Things to Know

Things to Know About…

Things to Know About… is our series of informational fact sheets. The first section contains information on Health Care Planning and Massachusetts planning documents. The second section includes information on medical, legal, and care related topics. You can download a free copy or send to a friend or loved one.

I. Health Care Planning: Things to Know About…

Health Care Planning 101

Health Care Planning is a process of choosing care that’s right for you, and communicating your choices in a personal plan to receive quality person-centered care, all through your life. It’s both “Everyday Care Planning” with your doctors for proactive care, and “Advance Care Planning” to write down your choices for the care you want in case one day you are unable to make medical decisions for yourself. Health Care Planning helps to ensure your choices for care are well defined and honored. Read more.


A Health Care Proxy

A Massachusetts Health Care Proxy is a legal document in which you choose a trusted person to be your Health Care Agent. Your Health Care Agent steps in to make health care decisions on your behalf, if in the future your attending physician determines in writing that you are unable to make effective health care decisions for yourself. You can create your own Health Care Proxy if you are competent and 18 years old and older.  Read more.


Choosing a Health Care Agent

Who should you choose to carry out your preferences and choices for care and make medical decisions on your behalf? Here’s some helpful information to consider when choosing a Health Care Agent. Read more.


A Personal Directive

A Personal Directive, also known as a Living Will, is a personal document or statement in which you give your Health Care Agent information and instructions about your preferences and choices for future medical care and treatment.  You can create your own Personal Directive. Read more.


A Durable Power of Attorney

A Durable Power of Attorney is a legal document in which you choose a trusted person, called an Attorney-in-fact, to manage your money, property and financial matters if you become disabled or incapacitated and are unable to effectively manage your financial matters yourself.  Your Attorney-in-fact carries out your instructions in arranging and paying for your medical care and long term health care needs. It is recommended that competent adults create a Durable Power of Attorney with the help of an attorney. Read more.


Life-Sustaining Treatments

Life-sustaining treatment refers to medical treatments that are used to prolong life by supporting an essential body function, such as the heart beating, breathing, or adequate nutrition, when that body function is not able to work on its own. It’s important to talk with your doctor about your specific medical condition and the risks and benefits of life-sustaining treatments at your stage of health. Read more.


Medical Orders for Life-Sustaining Treatment, MOLST

MOLST is a medical order in which adults with advanced or terminal illness have a discussion with their clinicians about their specific health condition and the benefits and risks of attempting a range of life-sustaining treatments. After the discussion, you make choices for the care you want and don’t want, and record your decisions in the MOLST form with your clincican. Competent adults (their Health Care Agents & Guardians) can create a MOLST form with a clinician. Read more.


Comfort Care/Do Not Resuscitate Order, CC/DNR

A CC/DNR is a medical document that directs medical personnel not to restart your heart beat and breathing if your heart beat and breathing have stopped, but to provide comfort care measures. Competent adults (their Health Care Agents & Guardians) can create a CC/DNR form with a clinician. Read more.

Health Care Planning Facilitator

A health care planning facilitator is a care professional or community program staff member who has enhanced knowledge and skills to help engage adults in health care planning discussions and to connect adults to person-centered care in their community.  Read More.

II. Topics: Things to Know About…


Guardianship is a legal process for adults who have a clinically diagnosed medical condition and are unable to make or communicate effective decisions about their everyday self-care, health, and safety. If the adult has not previously appointed a Health Care Agent, the Massachusetts court can appoint a Guardian to safeguard the adult’s personal rights and autonomy and make some or all personal decisions on the adult’s behalf. Read more.


What Does a Guardian Do?

Attorney Sarah Peterson explores the role of a guardian and the duties a guardian has to the adult and to the court. Read more.



Hospice helps provide compassionate care to adults with a terminal illness with a life expectancy of six months or less. The Hospice and Palliative Care Federation of Massachusetts has generously shared their helpful fact sheet,  “About Hospice- The 5 W’s”. Read more.


Palliative Care

Palliative Care can help a person of any age with a serious or life limiting disease, to minimize pain, manage symptoms, and reduce distress.  The Palliative Care team or specialist works with your doctors to improve your daily quality of life in alignment with your choices, values, and goals for care. Read more.


Grief and Bereavement

“Grief has no timetable. It may come in waves during the turbulent months of a loved one’s illness and then intensify after he or she has passed away. Each experience is unique and deeply personal”,  says Nathaniel R. Lamkin, LICSW, ACHP-SW,  Senior Director of Patient & Family Support Services at Care Dimensions. Mr. Lamkin offers an informative and compassionate view of coping with grief and helping someone who is grieving. Read Here.