This form is intended as a SAMPLE only. The form below is a variation
of the standard New York form. Do not use this form without consulting
To My Family, Doctors, and All Those Concerned with My Care I,_____________
________________________ being of sound mind, make this statement as a
directive to be followed and shall take effect in the event I become unable, to
a reasonable degree of medical certainty, to make my own health care decisions
or communicate instructions in addition to those herein stated.
I designate the following person to act as my health care agent with the
intent that (s)he shall make any and all health care decisions on my behalf,
except to the extent I state otherwise:
If the person I have named above is unable to act on my behalf, I authorize
the following person to do so:
It is my intention that my health care agent shall have [shall not have]
the authority, in addition to other authority hereby granted to direct my
doctors to withdraw artificial nutrition and hydration.
I direct my agent to make health care decisions in accordance with these
instructions and my wishes as stated above and in accord with my wishes
otherwise made known to my agent, whether or not expressed in a "Living
Will" or other type of advance directive.
These directions express my legal right to refuse treatment. Therefore I
expect my family, doctors, and everyone concerned with my care to regard
legally and morally bound to act in accord with my wishes, and in so doing to
be free of any legal liability for having followed my directions.
I especially do not want to be kept alive artificially when I have no
prospect for a recovery such that I would be able to have a meaningful life. I
therefore do not want to be dependent upon feeding tubes, respirators or
ventilators, for example, when such treatments only prolong my dying, and I
hereby direct that my agent has the specific authority to cause a notice to be
placed on my hospital chart, pursuant to Article 29_B of the Public Health Law
of the State of New York, as now enacted or hereafter amended, not to
resuscitate me if such agent believes that I would want such an order to be
included on my chart.
I understand that unless I revoke this proxy, this proxy will remain in
We the undersigned witnesses to the Health Care Proxy of ___________________
have hereunto subscribed our names at her request, and hereby attest that such
instrument was signed willingly by ___________________ and who at the time of so
signing was, in the opinion of the undersigned, free from duress.