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New Jersey _________________________ Signature of (check one): _____Notary Public _____ Attorney at Law 4 ch person or who provided satisfactory proof of identity, and the declarant did then and there execute this declaration. Sworn before me this ___________ day of _________________, 19 _____. __________ddress: ______________________________________ Date __________________ OR On __________________ (date), before me came _____________________________________, (name of declarant) whom I know to be su___ Address: ______________________________________ Date __________________ _____________________________________________ (Second Witness Signature) Print Name: ___________________________________ Ahe person's health care representative or alternate health care representative. 3 _____________________________________________ (First Witness Signature) Print Name: ________________________________that he or she is personally known to me and that he or she appears to be of sound mind and free of duress or undue influence. I am 18 years of age or older, and am not designated by any document as t_______________________________________________________________ I declare that the person who signed this document or asked another to sign this document on his or her behalf, did so in my presence, __________ (Declarant's Signature) Address: __________________________________________________________________ ______________________________________ Zip Code: ___________________________ Phone: _____d the purpose and effect of this document and sign it knowingly, voluntarily and after careful deliberation. Signed this _____ day of ______________________ 20_____. ________________________________health care of my wishes and to ease the burdens of decision- making, which this responsibility may impose. I have discussed the terms of this designation with my family and/or loved ones. I understan_____________________________ ____________________________________________________________________________ I have written this Instruction Directive to inform those who may become responsible for my ___________________________________________________________________________ ____________________________________________________________________________ _______________________________________________death to be declared only when my heartbeat and breathing have irreversibly stopped. Additional Instructions (optional): ____________________________________________________________________________ _ death standard (i.e. when there has been an irreversible cessation of all functions of the entire brain, including the brain stem) would violate my personal or religious beliefs. I therefore wish my _______________________________________________________________ 2 BRAIN DEATH (initial the following statement only if it applies to you): _______ To declare my death on the basis of the whole brainmply with following instructions (optional): ________________________________________________________________________ ________________________________________________________________________ _________ remaining life. (6) Pregnancy (only applicable to females): If I am pregnant at the time that I am diagnosed as having any of the conditions described above, I direct that my health care provider coration. ______ I do not want tube feeding. ______ I do not want cardiopulmonary resuscitation (CPR). ______ I do not want antibiotics. ______ I do want maximum pain relief, even if this may shorten myopriate. (5) If I am in any of the conditions described above I feel especially strongly about the following forms of treatment: (initial all those that apply): ______ I do not want mechanical respi given all medically appropriate care necessary to make me comfortable and to relieve pain and to alleviate any suffering. _____ I direct that life-sustaining treatment be continued, if medically apprnd not a proven therapy, or is likely to be ineffective or futile in prolonging life (initial one): _____ I direct that such life-sustaining treatment be withheld or withdrawn. I also direct that I beovide for my personal hygiene and dignity. _____ I direct that life-sustaining treatment be continued, if medically appropriate. (4) If I am receiving life-sustaining treatment that is experimental abe withheld or discontinued. I understand that I will not experience pain or discomfort in this condition, and I 1 direct that I be given all medically appropriate treatment and care necessary to prally examined me, that I have totally and irreversibly lost consciousness and my ability to interact with other people and my surroundings (initial one): _____ I direct that life-sustaining treatment nued, if medically appropriate. (3) If I become permanently unconscious, and it is determined by my attending physician and at least one additional physician with appropriate expertise who has personcontinued and that I be given all medically appropriate care necessary to make me comfortable and to relieve pain and to alleviate any suffering. _____ I direct that life-sustaining treatment be contid worsening physical or mental deterioration, and I will never regain the ability to make decisions and express my wishes (initial one): _____ I direct that life-sustaining measures be withheld or dis continued, if medically appropriate. (2) If I am ever diagnosed as having an incurable and irreversible illness, disease or condition which may not be terminal, but causes me to experience severe an treatment and care necessary to make me comfortable and to relieve pain and to alleviate any suffering even though this may shorten my remaining life. _____ I direct that life-sustaining treatment beminal (initial one): _____ I direct that life-sustaining treatment which would serve only to artificially prolong my death be withheld or ended. I also direct that I be given all medically appropriatencurable and/or irreversible injury, disease, illness or condition and if my attending physician and at least one additional physician who has personally examined me determine that my condition is terme incapable of making informed decisions regarding my health care, I direct my health care providers and my loved ones to follow the instructions set forth below: (1) If I am diagnosed as having an ing Will) I, ________________________________________________________________, (name of declarant) being of sound mind, willfully and voluntarily make this declaration as follows: If at any time I becois document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Instruction Directive (Livirney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of thtitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attoed or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a subshing in this act shall be construed to impair the legal force and effect of an instruction directive executed prior to the effective date of this act. [_] These forms are provided "as is" and no implinot foreseen or contemplated by the instruction directive, including, but not limited to, the circumstances of the patient's medical condition. Living Will Information & Instructions ­ Page 5 c. Notull weight to the terms, intent, and spirit of the instruction directive. Departure from the specific terms and provisions of the instruction directive shall be based upon clearly articulable factors n consultation with a legally appointed guardian, if any, family members, or others acting on the patient's behalf, shall exercise reasonable judgment to effectuate the wishes of the patient, giving fpatient's behalf. b. If the instruction directive is, in the exercise of reasonable judgment, not specific to the patient's medical condition and the treatment alternatives, the attending physician, iaccordance with its specific terms by a legally appointed guardian, if any, family members, the physicians, nurses, other health care professionals, health care institutions, and others acting on the able or available to serve, the instruction directive shall be legally operative. If the instruction directive provides clear and unambiguous guidance under the circumstances, it shall be honored in ve 12. a. If the patient has executed an instruction directive but has not designated a health care representative, or if neither the designated health care representative or any alternate designee is of a particular health care decision, including the benefits and risks of, and alternatives to, the proposed health care, and to reach an informed decision. 26:2H-64. - Effect of instruction directietermination that a patient lacks decision making capacity shall be based upon, but need not be limited to, evaluation of the patient's ability to understand and appreciate the nature and consequencesctive in accordance with the provisions of this act, and shall not be construed as a determination of a patient's incapacity or incompetence for any other purpose. g. For purposes of this section, a dare representative shall be documented in the patient's medical records. f. A determination of lack of decision making capacity under this act is solely for the purpose of implementing an advance direis determination; and (3) each may have recourse to the dispute resolution process established by the health care institution pursuant to section 14 of this act. Notice to the patient and the health ccapacity, and the health care representative that: (1) the patient has been determined to lack decision making capacit y to make a particular health care decision; (2) each has the right to contest thermination of a lack of decision making capacity. e. The attending physician shall inform the patient, if the patient has any ability to comprehend that he has been determined to lack decision making he attending physician. Living Will Information & Instructions ­ Page 4 d. A physician designated by the patient's advance directive as a health care representative shall not make or confirm the detwith appropriate specialized training or experience. The opinion of the confirming physician shall be stated in writing and made a part of the patient's medical records in the same manner as that of tsing mental or psychological conditions or developmental disabilities of the same or similar nature, a determination of a lack of decision making capacity shall be confirmed by one or more physicians capacity because of a mental or psychological impairment or a developmental disability, and neither the attending physician or the confirming physician has specialized training or experience in diagnottending physician and the health care representative agree that confirmation is unnecessary. c. If the attending physician or the confirming physician determines that a patient lacks decision making he same manner as that of the attending physician. Confirmation of a lack of decision making capacity is not required when the patient's lack of decision making capacity is clearly apparent, and the a lack of decision making capacity shall be confirmed by one or more physicians. The opinion of the confirming physician shall be stated in writing and made a part of the patient's medical records in tnion concerning the nature, cause, extent, and probable duration of the patient's incapacity, and shall be made a part of the patient's medical records. b. The attending physician's determination of aending physician shall determine whether the patient lacks capacity to make a particular health care decision. The determination shall be stated in writing, shall include the attending physician's opiportunity to establish, and where appropriate confirm, a reliable diagnosis and prognosis for the patient. 26:2H-60. - Determination of patient's capacity to make a health care decision 8. a. The atthat the patient lacks capacity to make a particular health care decision. b. Treatment decisions pursuant to an advance directive shall not be made and implemented until there has been a reasonable opative 7. a. An advance directive becomes operative when (1) it is transmitted to the attending physician or to the health care institution, and (2) it is determined pursuant to section 8 of this act ttment; or both. An instruction directive may, but need not, be executed contemporaneously with, or be attached to, a proxy directive. 26:2H-59. - Conditions under which advance directive becomes opereclarant's general treatment philosophy and objectives; or the declarant's specific wishes regarding the provision, withholding or withdrawal of any form of health care, including life-sustaining treaf the declarant is pregnant. Living Will Information & Instructions ­ Page 3 b. A declarant may execute an instruction directive, pursuant to the requirements of section 4 of this act, stating the dsion making process. (5) A declarant shall state the limitations, if any, to be placed upon the authority of the health care representative including the limitations, if any, which may be applicable ire representative. (4) A declarant may direct the health care representative to consult with specified individuals, including alternate designees, family members and friends, in the course of the deciresentative. In the event the primary designee subsequently becomes available and able to serve as health care representative, the primary designee may, insofar as then practicable, serve as health caunable or unwilling to serve as health care representative, or is disqualified from such service pursuant to this section or any other law, the next designated alternate shall serve as health care reph care representative at the same time. (3) A declarant may designate one or more alternate health care representatives, listed in order of priority. In the event the primary designee is unavailable, is related to the declarant by blood, marriage or adoption. This restriction does not apply to a physician, if the physician does not serve as the patient's attending physician and the patient's healtr or employee of a health care institution in which the declarant is a patient or resident shall not serve as the declarant's health care representative unless the operator, administrator or employee ld, parent or other family member, friend, religious or spiritual advisor, or other person of the declarant's choosing, may be designated as a health care representative. (2) An operator, administratothe requirements of section 4 of this act, designating a competent adult to act as his health care representative. (1) A competent adult, including, but not limited to, a declarant's spouse, adult chi or other health care professional responsible for the patient's care. 26:2H-58. - Designation of health care representative; limitations 6. a. A declarant may execute a proxy directive, pursuant to ion or suspension of an advance directive is effective upon communication to any person capable of transmitting the information including the health care representative, the attending physician, nursel or written notification to the health care representative, physician, nurse or other health care professional of an intent to reinstate the advance directive. e. Reaffirmation, modification, revocatective, or both, by any of the means stated in paragraph (1) of subsection b. of this section. An incompetent patient who has suspended an advance directive may reinstate that advance directive by oraerwise specified in the advance directive. Living Will Information & Instructions ­ Page 2 d. An incompetent patient may suspend an advance directive, including a proxy directive, an instruction dirction directive, or both, in accordance with section 4 of this act. c. Designation of the declarant's spouse as health care representative shall be revoked upon divorce or legal separation, unless othysician, nurse or other health care professional, or other reliable witness, or by any other act evidencing an intent to revoke the document; or (2) Execution of a subsequent proxy directive or instruay revoke an advance directive, including a proxy directive, or an instruction directive, or both, by the following means: (1) Notification, orally or in writing, to the health care representative, phuction directive, or both. The reaffirmation or modification shall be made in accordance with the requirements for execution of an advance directive pursuant to section 4 of this act. b. A declarant m advance directive shall have if she is pregnant. 26:2H-57. - Proxy, instruction directive; reaffirmed, modified, revoked 5.a. A declarant may reaffirm or modify either a proxy directive, or an instradminister oaths. An advance directive may be supplemented by a video or audio tape recording. A female declarant may include in an advance directive executed by her, information as to what effect the, the advance directive shall be signed and dated by, or at the direction of, the declarant and be acknowledged by the declarant before a notary public, attorney at law, or other person authorized to t that the declarant is of sound mind and free of duress and undue influence. A designated health care representative shall not act as a witness to the execution of an advance directive. Alternativelynce directive for health care at any time. The advance directive shall be signed and dated by, or at the direction of, the declarant in the presence of two subscribing adult witnesses, who shall attesr your convenience, we have included useful excerpts from the New Jersey Statutes relating to Living Wills. 26:2H-56. - Advance directive for health care; execution 4. A declarant may execute an advaving Will); (2) New Jersey Instruction Directive (Living Will). This New Jersey Instruction Directive (Living Will) is based Title 26 Section 26:2H-60 et. Seq. of the New Jersey Permanent Statutes. Fo one): _____Notary Public _____ Attorney at Law -3- Information and Instructions New Jersey Living Will This package contains (1) Information and Instruction for New Jersey Instruction Directive (Liuch person, and the declarant did then and there execute this declaration. Sworn before me this ___________day of _________________, 20 ______. ___________________________________ Signature of (check____________ Date: _______________________________________ OR Option 2: Notary Public On __________________, (date) before me came __________________________, (name of declarant) whom I know to be s: _______________________________________ _____________________________________________ (Witness 2 Signature) Print Name: ___________________________________ -2- Address: __________________________te health care representative. _____________________________________________ (Witness 1 Signature) Print Name: ___________________________________ Address: ______________________________________ Dateears to be of sound mind and free of duress or undue influence. I am 18 years of age or older, and am not designated by this or any other document as the person's health care representative or alternas I declare that the person who signed this document or asked another to sign this document on his or her behalf, did so in my presence, that he or she is personally known to me and that he or she app______________ Address: _________________________________________________________________ This document must be (1) witnessed by two qualified adult witnesses or (2) notarized. Option 1: Two Witnessef this document and sign it knowingly, voluntarily and after careful deliberation. Signed this _____ day of ___________________ 20 _____. Signature: __________________________________________________tative(s) and my representative(s) has/have willingly agreed to accept the responsibility for acting on my behalf in accordance with this directive and my wishes. I understand the purpose and effect oible for my health care of my wishes and intend to ease the burdens of decision making which this responsibility may impose. I have discussed the terms of this designation with my health care represen________________________________________________ ______________________________________________________________________________ By writing this advance directive, I inform those who may become respons-1- I direct that my health care representative comply with the following instructions in the event that I am pregnant when this Directive becomes effective (optional): ______________________________tructions and/or limitations (optional): ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________ (Insert name, address, and telephone number of second alternate agent.) I direct that my health care representative comply with the following ins__ _________________________________________________________ (Insert name, address, and telephone number of first alternate agent.) (B) Second Alternate Agent: __________________________________ _____to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below: (A) First Alternate Agent: __________________________________to make health care decisions for me, or if I revoke that person's appointment or authority to act as my agent to make health care decisions for me, then I designate and appoint the following persons est interests. If the person designated as my agent in the first paragraph is not available or becomes ineligible to act as my agent to make a health care decision for me or loses the mental capacity if any, to be an organ or tissue donor. In the event my wishes are not clear, or if a situation arises that I did not anticipate, my health care representative is authorized to make decisions in my bincluding, but not limited to, my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures and informing my family or next of kin of my desire, had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, ubject to any limitations in this document, I hereby grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if Icare decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition. Sly as your agent to make health care decisions for you). as my attorney in fact (agent) to make health care decisions for me as authorized in this document. For the purposes of this document, "health ____________________________ (insert your name and address) do hereby designate and appoint: __________________________________________ (insert name, address, and telephone number of one individual onh a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Power of Attorney for Health Care I, ____________________ your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed witould only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fitse or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms shion in the best interests of the patient. -2- [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purposre decision the patient would have made had he possessed decision making capacity under the circumstances, or, when the patient's wishes cannot adequately be determined, shall make a health care decistreatment options, and to give informed consent to, or refusal of, health care. f. In the exercise of these rights and responsibilities, the health care representative shall seek to make the health cahealth care representative may decline to serve in that capacity. e. The health care representative shall exercise the patient's right to be informed of the patient's medical condition, prognosis and be construed to impose liability upon the health care representative for any portion of the patient's health care costs. d. An individual designated as a health care representative or as an alternate e patient's behalf, unless the terms of the legal guardian's court appointment or other court decree provide otherwise. c. The conferral of legal authority on the health care representative shall not ective and by this act. b. If a different individual has been appointed as the patient's legal guardian, the health care representative shall retain legal authority to make health care decisions on thve shall have authority to make health care decisions on behalf of the patient. The health care representative shall act in good faith and within the bounds of the authority granted by the advance dirre, and to reach an informed decisio n. 26:2H-61. Authority to make health care decisions 9. a. If it has been determined that the patient lacks decision making capacity, a health care representatiof the patient's ability to understand and appreciate the nature and consequences of a particular health care decision, including the benefits and risks of, and alternatives to, the proposed health caacity or incompetence for any other purpose. g. For purposes of this section, a determination that a patient lacks decision making capacity shall be based upon, but need not be limited to, evaluation capacity under this act is solely for the purpose of implementing an advance directive in accordance with the provisions of this act, and shall not be construed as a determination of a patient's incaptution pursuant to section 14 of this act. Notice to the patient and the health care representative shall be documented in the patient's medical records. f. A determination of lack of decision making make a particular health care decision; (2) each has the right to -1- contest this determination; and (3) each may have recourse to the dispute resolution process established by the health care instiny ability to comprehend that he has been determined to lack decision making capacity, and the health care representative that: (1) the patient has been determined to lack decision making capacity to e directive as a health care representative shall not make or confirm the determination of a lack of decision making capacity. e. The attending physician shall inform the patient, if the patient has aonfirming physician shall be stated in writing and made a part of the patient's medical records in the same manner as that of the attending physician. d. A physician designated by the patient's advancthe same or similar nature, a determination of a lack of decision making capacity shall be confirmed by one or more physicians with appropriate specialized training or experience. The opinion of the cal disability, and neither the attending physician or the confirming physician has specialized training or experience in diagnosing mental or psychological conditions or developmental disabilities of tion is unnecessary. c. If the attending physician or the confirming physician determines that a patient lacks decision making capacity because of a mental or psychological impairment or a development of decision making capacity is not required when the patient's lack of decision making capacity is clearly apparent, and the attending physician and the health care representative agree that confirmacians. The opinion of the confirming physician shall be stated in writing and made a part of the patient's medical records in the same manner as that of the attending physician. Confirmation of a lackatient's incapacity, and shall be made a part of the patient's medical records. b. The attending physician's determination of a lack of decision making capacity shall be confirmed by one or more physike a particular health care decision. The determination shall be stated in writing, shall include the attending physician's opinion concerning the nature, cause, extent, and probable duration of the pr of Attorney for Health Care Form. 26:2H-60. Determination of patient's capacity to make a health care decision 8. a. The attending physician shall determine whether the patient lacks capacity to maer of Attorney for Health Care is based on Title 26 Section 26:2H-60 et. Seq. of the New Jersey Statutes. The following are useful excerpts from the New Jersey Statutes relating to the New Jersey Powerney for Health Care This package contains (1) Information and Instruction fo r New Jersey Power of Attorney for Health Care; (2) New Jersey Power of Attorney for Health Care Form. This New Jersey Powussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions New Jersey Power of Atto fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discx advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure itave been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tavance Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties hNew Jersey Advance Health Care Directive This package contains both a New Jersey Power of Attorney for Health Care and a New Jersey Living Will. Together these forms are also sometimes known as an Ad New Jersey