Will) & Organ Donation

How to fill out the Health Care Proxy & Advance Care Directive (Living Will) Forms

Health Care Proxy Form

Advance Care Directive (Living Will) Form


This information is provided as a public service for friends of RGHS.

Rochester General Health System is a partnership between Rochester General and Newark-Wayne hospitals and their respective foundations, as well as a Behavioral Health Network of inpatient and community-based mental health and substance abuse programs, and a Continuing Care Network of long-term and chronic care services such as Independent Living for Seniors, Hill Haven nursing home and DeMay Living Center.