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Advance Directives and Health Care Proxy


Who will speak for you?

What is an Advance Directive?

A statement that lets your doctors and other health care providers know the type of medical treatments you would or would not want if you were unable to make your own health care decisions.

What types of Advance Directives are there?

    A signed, dated and witnessed document that names someone you choose (Health Care Agent) to make medical decisions for you in case you are unable to make your own decisions.
    A written statement expressing what types of treatment you would or would not want a health care provider or institution to provide, as well as any health care instructions you want known if you are unable to make your own health care decisions.
  • DNR
    "Do Not Resuscitate" - These instructions establish whether you wish to receive cardiopulmonary resuscitation, also called CPR. If you have a DNR order, you will be allowed to die a natural death and not have any measures used to try to get you to start breathing again or to get your heart to start beating again.



What should I do with my Advance Directive?

Always make it known that you have an advance directive. You should give copies of your advance directives to: doctors, health care agent, health care facility, and friends/family that you think should have it. Bring a copy with you during an admission to a health care facility.

How long is my Advance Directive in effect?

Indefinitely, unless you include an expiration date or change it. ARE ADVANCE DIRECTIVES ONLY FOR END-OF-LIFE DECISIONS? No. They are for guidance concerning your medical treatment at any time you may not be able to make decisions for yourself.


How do I create a Health Care Proxy?

  • Write your wishes down on a piece of paper.
  • Appoint your Health Care Agent (the person you chose to make decisions for you).
  • Sign and date it.
  • Have it signed and witnessed by two people (18 years of age or older). Your agent can not be a witness.
  • Click here for a printable Health Care Proxy form. (PDF, 43K)
    You will need Adobe® Acrobat or Reader to view the form. Click here to download Adobe Reader for free.


NOTE: This does not need to be notarized. You do not need a special form, although one can be obtained from UPMC Chautauqua, your doctor, or use this the provided on the back.

Do I need a lawyer to create a Health Care Proxy?


Who can I choose to be my Health Care Agent?

You may appoint anyone you trust to make decisions for you if you are unable to make them for yourself. Your health care agent must be:



How many Health Care Agents can I have?

One. However, an alternate can be named in case your health care agent cannot be reached.

What should my Health Care Agent know?


NOTE: If the person you have chosen does not agree to accept, you should choose someone else.

Can I change my Health Care Proxy once it has been signed?

Yes, but you need to let your agent, family and friends know of any changes. Send UPMC Chautauqua and your doctor the updated copy.

Are there any treatment decisions my Health Care Agent cannot make?

Your agent can make the same treatment decisions that you could make for yourself. In New York State the only exception is artificial nutrition and hydration (nourishment and water that are given to you through a vein or through inserted feeding tubes). A simple written statement saying your health care agent knows your wishes regarding nutrition and hydration will permit your agent to make this decision.

The best time to express your wishes is not after you become ill, but while you are healthy and fully able to make your decisions known.

If you would like more information regarding Advance Directives, contact the UPMC Chautauqua Patient Representative at 716-664-8271.