New York State Assembly, Albany, NY 12248
Updated 1/23
If a patient can’t
make health care
decisions...
WHO DECIDES?
Helping guide your
care when you can’t
New York’s
Health Care
Proxy Law
and Family
Health Care
Decisions Act
Dear Neighbor,
When patients are too sick to make their own health care decisions, who decides for them? In New
York, you can appoint someone to make health care decisions for you if you lose decision-making
capacity. The Health Care Proxy Law allows you to sign a health care proxy and name your health
care agent. This simple form also allows you to include other wishes and instructions, including
whether you want to be an organ, eye or tissue donor.
Because many people never sign a health care proxy (and some do not have the capacity to do
so), the Legislature enacted another bill, the Family Health Care Decisions Act (FHCDA). This law
empowers family members to make decisions in diicult circumstances, when you are unable to do
so.
Even with the FHCDA, signing a health care proxy is still the best option. This brochure explains
health care proxies and the FHCDA. It also contains an actual health care
proxy form for you to fill out to indicate your wishes in the event of a medical
condition that leaves you unable to be in charge of your care. I urge you to
discuss and share this with your loved ones.
Sincerely,
Carl E. Heastie
Speaker of the Assembly
250 Broadway, Suite 2301
New York, NY 10007
212-312-1400
Room 932, LOB
Albany, NY 12248
518-455-3791
speaker@nyassembly.gov
From Speaker of the Assembly
Carl E. Heastie
What is a health care proxy?
The Health Care Proxy Law lets you voluntarily appoint a
competent adult to make decisions about your medical treatment
in the event you lose the ability to decide for yourself – including
decisions to remove or provide life-sustaining treatment. Health
care means any treatment, service or procedure to diagnose or
treat your physical or mental condition. You can appoint a family
member, a close friend or anyone you choose to be your health
care agent.
You can give your health care agent as little or as much authority
as you want over all or only specific health care treatments. You
may also include wishes or instructions, as well as use your health
care proxy to state your organ donation preferences.
Hospitals, doctors and other health care providers must follow
your agent’s decisions as if they were your own. Your agent must
act according to your known wishes. If your wishes are not known,
your agent must act in your best interests.
It is important to name a health care agent because we all face
health conditions we do not expect. Your agent can decide how
your wishes apply as your medical condition changes. Also, your
choice of decision-maker might be dierent from the list of allowed
surrogates in the Family Health Care Decisions Act (FHCDA).
Is a health care proxy the same as a living will?
No. A living will is a written statement of your wishes or
instructions about health care treatment which may be included in
your health care proxy.
Why should I choose a health care agent?
If you become too sick to make health care decisions, someone
must decide for you. The health care proxy lets you control your
medical treatment by:
■ choosing one person over the age of 18 – even a non-family
member if you feel it’s best – to make decisions for you;
■ avoiding conflict or confusion;
■ ensuring your wishes are correctly carried out; and
■ giving your agent the power to stop treatment when he or
she decides it’s what you would want or what is best for you
under the circumstances.
What decisions can my health care agent make?
Unless you limit your agent’s authority, he or she can make any
treatment decisions you could make. Your agent can:
■ agree that you should receive treatment;
■ choose among dierent treatments; and
■ decide that treatments should not be provided, in
accordance with your wishes and interests.
If you want your agent to be able to make decisions about artificial
nutrition and hydration (nourishment and water by feeding tube
and intravenous lines), he or she must be aware of your wishes
concerning it. Otherwise, your medical provider will decide. There
is a section on the NYS health care proxy form for this type of
information.
What about organ donation?
You may include your wishes about organ donation on your health
care proxy. You may donate all your organs, only specific organs or
none. You may say whether you want your organs to be used only
for transplantation, or also for medical education or research.
How will my health care agent make decisions?
Your agent must follow your oral and written instructions, as well
as your moral and religious beliefs, if they are known. If these are
unknown, your agent is legally required to make decisions about
your health in your best interest when you can’t.
When would my agent make treatment
decisions?
After your doctor or nurse practitioner decides you are unable to
make your own health care decisions, your agent would step in
and have authority to make decisions. As long as you can make
decisions for yourself, you are in charge. Even if your agent has
authority to act, you still have the legal right to speak up and reject
your agent’s decision.
Who will obey my agent?
All hospitals, doctors and other health care providers are legally
required to follow your agent’s decisions. If a hospital objects to
some treatment options (such as removing certain treatments),
they must tell you or your agent in advance.
Who signs the proxy form?
You sign the form, along with two witnesses who are at least 18
years old. The agent or alternate agent can’t sign as a witness.
How do I choose a health care agent?
Talk about choosing an agent with your family and close
friends. Discuss this form with your agent, doctor or health
care professional before signing. This will help you understand
decisions that may be made for you. If you select a doctor or nurse
practitioner to be your health care agent, he or she may have
to choose between acting as your agent or as your health care
provider. A health care provider cannot do both at the same time.
You don’t need a lawyer, just two adult witnesses. You may use the
form printed on the reverse side of this brochure.
For patients or residents of a hospital, nursing home or mental
hygiene facility, special restrictions apply when naming someone
as your agent who works for that facility. Ask the facility sta to
explain those restrictions.
What if the person I appoint is unavailable or
unwilling?
You can include an alternate agent in the event your health care
agent isn’t available – or is unable or unwilling to act – when
decisions must be made.
What if I change my mind about my agent or
treatment instructions?
Just fill out a new form and destroy the old one. A health care
proxy is valid indefinitely unless you revoke it. Also, if you choose
to, you can set an expiration date or other conditions for it to
expire. If your spouse is your agent and you get divorced or legally
separated, the proxy is automatically canceled, unless it says
otherwise.
Unless you have been determined by a court to lack the capacity
to make health care decisions, you have the legal right to overrule
your agent’s decision.
Can my health care agent be sued for decisions
made on my behalf?
No. Your agent will not be liable for treatment decisions made in
good faith. Also, your agent cannot be required to pay for your
health care costs.
Where should I keep my proxy?
Give a copy to your agent, health care provider and other family
members or close friends. Keep a copy with your important
papers. You might want to put a note on your refrigerator stating
who your agent is and where a copy of the proxy is located. Also,
this brochure includes a form you can cut out and carry in your
wallet to help identify your health care wishes.
Health Care Proxy Law – what you need to know
Item (1)
Write the name, home address and telephone number of the
person you are selecting as your agent.
Item (2)
If you want to appoint an alternate agent, write the name, home
address and telephone number of the person you are selecting
as your alternate agent.
Item (3)
Your health care proxy will remain valid indefinitely unless
you set an expiration date or condition for its expiration. This
section is optional and should be filled in only if you want your
health care proxy to expire.
Item (4)
If you have special instructions for your agent, write them here.
Also, if you wish to limit your agent’s authority in any way, you
may say so here or discuss it with your health care agent. If you
do not state any limitations, your agent will be allowed to make
all health care decisions that you could have made, including
the decision to consent to or refuse life-sustaining treatment.
If you want to give your agent broad authority, you may do so
right on the form. Simply write: I have discussed my wishes
with my health care agent and alternate and they know my
wishes including those about artificial nutrition and hydration.
If you wish to make more specific instructions, you could say:
If I become terminally ill, I do/don’t want to receive the
following types of treatments: ...
If I am in a coma or have little conscious understanding,
with no hope of recovery, then I do/don’t want the following
types of treatments: ...
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 the following
types of treatments: ...
I have discussed with my agent my wishes about
____________ and I want my agent to make all decisions
about these measures.
Examples of medical treatments about which you may wish to
give your agent special instructions are listed below. This is not
a complete list:
■ artificial respiration
■ artificial nutrition and
hydration (nourishment
and water provided by
feeding tube)
■ cardiopulmonary
resuscitation (CPR)
■ antipsychotic medication
■ electric shock therapy
■ antibiotics
■ surgical procedures
■ dialysis
■ transplantation
■ blood transfusions
■ abortion
■ sterilization
Item (5)
You must date and sign this health care proxy form. If you are
unable to sign yourself, you may direct someone else to sign in
your presence. Be sure to include your address.
Item (6)
You may state wishes or instructions about organ and/or
tissue donation on this form. New York law does provide for
certain individuals in order of priority to consent to an organ
and/or tissue donation on your behalf: your health care agent,
an agent you’ve designated to control the disposition of your
remains, your spouse, if you are not legally separated, or your
domestic partner, a son or daughter 18 years of age or older,
either of your parents, a brother or sister 18 years of age or
older, an adult grandchild, a grandparent, a guardian appointed
by a court prior to your death, or other person authorized to
dispose of your body.
Item (7)
Two witnesses 18 years of age or older must sign this health
care proxy form. The person who is appointed your agent or
alternate agent cannot sign as a witness.
How to fill out the Health Care Proxy Form
For help, visit:
www.health.ny.gov/publications/1430.pdf
For other languages visit:
https://www.health.ny.gov/professionals/
patients/health_care_proxy/
The Family Health Care Decisions Act (FHCDA) allows family
members or a close friend (if there are no family members) to act
as a “surrogate” or representative of the patient to make health care
decisions, including withholding or withdrawing of life-sustaining
treatment, for a patient who loses the ability to make those decisions
and has not signed a health care proxy. The law includes extensive
rules and procedures to protect patients.
Even with the FHCDA, New Yorkers are encouraged to appoint a
health care agent to make health care decisions if you later lose the
capacity to make those decisions.
Under the FHCDA, your surrogate’s role will be very similar to a
health care agent. However, a surrogate only has authority to act if
you are in a hospital or a nursing home or if the decision is about
hospice care. A health care agent may make decisions wherever you
are.
What is the Family Health Care Decisions Act?
(1) I, ____________________________________________________________________________________________
hereby appoint _________________________________________________________________________________
(name, home address and telephone number)
as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.
This proxy shall take eect only when and if I become unable to make my own health care decisions.
(2) Optional: Alternate Agent. If the person I appoint is unable, unwilling or unavailable to act as my health care agent, I
hereby appoint
_____________________________________________________________________________________________
(name, home address and telephone number)
as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.
(3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall remain in eect
indefinitely.
(Optional: If you want this proxy to expire, state the date or conditions here.)
This proxy shall expire: (specify date or conditions) _______________________________________________________
(4) Optional: I direct my health care agent to make health care decisions according to my wishes and limitations, as he
or she knows or as stated below.
(If you want to limit your agent’s authority to make health care decisions for you or to give specific
instructions, you may state your wishes or limitations here.) I direct my health care agent to make health care decisions in
accordance with the following limitations and/or instructions (attach additional pages as necessary):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
In order for your agent to make health care decisions for you about artificial nutrition and hydration
(nourishment and
water provided by feeding tube and intravenous line), your agent must reasonably know your wishes. You can either tell your
agent what your wishes are or include them in this section. See instructions for sample language that you could use if
you choose to include your wishes on this form, including your wishes about artificial nutrition and hydration.
(5) Your Identification
(please print)
Your Name ____________________________________________________________________________________
Your Signature __________________________________________________ Date _______________________
Your Address __________________________________________________________________________________
(6) Optional: Organ, Eye and/or Tissue Donation
I hereby make an anatomical gift, to be eective upon my death, of:
(check any that apply)
Any needed organs, eyes and/or tissues
The following organs, eyes and/or tissues _________________________________________________________
Limitations __________________________________________________________________________________
If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to
mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a
donation on your behalf.
Your Signature __________________________________________________ Date _______________________
(7) Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the health care agent or alternate.)
I declare that the person who signed this document is personally known to me and appears to be of sound mind and
acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence.
Date ________________________________________ Date ___________________________________________
Witness 1 Name
(print) ___________________________ Witness 2 Name (print) _____________________________
Signature ____________________________________ Signature _______________________________________
Address ______________________________________ Address ________________________________________
____________________________________________ _______________________________________________
Health Care Proxy Form
I have a health care proxy.
In case of emergency, please notify my health care agent:
My Name _______________________________________________________________________________
Address ________________________________________________________________________________
Phone _________________________________________________________________________________
My Agent’s Name ________________________________________________________________________
Agent’s Address _________________________________________________________________________
Agent’s Phone ___________________________________________________________________________
Agent’s Email ___________________________________________________________________________
Complete, clip and carry this wallet-sized form to help identify your health care wishes.