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New Jersey worn before me this ___________ day of _________________, 19 _____. ___________________________________ Signature of (check one): _____Notary Public _____ Attorney at Law 4 ____________________________________, (name of declarant) whom I know to be such person or who provided satisfactory proof of identity, and the declarant did then and there execute this declaration. Sre) Print Name: ___________________________________ Address: ______________________________________ Date __________________ Date __________________ OR On __________________ (date), before me came _________ (First Witness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Second Witness Signatuence. I am 18 years of age or older, and am not designated by any document as the person's health care representative or alternate health care representative. 3 _____________________________________ked 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 appears to be of sound mind and free of duress or undue influ_____________________________ Zip Code: ___________________________ Phone: ____________________________________________________________________ I declare that the person who signed this document or asis _____ day of ______________________ 20_____. __________________________________________ (Declarant's Signature) Address: __________________________________________________________________ _________cussed the terms of this designation with my family and/or loved ones. I understand the purpose and effect of this document and sign it knowingly, voluntarily and after careful deliberation. Signed thitten this Instruction Directive to inform those who may become responsible for my health care of my wishes and to ease the burdens of decision-making, which this responsibility may impose. I have dis____________________________________ ____________________________________________________________________________ ____________________________________________________________________________ I have wrnal): ____________________________________________________________________________ ____________________________________________________________________________ ________________________________________ the brain stem) would violate my personal or religious beliefs. I therefore wish my death to be declared only when my heartbeat and breathing have irreversibly stopped. Additional Instructions (optioly if it applies to you): _______ To declare my death on the basis of the whole brain death standard (i.e. when there has been an irreversible cessation of all functions of the entire brain, including__ ________________________________________________________________________ ________________________________________________________________________ 2 BRAIN DEATH (initial the following statement onaving any of the conditions described above, I direct that my health care provider comply with following instructions (optional): ______________________________________________________________________ot want antibiotics. ______ I do want maximum pain relief, even if this may shorten my remaining life. (6) Pregnancy (only applicable to females): If I am pregnant at the time that I am diagnosed as hms of treatment: (initial all those that apply): ______ I do not want mechanical respiration. ______ I do not want tube feeding. ______ I do not want cardiopulmonary resuscitation (CPR). ______ I do nsuffering. _____ I direct that life-sustaining treatment be continued, if medically appropriate. (5) If I am in any of the conditions described above I feel especially strongly about the following forct that such life-sustaining treatment be withheld or withdrawn. I also direct that I be given all medically appropriate care necessary to make me comfortable and to relieve pain and to alleviate any ally appropriate. (4) If I am receiving life-sustaining treatment that is experimental and not a proven therapy, or is likely to be ineffective or futile in prolonging life (initial one): _____ I direI 1 direct that I be given all medically appropriate treatment and care necessary to provide for my personal hygiene and dignity. _____ I direct that life-sustaining treatment be continued, if medic people and my surroundings (initial one): _____ I direct that life-sustaining treatment be withheld or discontinued. I understand that I will not experience pain or discomfort in this condition, and physician and at least one additional physician with appropriate expertise who has personally examined me, that I have totally and irreversibly lost consciousness and my ability to interact with otherain and to alleviate any suffering. _____ I direct that life-sustaining treatment be continued, if medically appropriate. (3) If I become permanently unconscious, and it is determined by my attending s my wishes (initial one): _____ I direct that life-sustaining measures be withheld or discontinued and that I be given all medically appropriate care necessary to make me comfortable and to relieve pess, disease or condition which may not be terminal, but causes me to experience severe and worsening physical or mental deterioration, and I will never regain the ability to make decisions and expresthough this may shorten my remaining life. _____ I direct that life-sustaining treatment be continued, if medically appropriate. (2) If I am ever diagnosed as having an incurable and irreversible illnlong my death be withheld or ended. I also direct that I be given all medically appropriate treatment and care necessary to make me comfortable and to relieve pain and to alleviate any suffering even one additional physician who has personally examined me determine that my condition is terminal (initial one): _____ I direct that life-sustaining treatment which would serve only to artificially proloved ones to follow the instructions set forth below: (1) If I am diagnosed as having an incurable and/or irreversible injury, disease, illness or condition and if my attending physician and at leastund mind, willfully and voluntarily make this declaration as follows: If at any time I become incapable of making informed decisions regarding my health care, I direct my health care providers and my o the Disclaimers and Terms of Use found at findlegalforms.com Instruction Directive (Living Will) I, ________________________________________________________________, (name of declarant) being of so when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject tnly be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommendeds 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 should o prior to the effective date of this act. [_] 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 purpose or acumstances of the patient's medical condition. Information & Instructions ­ Page 5 c. Nothing in this act shall be construed to impair the legal force and effect of an instruction directive executedific terms and provisions of the instruction directive shall be based upon clearly articulable factors not foreseen or contemplated by the instruction directive, including, but not limited to, the cir patient's behalf, shall exercise reasonable judgment to effectuate the wishes of the patient, giving full weight to the terms, intent, and spirit of the instruction directive. Departure from the spec specific to the patient's medical condition and the treatment alternatives, the attending physician, in consultation with a legally appointed guardian, if any, family members, or others acting on thehysicians, nurses, other health care professionals, health care institutions, and others acting on the patient's behalf. b. If the instruction directive is, in the exercise of reasonable judgment, nottion directive provides clear and unambiguous guidance under the circumstances, it shall be honored in accordance with its specific terms by a legally appointed guardian, if any, family members, the pre representative, or if neither the designated health care representative or any alternate designee is able or available to serve, the instruction directive shall be legally operative. If the instruc the proposed health care, and to reach an informed decision. 26:2H-64. - Effect of instruction directive 12. a. If the patient has executed an instruction directive but has not designated a health calimited to, evaluation of 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,on of a patient's incapacity 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 ack of decision making 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 determinatiy the health care institution 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 ldecision making capacity to make a particular health care decision; (2) each has the right to contest this determination; and (3) each may have recourse to the dispute resolution process established batient, if the patient has any 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 ated by the patient's advance 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 pphysician 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. Information & Instructions ­ Page 4 d. A physician designr 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 confirming ity, and neither the attending physician or the confirming physician has specialized training or experience in diagnosing mental or psychological conditions or developmental disabilities of the same onecessary. 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 developmental disabilon 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 confirmation is un 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 lack of decisincapacity, 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 physicians. Thecular 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 patient's iognosis for the patient. 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 make a partiment decisions pursuant to an advance directive shall not be made and implemented until there has been a reasonable opportunity to establish, and where appropriate confirm, a reliable diagnosis and prhe attending physician or to the health care institution, and (2) it is determined pursuant to section 8 of this act that the patient lacks capacity to make a particular health care decision. b. Treataneously with, or be attached to, a proxy directive. 26:2H-59. - Conditions under which advance directive becomes operative 7. a. An advance directive becomes operative when (1) it is transmitted to tic wishes regarding the provision, withholding or withdrawal of any form of health care, including life-sustaining treatment; or both. An instruction directive may, but need not, be executed contempor A declarant may execute an instruction directive, pursuant to the requirements of section 4 of this act, stating the declarant's general treatment philosophy and objectives; or the declarant's specifany, to be placed upon the authority of the health care representative including the limitations, if any, which may be applicable if the declarant is pregnant. Information & Instructions ­ Page 3 b.ntative to consult with specified individuals, including alternate designees, family members and friends, in the course of the decision making process. (5) A declarant shall state the limitations, if vailable and able to serve as health care representative, the primary designee may, insofar as then practicable, serve as health care representative. (4) A declarant may direct the health care represequalified from such service pursuant to this section or any other law, the next designated alternate shall serve as health care representative. In the event the primary designee subsequently becomes a one or more alternate health care representatives, listed in order of priority. In the event the primary designee is unavailable, unable or unwilling to serve as health care representative, or is disriction does not apply to a physician, if the physician does not serve as the patient's attending physician and the patient's health care representative at the same time. (3) A declarant may designatea patient or resident shall not serve as the declarant's health care representative unless the operator, administrator or employee is related to the declarant by blood, marriage or adoption. This restisor, or other person of the declarant's choosing, may be designated as a health care representative. (2) An operator, administrator or employee of a health care institution in which the declarant is ult to act as his health care representative. (1) A competent adult, including, but not limited to, a declarant's spouse, adult child, parent or other family member, friend, religious or spiritual adve. 26:2H-58. - Designation of health care representative; limitations 6. a. A declarant may execute a proxy directive, pursuant to the requirements of section 4 of this act, designating a competent adation to any person capable of transmitting the information including the health care representative, the attending physician, nurse or other health care professional responsible for the patient's caran, nurse or other health care professional of an intent to reinstate the advance directive. e. Reaffirmation, modification, revocation or suspension of an advance directive is effective upon communicection b. of this section. An incompetent patient who has suspended an advance directive may reinstate that advance directive by oral or written notification to the health care representative, physici& Instructions ­ Page 2 d. An incompetent patient may suspend an advance directive, including a proxy directive, an instruction directive, or both, by any of the means stated in paragraph (1) of subsf this act. c. Designation of the declarant's spouse as health care representative shall be revoked upon divorce or legal separation, unless otherwise specified in the advance directive. Information er reliable witness, or by any other act evidencing an intent to revoke the document; or (2) Execution of a subsequent proxy directive or instruction directive, or both, in accordance with section 4 oive, or an instruction directive, or both, by the following means: (1) Notification, orally or in writing, to the health care representative, physician, nurse or other health care professional, or othtion shall be made in accordance with the requirements for execution of an advance directive pursuant to section 4 of this act. b. A declarant may revoke an advance directive, including a proxy direct-57. - Proxy, instruction directive; reaffirmed, modified, revoked 5.a. A declarant may reaffirm or modify either a proxy directive, or an instruction directive, or both. The reaffirmation or modificated 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 advance directive shall have if she is pregnant. 26:2Hr at the direction of, the declarant and be acknowledged by the declarant before a notary public, attorney at law, or other person authorized to administer oaths. An advance directive may be supplemens and undue influence. A designated health care representative shall not act as a witness to the execution of an advance directive. Alternatively, the advance directive shall be signed and dated by, odirective shall be signed and dated by, or at the direction of, the declarant in the presence of two subscribing adult witnesses, who shall attest that the declarant is of sound mind and free of duresrom the New Jersey Statutes relating to Living Wills. 26:2H-56. - Advance directive for health care; execution 4. A declarant may execute an advance directive for health care at any time. The advance ng Will). This New Jersey Instruction Directive (Living Will) is based Title 26 Section 26:2H-60 et. Seq. of the New Jersey Permanent Statutes. For your convenience, we have included useful excerpts fInformation and Instructions New Jersey Living Will This package contains (1) Information and Instruction for New Jersey Instruction Directive (Living Will); (2) New Jersey Instruction Directive (Livi New Jersey