Complaint,Petition: In the matter of: Guirand, Jean

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                                Docket No. 7-~ Commonwealth of Massachusetts

—~ The Trial Court
aa Piri

PETITION FOR SF SIAL

PROCEEDING IN RE:

A HEALTH CARE PROXY
PURSUANT TO G.L. c. 201D

In the Interests of:

Probate and Family Court

Middlesex Division

Guirand
Tast Name

Jean
First Name

Middle Name

Principal/Respondent

1. Information about the Petitioner(s): '

Name: Beth Israel Deaconess Medical Center
First Name MT. fame
330 Brookline Avenue Boston MA 02215
ress) Apt Unit, No. etey (City/Town) (State)
Primary Phone #: (781) 234-0850
Interest of the Petitioner: [kX] Health Care Provider [[] Conservator [_] Guardian C1 family member close friend

(J Commissioner of the Department of Public Health

2. Information about the Principal/Respondent:

Name: Jean Guirand
First Name Middle Name —bastName—~—

129 Park Avenue . Arlington MA 02476
ress) Apt Unit, No. etcy_ (City/Towny ~Cuatey ~~ —Sp)—

Principal/Respondent is currently receiving inpatient treatment or resides at a facility, as defined in G.L. c. 201D, § 1,

located at: 330 Brookline Avenue Boston MA 02215
(Address) pt, Unit, No. etc.y (City/Town) (tate) ~~ (ip)

(1 Principal/Respondent is under Guardianship. .
: "Division (or state Fotin Massachusetts)... DocketNumber

3. The Principal/Respondent executed a Health Care Proxy while eighteen (18) years of age or older and when presumed

to be competent; on . Acopy of the Health Care Proxy is filed with this Petition.
(date)

4.‘ The Principal/Respondent appointed . Yanick Douyon as Health Care Agent
ame

and Vanessa Guirand as alternate Health Care Agent.
Name

5. The Health Care Proxy gives the Health Care Agent or Alternate Health Care Agent the authority to make any and all health
care decisions with the following exceptions:

KI No exceptions noted.

This aon luled for hearing on: at:

8 2023 oot cg

If you object to this Petition, you or your Attorney may file an Appearance and Objection with the court \
OR you may appear at the hearing and ask the Judge if your objection may be heard.6. List Principal's/Respondents: A. Spouse, if any. E. Health Care Agent.

B. Children, ifany. Ifnone, list closest relative. F. Altemate Health Care Agent, if any
C. Guardian in the Commonwealth or elsewhere, if any. G. Durable Power of Attomey, if any.
D. Conservator in the Commonwealth or elsewhere, ifany. File or include relevant documents, if applicable.
i Relationship Indicate if this
Name Primary Address Primary Phone (Check al that apply person i:
X Spouse L] Conservator [Minor
Di chile X] Health Care Agent [7 Incompetent
i 129 Park Avenue r ! 4
Yanick Douyon Aingon MA 02476 (781) 859-9847 L] Guardian LJ Alternate Health Care Agent
L Relative:
il) HAN Hee NTN
LJ Durable Power of Attorney |
LZ Spouse [Conservator LI Winor
& child [] Health Care Agent 1 Incompetent
Vanessa Guirand Haiti 1150949001780 C Guardian X Alternate Health Care Agent
[] Relative:
i) HAN e220
L] Durable Power of Attorney
11 Spouse [J Conservator 1 Minor
& child [J Health Care Agent [1] Incompetent
Graham Guirand Unknown (450) 661-6194 [] Guardian [1 Alternate Health Care Agent
L] Relative:
relationship)
{_] Durable Power of Attorney7. «The attending Physician has detern’*~d that the Principal/Respondent lacks cap “y to make or to communicate health
care decisions. A Statement of Atte.__./1g Physician is filed with this Petition. Lu

8. To the best of my knowledge, the Principal/Respondent did not revoke the Health Care Proxy when she/he had the capacity
to do so.

9. [[] The Petitioner has no knowledge that the Principal/Respondent objects to the Health Care Agent acting on her/his behalf.
& The Petitioner has knowledge that the Principal/Respondent objects to the Health Care Agent acting on her/his behalf.

[X] The Principal/Respondent objects generally or objects to a specific decision made by the Health Care Agent

10. A dispute has arisen regarding the Health Care Proxy. The specific details of the dispute are as follows:
[] Validity of the Health Care Proxy.
Please explain:

C1 The Principal/Respondent has revoked or attempted to revoke the Health Care Proxy and there is a dispute as to the
Principal's/Respondent's capacity to make that revocation.

Please explain:

(0 Heath Care Agent should be removed as he/she is not reasonably available, willing, and competent to fulfill his or her
obligations, or is acting in bad faith.
Please explain:

\

C1 A decision of the Health Care Agent was made in bad faith or not in accordance with standards set forth in
G.L.c. 201D, § 5.

Please explain:

KK] Other
Please explain:

Principal/Respondent is objecting to certain decisions (including treatment choices) made by the health care
agent. There is a dispute as to the Principal's/Respondent's capacity to overrule the decisions of the health
care agent.

11. Counsel (You must choose one)
(a) ([] The Principal/Respondent is represented by counsel.
Name of Counsel for the Principal/Respondent:

Name (please print)

Address/Telephone
(b) [XJ To the best of my knowledge, the Principal/Respondent is not represented by counsel. | understand the court

will appoint counsel for her/him.12. A signed copy of this Petition with 2” ~aring date scheduled by the court will be ¢ “ad;

LY

(a) in-hand to the Principal/Responiéhtt.
(b) in-hand to all persons interested.

(c) in-hand or by facsimile (fax) to the above-named counsel (if any).
(d) in-hand or by facsimile (fax) to the above-named facility (if any).

no later than seventy-two (72) hours prior to the hearing. If counsel is appointed herein, a copy of this Petition must be
provided to counsel upon appointment.

This Petition requests that the Court:
XX] affirm the Health Care Proxy
OR
[] remove the Health Care Agent
OR

[1] override the Health Care Agent's decision about health care treatment

SIGNED UNDER THE PENALTIES OF PERJURY

| certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief.

Date: March 07, 2023 A] David Sontag BILH General Managing Counsel
Signature of Petitioner
Information on Attorney for Petitioner, if any /; / Br an Ho y Ht & UN uk ors
Signature of Attorney
Matthew H. Beaulieu/Brandon H. Saunders
(Print namey
565 Rounseville Road Suite 5
Aadressy Apt, Unit, No. etc
Rochester MA 02770
own) —Cuatey— py

Primary Phone #: (617) 227-1044
B.B.O. # 563194/660254
Email: BSaunders@BSKLawOffices.comr. STATEMENT OF A1_INDING —_ [DocketNo. jommonwealth of Massachusetts

PHYSICIAN FILED WITH PETITION : Probate and Family Court
FOR SPECIAL PROCEEDING IN RE: 23 P \z13
A HEALTH CARE PROXY
in the Interests of:

Jean Cc Guirand
First Name Middle Name Last Name

Division

Principal/Respondent

INSTRUCTIONS FOR COMPLETION

This Statement will be used by the Probate and Family Court in a special
proceeding regarding a Health Care Proxy. This Statement must be|
dated, and an examination must have taken place within 30 days|
prior to this Petition being filed with the Court. If a guardianship or|
conservatorship is being sought for this person, do not use this document.

To the Honorable Justices of the Probate and Family Court:

[am the attending physician as defined in G.L. c. 201D, §1 for the above-named Principal/Respondent. | am licensed in the
Commonwealth of Massachusetts. | personally examined the Principal/Respondent on:

2/26/23, 3/1/23, 3/2/23 and 3/3/23

@ate(s))

Based upon the examination, | have determined that the Principal/Respondent lacks the capacity to make or to communicate
health care decisions according to accepted standards of medical judgment.

It is my opinion that the cause and nature of the Principal's/Respondent's lack of capacity to make or to communicate health
care decisions is due to:

He has been deemed to lack capacity to make his own medical decisions due to inability to consistently
engage in discussions regarding his medical care felt to be due to combination of delirium (driven by prolonged
hospitalization, blindness, hearing difficulty) as well.as concern for neurocognitive decline and adjustment
disorder in the setting of his recent health events including blindness and left leg amputation.
The extent and probable duration of the Principal's/Respondent's lack of capacity to make or to communicate health care
decisions is: Patient currently lacks capacity to refuse medically necessary care due to the above and to make
decisions not only about major interventions but also about medication administration due to the
above impairments.

Please select, If applicable:

have determined that the Principal/Respondent lacks the capacity to make or to communicate health care decisions because
of: [_]mental illness OR [[] developmental disability

AND

| have specialized training or experience in diagnosing or treating mental illness or developmental disabilities of the same
or similar nature.

OR

CJ thave consulted with a health care professional who has such specialized training or experience.

Name: Specialty:
Name (Please print) ~ Specially

Date of Consultation

MPC 406 (7/1/14) page 1 of 2 2.YW. S

I certify that the above statement is trad to the best of my knowledge and belief !:...0 | certify that | have not been
appointed the Principal's/Respondent's Health Care Agent or Alternate Health Care Agent.

Signed Under the Penalties of Perjury:

Geb Date March 6th, 2023

Signaturé of Attending Physician .
S “ Office Address: 330 Brookline Avenue
Susan McGirr, MD address) Ap, Unit, No. ate)
Print Name
Boston MA 02215
267011 Cilyrowny “Cialey Tiny
License type, number, and date Office Phone #: 617-754-4677

MPC 406 (7/1/14) page 2 of 2