NEW JERSEY
APPOINTMENT OF A HEALTH CARE

REPRESENTATIVE

????????????
I, _____________________________________________________________________,

(name)

h e reby appoint: _______________________________________________________
(name of health care representative)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(address of health care representative)

________________________________ ______________________________
(home phone number (work phone number)

to be my health care re p resentative to make any and all health care
decisions for me, including decisions to accept or to refuse any
treatment, service or procedure used to diagnose or treat my physical or
mental condition, and decisions to provide, withhold or withdraw life-
sustaining treatment. I direct my health care re p resentative to make
decisions on my behalf in accordance with my wishes as stated in this
document, or as otherwise known to him or her. 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 best interests.

If the person I have designated above is unable, unwilling or unavailable
to act as my health care representative, I hereby designate the following
person(s) to act as my health care representative, in the following order
of priority:

1. Name _____________________________________________________________

Address ______________________________________________________________

City ____________________________________ State ________________________

Telephone ____________________________________________________________

INSTRUCTIONS
????

PRINT YOUR
NAME

PRINT THE
NAME,

ADDRESS AND
HOME AND

WORK
TELEPHONE

NUMBERS OF
YOUR HEALTH

CARE REP.

PRINT THE
NAME,

ADDRESS, AND
TELEPHONE
NUMBER OF
YOUR FIRST
ALTERNATE

HEALTH CARE
REPRESENTA -

TIVE

? 2000
PARTNERSHIP FOR

CARING, INC.



2. Name _____________________________________________________________

Address ______________________________________________________________

City _____________________________________ State _______________________

Telephone ____________________________________________________________

I direct that my health care re p resentative comply with the following
instructions and/or limitations (optional):

I direct that my health care re p resentative comply with the following
instructions in the event that I am pregnant when this Directive becomes
effective (optional):

PRINT THE
NAME, ADRESS

AND
TELEPHONE
NUMBER OF

YOUR SECOND
ALTERNATE

HEALTH CARE
REPRESENTA -

TIVE

ADD PERSONAL
INSTRUCTIONS

(IF ANY)

ADD
INSTRUCTIONS

TO BE
FOLLOWED IN

THE EVENT YOU
ARE PREGNANT

(IF ANY)

? 2000
PARTNERSHIP FOR

CARING, INC.

NEW J ERSEY APPOINTMENT OF A HEALTH CARE REPRESENTATIVE ? PAGE 2 OF 4



By writing this advance directive, I inform those who may become
responsible for my health care of my wishes and intend to ease the
burdens of decisionmaking which this responsibility may impose. I have
discussed the terms of this des ignation with my health care
re p resentative(s) and my re p resentative(s) has/have willingly agreed to
accept the responsibility for acting on my behalf in accordance with this
d i rective and my wishes. I understand the purpose and effect of this
document and sign it knowingly, voluntarily and after care f u l
deliberation.

Signed this _________ day of ________________________ 20 _________.

Signature _______________________________________________________

A d d re s s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City ____________________________________ State __________________

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 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 this or any other document as the
person?s health care re p resentative or alternate health care
representative.

1. Witness _________________________________________________________

A d d re s s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City _____________________________________ State _________________

Signature _______________________________________________________

D a t e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. Witness _________________________________________________________

A d d re s s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City _____________________________________ State _________________

Signature _______________________________________________________

Date ____________________________________________________________

SIGN AND DATE
YOUR

DOCUMENT

PRINT YOUR
ADDRESS

WITNESSING
PROCEDURE
????

YOUR
WITNESSES
MUST SIGN

BELOW

WITNESS #1

WITNESS #2
TURN TO THE
NEXT PAGE TO

NOTARIZE YOUR
DOCUMENT

INSTEAD

? 2000
PARTNERSHIP FOR

CARING, INC.

NEW J ERSEY APPOINMENT OF A HEALTH CARE REPRESENTATIVE ? PAGE 3 OF 4



OR

On __________________, before me came ________________________________,
(date) (name of declarant)

whom I know to be such person, and the declarant did then and there
execute this declaration.

Sworn before me this ___________day of ____________________, 20 _______.

_________________________________________
Signature of:

_____Notary Public
_____ Attorney at Law

(check one)

OR

A NOTARY
PUBLIC OR

ATTORNEY AT
LAW SHOULD

COMPLETE THIS
SECTION

? 2000
PARTNERSHIP FOR

CARING, INC.

(Drafted with the assistance of Robert S. Olick, Esq., Montclair, NJ)

NEW J ERSEY APPOINTMENT OF A HEALTH CARE REPRESENTATIVE ? PAGE 4 OF 4

Courtesy of Partnership for Caring, Inc. 6/96
1620 Eye Street, NW Suite 202 Washington, DC 20006 800-989-9455



INSTRUCTIONS
????

INITIAL ALL
STATEMENTS

THAT REFLECT
YOUR WISHES

TERMINAL
CONDITION

PERMANENTLY
UNCONSCIOUS

? 2000
PARTNERSHIP FOR

CARING, INC.

NEW JERSEY
INSTRUCTION DIRECTIVE
???????????

If I am incapable of making an informed decision regarding my health

c a re, I direct my loved ones and health care providers to follow my

instructions as set forth below. (Initial all those that apply.)

(1) If I am diagnosed as having an incurable and irreversible illness,

disease, or condition and if my attending physician and at least one

additional physician who has personally examined me determine that

my condition is terminal:

_____ I direct that life-sustaining treatment which would serve

only to artificially prolong my dying 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.

_____ I direct that life-sustaining treatment be continued, if

medically appropriate.

(2) If there should come a time when I become perm a n e n t l y

unconscious, and it is determined by my attending 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 other people and my

surroundings:

_____ I direct that life-sustaining treatment be withheld or

discontinued. I understand that I will not experience pain or

discomfort in this condition, and I 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

medically appropriate.



(3) If there comes a time when I am diagnosed as having an incurable

and irreversible illness, 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

express my wishes:

_____ 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 pain.

_____ I direct that life-sustaining treatment be continued, if

medically 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:

_____ I direct 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.

_____ I direct that life-sustaining treatment be continued, if

medically appropriate.

(5) If I am in the condition(s) described above I feel especially strongly

about the following forms of treatment: (initial all those that apply)

______ I do not want cardiopulmonary resuscitation (CPR).

______ I do not want mechanical respiration.

______ I do not want tube feeding.

______ I do not want antibiotics.

______ I do want maximum pain relief, even if it may hasten my

death.

(6) Pregnancy:

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 pro v i d e r

comply with following instructions (optional):

INCURABLE
AND

IRREVERSIBLE
CONDITION

THAT IS NOT
TERMINAL

EXPERIMENTAL
AND/OR FUTILE

TREATMENT

SPECIFIC
PROCEDURES

AND/OR
TREATMENT

ADD
INSTRUCTIONS

TO BE
FOLLOWED IN

THE EVENT YOU
ARE PREGNANT

(IF ANY)

? 2000
PARTNERSHIP FOR

CARING, INC.

NEW J ERSEY INSTRUCTION DIRECTIVE ? PAGE 2 OF 4



OBJECTION TO
NEW J ERSEY
BRAIN DEATH
DEFINITION
(IF ANY)

ADD FURTHER
INSTRUCTIONS

(IF ANY)

SIGN AND DATE
YOUR

DOCUMENT

PRINT YOUR
ADDRESS

? 2000
PARTNERSHIP FOR

CARING, INC.

BRAIN DEATH:
The State of New Jersey has determined that an individual may be
declared legally dead when there has been an irreversible cessation of all
functions of the entire brain, including the brain stem (also known as
whole brain death). However, individuals who do not accept this definition
of brain death because of their personal religious beliefs may request that it
not be applied in determining their death.

Initial the following statement only if it applies to you:

____ To declare my death on the basis of the whole brain death
standard would violate my personal religious beliefs. I therefore
wish my death to be declared only when my heartbeat and breathing
have irreversibly stopped.

FURTHER INSTRUCTIONS:

By writing this advance directive, I inform those who may become
responsible for my health care of my wishes and intend to ease the burdens
of decisionmaking which this responsibility may impose. I have discussed
the terms of this designation with my health care representative(s) and my
re p resentative(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 of this document and sign it knowingly,
voluntarily and after careful deliberation.

Signed this ________ day of _________________________ 20 __________.

S i g n a t u re _______________________________________________________

A d d re s s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City _________________________________ State _____________________

NEW J ERSEY INSTRUCTION DIRECTIVE ? PAGE 3 OF 4



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 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 this or any other document as the
person?s health care re p resentative or alternate health care
representative.

1. Witness _________________________________________________________

Address ________________________________________________________

City ________________________________ State _____________________

Signature ____________________________ Date _____________________

2. Witness _________________________________________________________

Address ________________________________________________________

City _______________________________ State ______________________

Signature ___________________________ Date ______________________

OR

On __________________, before me came ________________________________,
(date) (name of declarant)

whom I know to be such person, and the declarant did then and there
execute this declaration.

Sworn before me this ___________ day of ____________________, 20 ______.

_________________________________________
Signature of:

_____Notary Public
_____ Attorney at Law

(check one)

(Drafted with the assistance of Robert S. Olick, Esq., Montclair, NJ)

WITNESSING
PROCEDURE
????

YOUR
WITNESSES
MUST SIGN

BELOW

WITNESS #1

WITNESS #2

OR

A NOTARY
PUBLIC OR

ATTORNEY AT
LAW SHOULD

COMPLETE THIS
SECTION

? 2000
PARTNERSHIP FOR

CARING, INC.

NEW J ERSEY INSTRUCTION DIRECTIVE ? PAGE 4 OF 4

Courtesy of Partnership for Caring, Inc. 6/96
1620 Eye Street, NW Suite 202 Washington, DC 20006 800-989-9455



Advance Directives for
Health Care

Planning Ahead for Important
Health Care Decisions



? American Association of Retired Persons
? American College of Physicians (N.J. Chapter)
? American Jewish Congress
? Citizens Committee on Biomedical Ethics
? Committee on Bioethics of the Union of American

Hebrew Synagogues
? Episcopal Diocese of Newark
? Federation of Reformed Synagogues of Greater

Philadelphia (South Jersey)
? Home Care Council of New Jersey
? Medford Leas Retirement Community
? Medical and Dental Staff of the Medical Center at

Princeton
? Medical Society of New Jersey
? Memorial Societies of Ocean, Monmouth and Morris

Counties and South Jersey
? Memorial Societies of Princeton, Plainfield and the

Raritan Valley
? New Jersey Advisory Council on Organ Transplantation

(Workgroup on Public and Professional Education)

? New Jersey Department of Health and Senior Services
? New Jersey Department of Human Services
? New Jersey Division on Aging
? New Jersey Office of the Ombudsman for the

Institutionalized Elderly
? New Jersey Office of the Public Advocate
? New Jersey Office of the Public Guardian
? New Jersey Association of Health Care Facilities
? New Jersey Association of Non-Profit Homes for the

Aging
? New Jersey Home Health Agency Assembly
? New Jersey Hospice Association
? New Jersey Hospital Association
? New Jersey State Nurses Association
? Overlook Hospital Bioethics Committee
? Older Women?s League (Central New Jersey)
? Pennsylvania Council of the Union of American Hebrew

Congregations
? Robert Wood Johnson University Hospital
? University of Medicine and Dentistry of New Jersey

The following organizations and institutions have endorsed this brochure:

This brochure is a publication of the State of New Jersey Commission of Legal and
Ethical Problems in the Delivery of Health Care (The New Jersey Bioethics Commission).

Copyright ? 1991 by The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care. All rights
reserved. The Commission expressly grants permission for the photocopying of any and all materials contained in this brochure.



State of New JerseyState of New JerseyState of New JerseyState of New Jersey
Commission on Legal and Ethical Pr blems in the Delivery of Health Care

PAUL W. ARMSTRONG, ESQ. ROBERT S. OLICK, ESQ.
CHAIRMAN EXECUTIVE DIRECTOR

SISTER JANE FRANCES BRADY
VICE-CHAIRMAN

Dear New Jersey Citizen,

This booklet was prepared by the New Jersey Commission on Legal and Ethical Problems in the
Delivery of Health Care and its Task Force on Public and Professional Education. Its purpose is to help you
to plan ahead for important health care decisions by utilizing documents known as advance directives for
health care, more commonly known as ?living wills? and ?durable powers of attorney for health care?.

Advance directives are legally recognized documents which may have important consequences for
your future health care. It is important that you read all of the material in this booklet carefully before
completing your directive. It is designed to help you prepare a directive which clearly reflects your medical
treatment preferences. In addition to basic information on advance directives, the booklet includes 3 sample
advance directive forms and a description of the advantages and disadvantages of each one. You should use
whichever form best suits your personal needs.

Understandably, the subjects of death, dying and our own incapacity are difficult to discuss with
others. Nonetheless, we at the Commission feel strongly that it is especially important to discuss your
feelings and beliefs about these subjects with those who may become responsible for making decisions for
you, such as family members, friends and your physician. Advance directives provide an important written
statement of your wishes to others, but direct communication is the key to insuring that those wishes are
clearly understood by others. Candid conversation can significantly reduce the chances of disagreements
among those who care for you, may relieve your loved ones of some of the heavy burdens of decision
making, and lend additional assurance that your wishes will be respected.

You do not need an attorney or a physician to complete a directive, although you should consult one if
you wish. Make sure to have your directive witnessed by two adults (if you choose to legally designate a
person to make decisions for you, he or she cannot also be a witness). Give copies of the completed form to
those who should know about your preferences, such as family members, friends and your doctor. If you
enter a hospital or nursing home make sure your directive is made part of your medical records.

The Commission would like to express its gratitude to the prestigious organizations and institutions
who have supported us in the production of this brochure. We also thank you for your interest in the
Commission along with our hope that the enclosed information is helpful to you and your family.

Sincerely,

(P. W. Armstrong)
Chairman
o



Paul W. Armstrong, M.A., J.D., LL., Chairman
Counsellor at Law
Sr. Jane Frances Brady, Vice-Chairman
President, St. Joseph?s Medical Center
The Hon. Gabriel M. Ambrosio, Esq.
Senator - District 36
Rabbi Shmuel Blech
Rabbi, Lakewood, New Jersey
The Hon. Stephanie Bush, Esq.
Assemblywoman - District 27
The Hon. Gerald Cardinale, D.D.S.
Senator - District 39
Harold J. Cassidy, Esq.
Attorney
Robert W. Deaton
Director of Long Term Care, Diocese of Camden
Joseph Fennelly, M.D.
Vice Chairman, Bioethics Committee
Medical Society of New Jersey
Harold B. Garwin, Esq.
Assistant Public Advocate
Office of the Public Advocate
Harold George, Esq.
Ombudsman for the Institutionalized Elderly
J. Richard Goldstein, M.D.
President, Stopwatch, Inc.
Noreen Haveron, R.N., B.S.N.
Acting Nursing Supervisor, Nutley Nursing Service
Lois Hull
Director, Division on Aging
Department of Community Affairs
The Hon. C. Richard Kamin
Assemblyman - District 23
Rabbi Charles A. Kroloff
Rabbi, Temple Emanu-El

Paul Langevin
Assistant Commissioner for Health Facilities Evaluation
Department of Health
Mary K. Lindner, R.N.
Senior Vice President, Patient Services and Executive Director of Nursing,
Overlook Hospital
Rita Martin
Legislative Director, N.J. Citizens Concerned for Life
Russell L. McIntyre, Th.D.
Associate Professor, Robert Wood Johnson Medical School
Sarah Mitchell, Esq.
Director, Division of Advocacy for the Developmentally Disabled
Office of the Public Advocate
Patricia Ann Murphy, R.N., Ph.D.
Clinical Specialist (Bereavement)
Newark Beth Israel Medical Center
Michael Nevins, M.D.
Internist, Chairman, Bioethics Committee, Pascack Valley
Hospital
Anne Perone, Esq.
Attorney
Robert L. Pickens, M.D.
Chairman, Bioethics Committee
Medical Society of New Jersey
David Rogoff
Director, Haven Hospice, John F. Kennedy Medical Center
Joan Scerbo
Legislative Aide
Mary S. Strong
Chair, Citizen?s Committee on Biomedical Ethics
Edward Tetelman, Esq.
Assistant Commissioner for Intergovernmental Affairs
Department of Human Services
Harris Vernick, M.D.
Internist

New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care

Task Force on Public and Professional Education

Commissioners Strong (Chair); Deaton, Haveron, Martin and
Rogoff

Rabbi Richard F. Address
Regional Director of Union of American Hebrew Congregations
Theresa Dietrich
representing the New Jersey Division on Aging
Kenneth Dolan
Executive Director of the Home Care Council of New Jersey
Joanne Drake
representing Assemblyman Kamin
Lois Forrest
Executive Director, Medford Leas Continuing Care Retirement
Community
Shelia Paris Klein
Director of Public Relations, Jersey City Medical Center

Joseph C. d?Oronzio
Administrative Director of Medical Education, Overlook Hospital
Michael Rappeport
RL Associates
Ritamarie G. Rondum
member, AARP State Legislative Committee
Teresa Schaer, M.D.
Director of Geriatric Programs at St. Peter?s Medical Center
Marguerite K. Schlag
Director of Nursing Education and Development, Robert Wood
Johnson University Hospital
Joseph Slavin
Executive Director, New Jersey Catholic Health Association
Helen Handin Spiro
Robert Wood Johnson Medical School

The materials and forms included in this brochure were written and prepared by Robert S. Olick, M.A., J.D., Executive Director, Mihael Vollen,
Associate Director (Project Director), and members of the Task Force. The following former staff members provided additional advice and support:
Jancie Chiantese, Director of Government Relations (co-Project Director), Adrienne Asch, Associate in Social Science and Policy, Anne Reichman,
LL.B, LL.M, Associate in Law, Eve B. Sundelson, Esq., consultant, Ellen Friedlan, Esq., consultant. The Commission wishes to express its gratitude to
all these individuals for their contributions.



Planning Ahead For Your Health Care:
Making Your Wishes Known

The purpose of this brochure is to help you
prepare an advance directive which reflects your
wishes concerning medical care. While it contains
sample forms and directions, advance directives are
very personal documents and you should feel free to
develop one which best suits your own needs. The
brochure consists of the following parts:

1. Introduction
2. Questions and Answers
3. Terms You Should Understand
4. Sample Forms
5. Checklist
6. Wallet size I.D. cards (inside back cover)

1. Introduction:
Why this booklet?

As Americans, we take it for granted that we are
entitled to make decisions about our own health
care. Most of the time we make these decisions after
talking with our own physician about the advantages
and disadvantages of various treatment options. The
right of a competent individual to accept or refuse
medical treatment is a fundamental right protected
by law.

But what happens if serious illness, injury or
permanent loss of mental capacity makes us
incapable of talking to a doctor and deciding what
medical treatments we do or do not want? These
situations pose difficult questions to all of us as
patients, family members, friends and health care
professionals. Who makes these decisions if we
can?t make them for ourselves? If we can?t make
our preferences known how can we make sure that
our wishes will be respected? If disagreements arise
among those caring for us about different treatment
alternatives how will they be resolved? Is there a
way to alleviate the burdens shouldered by family
members and loved ones when critical medical
decisions must be made?

By using documents known as advance
directives for health care, you can answer some of
these questions and give yourself the security of
knowing that you can continue to have a say in your
own treatment. A properly prepared advance

directive permits you to plan ahead so you can both
make your wishes known, and select someone who
will see to it that your wishes are followed.

After all, if you are seriously ill or injured and
can?t make decisions for yourself someone will have
to decide about your medical care. Doesn?t it make
sense to

! Have a person you trust make decisions for you,
or

! Provide instructions about the treatment you do
and do not want, or

! Both. Appoint a person to make decisions and
provide them with instructions.

A Few Definitions

Throughout this booklet we?re going to use four
phrases. Each of these phrases has a special
meaning when it comes to allowing you to make
decisions about your future health care.

! Advance directive - If you want your wishes to
guide those responsible for your care you have
to plan for what you want in advance. Generally
such planning is more likely to be effective if
it?s done in writing. So, by an ?advance
directive? we mean any written directions you
prepare in advance to say what kind of medical
care you want in the event you become unable to
make decisions for yourself.

There are three kinds of advance directives:

1. Proxy directives -- One way to have a say in
your future medical care is to designate a person
(a proxy) you trust and give that person the legal
authority to decide for you if you are unable to
make decisions for yourself. Your chosen proxy
(known as a health care representative) serves
as your substitute, ?standing in? for you in
discussions with your physician and others
responsible for your care. So, by a proxy
directive we mean written directions that name a
?proxy? to act for you. Another term some
people use for a proxy directive is a ?durable
power of attorney for health care?.



2. Instruction directives -- Another way to have a
say in your future medical care is to provide those
responsible for your care with a statement of your
medical treatment preferences. By ?instruction
directive? we mean written directions that spell
out in advance what medical treatments you wish
to accept or refuse and the circumstances in
which you want your wishes implemented.
These instructions then serve as a guide to those
responsible for your care. Another term some
people use for an instruction directive is a ?living
will?.

3. Combined directives -- A third way combines
features of both the proxy and the instruction
directive. You may prefer to give both written
instructions, and to designate a health care
representative or proxy to see that your
instructions are carried out. So, by a ?combined
directive? we mean a single document in which
you select a health care representative and
provide him or her with a statement of your
medical treatment preferences.

Whichever form you choose, it is important to
remember to discuss your health care preferences
with others. In order to help you choose the kind of
directive which best suits your circumstances, the
following pages answer some frequently asked
questions about advance directives.

2. Questions and Answers
Why should I consider writing an advance
directive?

Serious injury, illness or mental incapacity may
make it impossible for you to make health care
decisions for yourself. In these situations, those
responsible for your care will have to make
decisions for you. Advance directives are legal
documents which provide information about your
treatment preferences to those caring for you,
helping to insure that your wishes are respected even
when you can?t make decisions yourself. A clearly
written directive helps prevent disagreements among
those close to you and alleviates some of the burdens
of decision making which are often experienced by
family members, friends and health care providers.

When does my advance directive take effect?

Your directive takes effect when you no longer
have the ability to make decisions about your health
care. This judgment is normally made by your
attending physician, and any additional physicians
who may be required by law to examine you. If
there is any doubt about your ability to make such
decisions, your doctor will consult with another
doctor with training and experience in this area.
Together they will decide if you are unable to make
your own health care decisions.

What happens if I regain the ability to make my
own decisions?

If you regain your ability to make decisions, then
you resume making your own decisions directly.
Your directive is in effect only as long as you are
unable to make your own decisions.

What is the advantage of having a health care
representative, isn?t it enough to have an
instruction directive?

Your doctor and other health care professionals
are legally obligated to consider your expressed
wishes as stated in your instruction directive or
?living will?. However, instances may occur in
which medical circumstances arise or treatments are
proposed that you may not have thought about when
you wrote your directive. If this happens your
health care representative has the authority to
participate in discussions with your health care
providers and to make treatment decisions for you in
accordance with what he or she knows of your
wishes. Your health care representative will also be
able to make decisions as your medical condition
changes, in accordance with your wishes and best
interests.

If I decide to appoint a health care
representative, who should I trust with this task?

The person you choose to be your health care
representative has the legal right to accept or refuse
medical treatment (including life-sustaining
measures) on your behalf and to assure that your
wishes concerning your medical treatment are
carried out. You should choose a person who knows



you well, and who is familiar with your feelings
about different types of medical treatment and the
conditions under which you would choose to accept
or refuse either a specific treatment or all treatment.

A health care representative must understand that
his or her responsibility is to implement your wishes
even if your representative or others might disagree
with them. So it is important to select someone in
whose judgment you have confidence. People that
you might consider asking to be your health care
representative include:

! a member of your family or a very close friend,
your priest, rabbi, or minister, or

! a trusted health care provider, but your attending
physician cannot serve as both your physician
and your health care representative.

Should I discuss my wishes with my health care
representative and others?

Absolutely! Your health care representative is
the person who speaks for you when you can?t speak
for yourself. It is very important that he or she has a
clear sense of your feelings, attitudes and health care
preferences. You should also discuss your wishes
with your physician, family members and others
who will be involved in caring for you.

Does my health care representative have the
authority to make all health care decisions for
me?

It is up to you to say what your health care
representative can and cannot decide. You may
wish to give him or her broad authority to make all
treatment decisions including decisions to forego
life-sustaining measures. On the other hand, you
may wish to restrict the authority to specific
treatments or circumstances. Your representative
has to respect these limitations.

Is my doctor obligated to talk to my health care
representative?

Yes. Your health care representative has the
legal authority to make medical decisions on your
behalf, in consultation with your doctor. Your
doctor is legally obligated to consult with your

chosen representative and to respect his or her
decision as if it were your decision.

Is my health care representative the only person
who can speak for me, or can other friends or
family members participate in making treatment
decisions?

It is generally a good idea for your health care
representative to consult with family members or
others in making decisions, and if you wish you can
direct that he or she do so. It should be understood
by everyone, however, that your health care
representative is the only person with the legal
authority to make decisions about your health care
even if others disagree.

If I want to give specific instructions about my
medical care, what should I say?

If you have any special concerns about particular
treatments you should clearly express them in your
directive. If you feel there are medical conditions
which would lead you to decide to forego all
medical treatment, including life-sustaining
measures, and accept an earlier death, this should be
clearly indicated in your directive.

Are there particular treatments I should
specifically mention in my directive?

It is a good idea to indicate your specific
preferences concerning two specific kinds of life-
sustaining measures: artificially provided fluids and
nutrition and cardiopulmonary resuscitation. Stating
your preferences clearly concerning these two
treatments will be of considerable help in avoiding
uncertainty, disagreements or confusion about your
wishes. The enclosed forms provide a space for you
to state specific directions concerning your wishes
with respect to these two forms of treatment.

Can I request all measures be taken to sustain my
life?

Yes. You should make this choice clear in your
advance directive. Remember, a directive can be
used to request medical treatments as well as to
refuse unwanted ones.



Does my doctor have to carry out my wishes as
stated in my instruction directive?

If your treatment preferences are clear your
doctor is legally obligated to implement your
wishes, unless doing this would violate his or her
conscience or accepted medical practice. If your
doctor is unwilling to honor your wishes he or she
must assist in transferring you to the care of another
doctor.

Can I make changes in my directive?

Yes. An advance directive can be updated or
modified, in whole or in part, at any time, by a
legally competent individual. You should update
your directive whenever you feel it no longer
accurately reflects your wishes. It is a good idea to
review your directive on a regular basis, perhaps
every 5 years. Each time you review the directive,
indicate the date on the form itself and have
someone witness the changes you make. If you
make a lot of changes, you may want to write a new
directive. Remember to notify all those important to
you of any changes you make.

Can I revoke my directive at any time?

Yes. You can revoke your directive at any time,
regardless of your physical or mental condition.
This can be done in writing, orally, or by any action
which indicates that you no longer want the directive
to be in effect.

Who should have copies of my advance directive?

A copy should be given to the person that you
named as your health care representative, as well as
to your family, your doctor, and others who are
important to you. If you enter a hospital, nursing
home, or hospice, a copy of your advance directive
should be provided so that it can be made part of
your medical records. The back cover of this
brochure contains a wallet size card you can
complete and carry with you to tell others that you
have an advance directive.

Can I be required to sign an advance directive?

No. An advance directive is not required for
admission to a hospital, nursing home, or other
health care facility. You cannot be refused

admission to a hospital, nursing home, or other
health care facility because you do not have an
advance directive.

Can I be required to complete an advance
directive as a condition of my insurance
coverage?

No. You cannot be required to complete an
advance directive as a condition for obtaining a life
or health insurance policy. Also, having, or not
having, an advance directive has no effect on your
current health or life insurance coverage, or health
benefits.

Can I use my advance directive to make an organ
donation upon my death?

Yes. The sample combined directive and
instruction directive included with this brochure
provide a place for you to state your wishes
regarding organ donation. Also, on the inside back
cover of this brochure is a wallet size organ donor
card. If you decide to make a gift of your organs
upon your death please complete the card and carry
it with you at all times. For further information
regarding organ donation you should contact either
an organ procurement agency or your local hospital.

Will another state honor my advance directive?

It is likely that your advance directive will be
honored in another state, but this is not guaranteed.

What if I already have a living will?

While you may want to review your existing
living will or advance directive and make sure it
reflects your wishes, there is no legal requirement
that you do so.

Do I need an attorney or a doctor to write one?

You should consult with anyone you think can be
helpful, but it is not necessary. This booklet and the
forms which are included are designed to enable you
to complete your advance directive without the need
for legal or medical advice. If the medical
terminology is unclear to you, most health care
professionals will be able to help you understand it.



3. Terms You Should Understand

1. Artificially provided fluids and nutrition: The
provision of food and water to seriously ill patients
who are unable or unwilling to eat. Depending on
the method used, such as insertion of a feeding tube
or an intravenous line, and the condition of the
patient, techniques may involve minor surgery,
continuous supervision by medical (and sometimes
surgical) personnel, risk of injury or infection, and
side effects.

2. Cardiopulmonary Resuscitation (CPR): A
treatment administered by health care professionals
when a person?s heartbeat and breathing stops. CPR
may restore functioning if administered properly and
in a timely fashion and may include the use of
mechanical devices and/or drugs.

3. Life-sustaining measures: Any medical
procedure, device, artificially provided fluids and
nutrition, drugs, surgery, or therapy that uses
mechanical or other artificial means to sustain,
restore or supplant a vital bodily function, thereby
prolonging the life of a patient.

4. Decision making capacity: A patient?s ability
to understand the benefits and risks of a proposed
medical treatment and its alternatives and to reach an
informed decision.

5. Health care representative or health care
proxy: In the event an individual loses decision
making capacity, a health care representative or
proxy is a person who has been legally designated to
make decisions on his or her behalf. A health care
representative is appointed through the execution of
a proxy directive (a durable power of attorney for
health care).

6. Terminal condition: The terminal stage of an
irreversibly fatal illness, disease, or condition.
While determination of a specific ?life expectancy?
is not required for a diagnosis of a ?terminal
condition?, a prognosis of a life expectancy of one
year or less, with or without the provision of life-

sustaining treatment, is generally considered
terminal.

7. Permanent unconsciousness: A medical
condition defined as total and irreversible loss of
consciousness. The term ?permanently
unconscious? includes the conditions persistent
vegetative state and irreversible coma. Patients in
this condition cannot interact with their surroundings
or others in any way and do not experience pleasure
or pain.

8. Persistent vegetative state: A condition of
permanent unconsciousness in which the patient
loses all capacity for interaction with their
environment or other people. It is usually caused by
an injury to the brain. It is normally not regarded as
a terminal condition and with the aid of medical care
and artificial fluids and nutrition patients can survive
for many years.

9. Incurable and irreversible chronic diseases:
Disabling diseases such as Alzheimer?s diseases,
organic brain syndrome or other diseases which get
progressively worse over time, eventually resulting
in death. Depending on the disease, the patient may
also experience partial or complete loss of physical
and mental abilities. Because the rate at which these
diseases advance may be slow, such diseases are not
considered terminal in their early stages.

10. Whole brain death: Death due to total and
irreversible loss of all functions of the entire brain,
including the brain stem. The criteria of whole brain
death must be used to accurately determine death in
individuals who have suffered massive or total brain
damage but whose heart and lungs are kept
functioning by machines. Brain dead individuals are
not vegetative or in a coma, but are, in fact, dead.

11. Attending physician: The doctor directly
responsible for your medical treatment. He or she
may or may not be your regular family physician.
Depending on your health care needs the attending
physician may consult with others in order to
diagnose and treat your medical condition, but he or
she remains directly responsible for your care.





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PROXY DIRECTIVE--(Durable Power of Attorney for Health Care)
Designation of Health Care Representative

I understand that as a competent adult, I have the right to make decisions about my health care. There may
come a time when I am unable, due to physical or mental incapacity, to make my own health care decision. In
these circumstances, those caring for me will need direction and they will turn to someone who knows my values
and health care wishes. By writing this durable power of attorney for health care I appoint a health care
representative with the legal authority to make health care decisions on my behalf and to consult with my
physician and others. I direct that this document become part of my permanent medical records.

A) CHOOSING A HEALTH CARE REPRESENTATIVE:

I, ______________________________, hereby designate _________________________________________,
of _________________________________________________________________________________________
___________________________________________________________________________________________,

(home address and telephone number of health care representative)

as my health care representative to make any and all health care decisions for me, including decisions to accept or
to refuse any treatment, service or procedure used to diagnose or treat my physical or mental condition and
decisions to provide, withhold or withdraw life-sustaining measures. I direct my representative to make decisions
on my behalf in accordance with my wishes as stated in this document, or as otherwise known to him or her. In
the event my wishes are not clear, my representative is authorized to make decisions in my best interest, based on
what is known of my wishes.

This durable power of attorney for health care shall take effect in the event I become unable to make my own
health care decisions, as determined by the physician who has primary responsibility for my care, and any
necessary confirming determinations.

B) ALTERNATE REPRESENTATIVES: If the person I have designated above is unable, unwilling or
unavailable to act as my health care representative, I hereby designate the following person(s) to act as my health
care representative, in the order of priority stated:

1. name ________________________________ 2. name ________________________________
address ______________________________ address ______________________________
city _____________________ state _______ city ______________________ state _______
telephone ____________________________ telephone _____________________________

C) SPECIFIC DIRECTIONS: Please initial the statement below which best expresses your wishes.

_____ My health care representative is authorized to direct that artificially provided fluids and nutrition,
such as by feeding tube or intravenous infusion, be withheld or withdrawn.

_____ My health care representative does not have this authority, and I direct that artificially provided
fluids and nutrition be provided to preserve my life, to the extent medically appropriate.



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(If you have any additional specific instructions concerning your care you may use the space below or attach an
additional statement.)

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

D) COPIES: The original or a copy of this document has been given to my health care representative and to the
following:

1. name ___________________________________
address _________________________________
city ________________________ state _______ telephone __________________________

2. name ___________________________________

address _________________________________
city ________________________ state _______ telephone __________________________

E) SIGNATURE: By writing this durable power of attorney for health care, I inform those who may become
entrusted with my care of my health care 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 representative and
he or she has willingly agreed to accept the responsibility for acting on my behalf in accordance with my wishes
as expressed in this document. I understand the purpose and effect of this document and sign it knowingly,
voluntarily and after careful deliberation.

Signed this _____________ day of ______________, 20______.
signature _____________________________________________

address ______________________________________________
city ____________________________________ state_________

F) WITNESSES: 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 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 this
or any other document as the person?s health care representative, nor as an alternate health care representative.

1. witness____________________________________ 2. witness _______________________________
address ___________________________________ address ______________________________
city _______________________ state __________ city ____________________ state _________

signature _________________________________ signature _____________________________

date ______________________________________ date _________________________________



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COMBINED ADVANCE DIRECTIVE FOR HEALTH CARE
(Combined Proxy and Instruction Directive)

I understand that as a competent adult I have the right to make decisions about my health care. There may
come a time when I am unable, due to physical or mental incapacity, to make my own health care decisions. In
these circumstances, those caring for me will need direction concerning my care and will turn to someone who
knows my values and health care wishes. I understand that those responsible for my care will seek to make health
care decisions in my best interests, based upon what they know of my wishes. In order to provide the guidance
and authority needed to make decisions on my behalf:

I, ___________________________________ hereby declare and make known my instructions and wishes for my
future health care. This advance directive for health care shall take effect in the event I become unable to make
my own health care decisions, as determined by the physician who has primary responsibility for my care, and
any necessary confirming determinations. I direct that this document become part of my permanent medical
records.

In completing Part One of this directive, you will designate an individual you trust to act as your legally
recognized health care representative to make health care decisions for you in the event you are unable to
make decisions for yourself.

In completing Part Two of this directive, you will provide instructions concerning your health care
preferences and wishes to your health care representative and others who will be entrusted with
responsibility for your care, such as your physician, family members and friends.

Part One: Designation of a Health Care Representative

A) CHOOSING A HEALTH CARE REPRESENTATIVE:

I hereby designate:
name _________________________________________

address _______________________________________

city ___________________________ state __________

telephone ______________________

as my health care representative to make any and all health decisions for me, including decisions to accept or to
refuse any treatment, service or procedure used to diagnose or treat my physical or mental condition, and
decisions to provide, withhold or withdraw life-sustaining measures. I direct my representative to make decisions
on my behalf in accordance with my wishes as stated in this document, or as otherwise known to him or her. In
the event my wishes are not clear, or a situation arises I did not anticipate, my health care representative is
authorized to make decisions in my best interests, based upon what is known of my wishes.

I have discussed the terms of this designation with my health care representative and he or she has willingly
agreed to accept the responsibility for acting on my behalf.



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B) ALTERNATE REPRESENTATIVES: If the person I have designated above is unable, unwilling or
unavailable to act as my health care representative, I hereby designate the following person(s) to act as my health
care representative, in order of priority stated:

1. name _____________________________________ 2. name ________________________________

address ___________________________________ address ______________________________

city __________________________ state _______ city _____________________ state _______

telephone _________________________________ telephone ____________________________

Part Two: Instruction Directive

In Part Two, you are asked to provide instructions concerning your future health care. This will require
making important and perhaps difficult choices. Before completing your directive, you should discuss these
matters with your health care representative, doctor, family members or others who may become responsible for
your care.

In Sections C and D, you may state the circumstances in which various forms of medical treatment, including
life-sustaining measures, should be provided, withheld or discontinued. If the options and choices below do not
fully express your wishes, you should use Section E, and/or attach a statement to this document which would
provide those responsible for your care with additional information you think would help them in making
decisions about your medical treatment. Please familiarize yourself with all sections of Part Two before
completing your directive.

C) GENERAL INSTRUCTIONS: To inform those responsible for my care of my specific wishes, I make the
following statement of personal views regarding my health care:

Initial ONE of the following two statements with which you agree:

1. _____ I direct that all medically appropriate
measures be provided to sustain my life, regardless
of my physical or mental condition

2. _____ There are circumstances in which I
would not want my life to be prolonged by
further medical treatment. In these
circumstances, life-sustaining measures should
not be initiated and if they have been, they
should be discontinued. I recognize that this is
likely to hasten my death. In the following, I
specify the circumstances in which I would
choose to forego life-sustaining measures.

If you have initialed statement 2, on the following page please initial each of the statements (a, b, c) with
which you agree:



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a. ______ I realize that there may come a time when I am diagnosed as having an incurable and irreversible
illness, disease, or condition. If this occurs, and my attending physician and at least one additional physician
who has personally examined me determine that my condition is terminal, I direct that life-sustaining
measures which would serve only to artificially prolong my dying be withheld or discontinued. I also direct
that I be given all medically appropriate care necessary to make me comfortable and to relieve pain.

In the space provided, write in the bracketed phrase with which you agree:

To me, terminal condition means that my physicians have determined that:

________________________________________________________________________________________

[I will die within a few days] [I will die within a few weeks]
[I have a life expectancy of approximately _______________ or less (enter 6 months, or 1 year)]

b. ______ If there should come a time when I become permanently unconscious, and it is determined by
my attending 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 capacity for interaction with other
people and my surroundings, I direct that life-sustaining measures be withheld or discontinued. I understand
that I will not experience pain or discomfort in this condition, and I direct that I be given all medically
appropriate care necessary to provide for my personal hygiene and dignity.

c. ______ I realize that there may come a time when I am diagnosed as having an incurable and
irreversible illness, disease, or condition which may not be terminal. My condition may cause me to
experience severe and progressive physical or mental deterioration and/or a permanent loss of capacities and
faculties I value highly. If, in the course of my medical care, the burdens of continued life with treatment
become greater than the benefits I experience, I direct that life-sustaining measures be withheld or
discontinued. I also direct that I be given all medically appropriate care necessary to make me comfortable
and to relieve pain.

(Paragraph c. covers a wide range of possible situations in which you may have experienced partial or
complete loss of certain mental and physical capacities you value highly. If you wish, in the space provided
below you may specify in more detail the conditions in which you would choose to forego life-sustaining
measures. You might include a description of the faculties or capacities, which, if irretrievably lost would
lead you to accept death rather than continue living. You may want to express any special concerns you have
about particular medical conditions or treatments, or any other considerations which would provide further
guidance to those who may become responsible for your care. If necessary, you may attach a separate
statement to this document or use Section E to provide additional instructions.)

Examples of conditions which I find unacceptable are:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________



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D) SPECIFIC INSTRUCTIONS: Artificially Provided Fluids and Nutrition; Cardiopulmonary
Resuscitation (CPR). On page 3 you provided general instructions regarding life-sustaining measures. Here
you are asked to give specific instructions regarding two types of life-sustaining measures-artificially provided
fluids and nutrition and cardiopulmonary resuscitation.

In the space provided, write in the bracketed phrase with which you agree:

1. In the circumstances I initialed on page 3, I also direct that artificially provided fluids and nutrition, such
as by feeding tube or intravenous infusion,

________________________________________________________________________________________

[be withheld or withdrawn and that I be allowed to die]
[be provided to the extent medically appropriate]

2. In the circumstances I initialed on page 3, if I should suffer a cardiac arrest, I also direct that
cardiopulmonary resuscitation (CPR)
________________________________________________________________________________________

[not be provided and that I be allowed to die]
[be provided to preserve my life, unless medically inappropriate or futile]

3. If neither of the above statements adequately expresses your wishes concerning artificially provided fluids
and nutrition or CPR, please explain your wishes below.

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

E) ADDITIONAL INSTRUCTIONS: (You should provide any additional information about your health care
preferences which is important to you and which may help those concerned with your care to implement your
wishes. You may wish to direct your health care representative, family members, or your health care providers to
consult with others, or you may wish to direct that your care be provided by a particular physician, hospital,
nursing home, or at home. If you are or believe you may become pregnant, you may wish to state specific
instructions. If you need more space than is provided here you may attach an additional statement to this
directive.)

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

F) BRAIN DEATH: (The State of New Jersey recognizes the irreversible cessation of all functions of the entire
brain, including the brain stem (also known as whole brain death), as a legal standard for the declaration of
death. However, individuals who cannot accept this standard because of their personal religious beliefs may
request that it not be applied in determining their death.)

Initial the following statement only if it applies to you:

_____ To declare my death on the basis of the whole brain death standard would violate my personal
religious beliefs. I therefore wish my death to be declared solely on the basis of the traditional criteria of
irreversible cessation of cardiopulmonary (heartbeat and breathing) function.



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G) AFTER DEATH - ANATOMICAL GIFTS: (It is now possible to transplant human organs and tissue in
order to save and improve the lives of others. Organs, tissues and other body parts are also used for therapy,
medical research and education. This section allows you to indicate your desire to make an anatomical gift and if
so, to provide instructions for any limitations or special uses.)

Initial the statements which express your wishes:

1. ______ I wish to make the following anatomical gift to take effect upon my death:

A. ______ any needed organs or body parts
B. ______ only the following organs or parts

_____________________________________________________________________________________

for the purposes of transplantation, therapy, medical research or education, or

C. ______ my body for anatomical study, if needed.
D. ______ special limitations, if any:

_____________________________________________________________________________________

If you wish to provide additional instructions, such as indicating your preference that your organs be given to a
specific person or institution, or be used for a specific purpose, please do so in the space provided below.

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

2. ______ I do not wish to make an anatomical gift upon my death.

Part Three: Signature and Witnesses

H) COPIES: The original or a copy of this document has been given to the following people (NOTE: If you
have chosen to designate a health care representative, it is important that you provide him or her with a copy of
your directive.)

1. name _____________________________________ 2. name ________________________________
address ___________________________________ address ______________________________
city __________________________ state _______ city _____________________ state _______

telephone _________________________________ telephone ____________________________



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I) SIGNATURE: By writing this advance directive, I inform those who may become entrusted with 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 representative and he or she has willingly agreed
to accept the responsibility for acting on my behalf in accordance with this directive. I understand the purpose
and effect of this document and sign it knowingly, voluntarily and after careful deliberation.

Signed this _____________ day of ______________, 20______.
signature ____________________________________________
address _____________________________________________
city ___________________________________ state_________

J) WITNESSES: 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 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 this
or any other document as the person?s health care representative nor as an alternate health care representative.

1. witness ____________________________________________
address ____________________________________________
city _________________________________ state _________
signature __________________________________________
date _______________________

2. witness ____________________________________________
address ____________________________________________
city _________________________________ state _________
signature __________________________________________

date _______________________



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INSTRUCTION DIRECTIVE

I understand that as a competent adult I have the right to make decisions about my health care. There may
come a time when I am unable, due to physical or mental incapacity, to make my own health care decisions. In
these circumstances, those caring for me will need direction concerning my care and they will require information
about my values and health care wishes. In order to provide the guidance and authority needed to make decisions
on my behalf:

A) I, _________________________________, hereby declare and make known to my family, physician, and
others, my instructions and wishes for my future health care. I direct that all health care decisions, including
decisions to accept or refuse any treatment, service or procedure used to diagnose, treat or care for my physical or
mental condition and decisions to provide, withhold or withdraw life-sustaining measures, be made in accordance
with my wishes as expressed in this document. This instruction directive shall take effect in the event I become
unable to make my own health care decisions, as determined by the physician who has primary responsibility for
my care, and any necessary confirming determinations. I direct that this document become part of my permanent
medical records.

Part One: Statement of My Wishes Concerning My Future Health Care

In Part One, you are asked to provide instructions concerning your future health care. This will require
making important and perhaps difficult choices. Before completing your directive, you should discuss these
matters with your doctor, family members or others who may become responsible for your care.

In Section B and C, you may state the circumstances in which various forms of medical treatment, including
life-sustaining measures, should be provided, withheld or discontinued. If the options and choices below do not
fully express your wishes, you should use Section D, and/or attach a statement to this document which would
provide those responsible for your care with additional information you think would help them in making
decisions about your medical treatment. Please familiarize yourself with all sections of Part One before
completing your directive.

B) GENERAL INSTRUCTIONS: To inform those responsible for my care of my specific wishes, I make the
following statement of personal views regarding my health care:

Initial ONE of the following two statements with which you agree:

1. _____ I direct that all medically appropriate
measures be provided to sustain my life,
regardless of my physical or mental condition

2. _____ There are circumstances in which I
would not want my life to be prolonged by
further medical treatment. In these
circumstances, life-sustaining measures should
not be initiated and if they have been, they
should be discontinued. I recognize that this is
likely to hasten my death. In the following, I
specify the circumstances in which I would
choose to forego life-sustaining measures.



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If you have initialed statement 2 on page 1, please initial each of the statements (a, b, c) with which you
agree:

a. ______ I realize that there may come a time when I am diagnosed as having an incurable and irreversible
illness, disease, or condition. If this occurs, and my attending physician and at least one additional physician
who has personally examined me determine that my condition is terminal, I direct that life-sustaining
measures which would serve only to artificially prolong my dying be withheld or discontinued. I also direct
that I be given all medically appropriate care necessary to make me comfortable and to relieve pain.

In the space provided, write in the bracketed phrase with which you agree:

To me, terminal condition means that my physicians have determined that:

________________________________________________________________________________________

[I will die within a few days] [I will die within a few weeks]
[I have a life expectancy of approximately ______________ or less (enter 6 months, or 1 year)]

b. ______ If there should come a time when I come permanently unconscious, and it is determined by my
attending 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 capacity for interaction with other
people and my surroundings, I direct that life-sustaining measures be withheld or discontinued. I understand
that I will not experience pain or discomfort in this condition, and I direct that I be given all my medically
appropriate care necessary to provide for my personal hygiene and dignity.

c. ______ I realize that there may come a time when I am diagnosed as having an incurable and
irreversible illness, disease, or condition which may not be terminal. My condition may cause me to
experience severe and progressive physical or mental deterioration and/or a permanent loss of capacities and
faculties I value highly. If, in the course of my medical care, the burdens of continued life with treatment
become greater than the benefits I experience, I direct that life-sustaining measures be withheld or
discontinued. I also direct that I be given all medically appropriate care necessary to make me comfortable
and to relieve pain.

(Paragraph c. covers a wide range of possible situations in which you may have experienced partial or
complete loss of certain mental and physical capacities you value highly. If you wish, in the space provided
below you may specify in more detail the conditions in which you would choose to forego life-sustaining
measures. You might include a description of the faculties or capacities, which, if irretrievably lost would
lead you to accept death rather than continue living. You may want to express any special concerns you have
about particular medical conditions or treatments, or any other considerations which would provide further
guidance to those who may become responsible for your care. If necessary, you may attach a separate
statement to this document or use Section D to provide additional instructions.)

Examples of conditions which I find unacceptable are:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________



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C) SPECIFIC INSTRUCTIONS: Artificially Provided Fluids and Nutrition; Cardiopulmonary
Resuscitation (CPR). On page 2 you provided general instructions regarding life-sustaining measures. Here
you are asked to give specific instructions regarding two types of life-sustaining measures-artificially provided
fluids and nutrition and cardiopulmonary resuscitation.

In the space provided, write in the bracketed phrase with which you agree:

1. In the circumstances I initialed on page 2, I also direct that artificially provided fluids and nutrition, such
as by feeding tube or intravenous infusion,

________________________________________________________________________________________

[be withheld or withdrawn and that I be allowed to die]
[be provided to the extent medically appropriate]

2. In the circumstances I initialed on page 2, if I should suffer a cardiac arrest, I also direct that
cardiopulmonary resuscitation (CPR)
________________________________________________________________________________________

[not be provided and that I be allowed to die]
[be provided to preserve my life, unless medically inappropriate or futile]

3. If neither of the above statements adequately expresses your wishes concerning artificially provided fluids
and nutrition or CPR, please explain your wishes below.

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

D) ADDITIONAL INSTRUCTIONS: (You should provide any additional information about your health care
preferences which is important to you and which may help those concerned with your care to implement your
wishes. You may wish to direct your family members or your health care providers to consult with others, or you
may wish to direct that your care be provided by a particular physician, hospital, nursing home, or at home. If
you are or believe you may become pregnant, you may wish to state specific instructions. If you need more space
than is provided here you may attach an additional statement to this directive.)

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

E) BRAIN DEATH: (The State of New Jersey recognizes the irreversible cessation of all functions of the entire
brain, including the brain stem (also known as whole brain death), as a legal standard for the declaration of
death. However, individuals who cannot accept this standard because of their personal religious beliefs may
request that it not be applied in determining their death.)

Initial the following statement only if it applies to you:

______ To declare my death on the basis of the whole brain death standard would violate my personal
religious beliefs. I therefore wish my death to be declared solely on the basis of the traditional criteria of
irreversible cessation of cardiopulmonary (heartbeat and breathing) function.



The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care

Page 4 of 5

F) AFTER DEATH - ANATOMICAL GIFTS: (It is now possible to transplant human organs and tissue in
order to save and improve the lives of others. Organs, tissues and other body parts are also used for therapy,
medical research and education. This section allows you to indicate your desire to make an anatomical gift and if
so, to provide instructions for any limitations or special uses.)

Initial the statements which express your wishes:

1. ______ I wish to make the following anatomical gift to take effect upon my death:

A. ______ any needed organs or body parts
B. ______ only the following organs or parts

_____________________________________________________________________________________

for the purposes of transplantation, therapy, medical research or education, or

C. ______ my body for anatomical study, if needed.
D. ______ special limitations, if any:

_____________________________________________________________________________________

If you wish to provide additional instructions, such as indicating your preference that your organs be given to a
specific person or institution, or be used for a specific purpose, please do so in the space provided below.

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

2. ______ I do not wish to make an anatomical gift upon my death.

Part Two: Signature and Witnesses

G) COPIES: The original or a copy of this document has been given to the following people (NOTE: It is
important that you provide a family member, friend or your physician with a copy of your directive.):

1. name _____________________________________ 2. name ________________________________

address ___________________________________ address ______________________________

city ___________________________ state ______ city ______________________ state ______

telephone _________________________________ telephone ____________________________



The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care

Page 5 of 5

H) SIGNATURE: By writing this advance directive, I inform those who may become entrusted with my health
care of my wishes and intend to ease the burdens of decision making which this responsibility may impose. I
understand the purpose and effect of this document and sign it knowingly, voluntarily and after careful
deliberation.

Signed this _____________ day of ______________, 20______.
signature ____________________________________________

address _____________________________________________

city ___________________________________ state_________

I) WITNESSES: 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 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 this
or any other document as the person?s health care representative nor as an alternate health care representative.

1. witness _____________________________________________
address _____________________________________________
city __________________________________ state _________
signature ___________________________________________
date ________________________

2. witness _____________________________________________
address _____________________________________________
city __________________________________ state _________
signature ___________________________________________
date ________________________





Notes:





Checklist: Questions to Ask Yourself
I. Thinking about Your Health Care Wishes?

A. Why am I writing an advance directive?
B. What are my treatment wishes?

1. in situations near the end of life?
2. in situations of serious injury or illness?

II. Talking with Others
A. Physicians and other health care professionals

1. do I understand the medical terminology?
2. do they understand my wishes?

B. My friends, family and others
1. have I directly and thoroughly discussed my wishes with them?
2. do they understand my wishes?

III. Selecting a Health Care Representative
A. Am I confident that my designated representative understands my personal values and health care wishes?
B. Does my health care representative understand his or her responsibilities?
C. Has he or she clearly agreed to serve as my representative and to communicate my wishes to my doctor and other

concerned with my care?
D. Have I selected an alternative health care representative?

IV. My Instructions. Have I clearly stated my instructions and included other relevant information about my treatment
wishes regarding:
A. the provision, withholding or withdrawal of specific treatments?
B. artificially provided fluids and nutrition?
C. the medical conditions in which I want my wishes implemented?
D. special considerations I may have concerning my care and treatment?

V. Witnesses. Have I had my directive properly witnessed?
VI. Distribution of My Advance Directive. Have I given a copy of my directive to those who should have one, such as:

A. my health care representative?
B. my physician or other health care provider?
C. the hospital or nursing home which I am about to enter?
D. family members, friends, alternate representatives and my religious advisor?

VII. Periodic Review. Have I made a note to review my directive on a regular basis in the future?
VIII. Wallet Card. Have I completed the wallet size card located on the inside back cover of this brochure which tells

others I have an advance directive and who to contact for further information?

I HAVE AN ADVANCE DIRECTIVE FOR HEALTH CARE
Name: _____________________________________________

Address: ___________________________________________
City: ______________________________ State: ___________

for information please contact as soon as possible:
Name: ____________________________ tel.# ____________
Address: ___________________________________________
City: ____________________________ State ___________

OR
Name: _____________________________tel.# ____________
Address: ____________________________________________
City: ______________________________ State: ___________

ORGAN DONOR CARD
In the hope that I may help others, I hereby make this anatomical
gift, to take effect upon my death. The words and marks below
indicate my desires.
I give: ______ Any needed organs or parts

or: ______ Only the following organs or parts.
_____________________________________________________

For the purposes of transplantation, therapy, medical research or education.

Signed by the Donor and the following two witnesses in the
presence of each other.

Date of birth
Signature of donor _____________________ of Donor ________
Date Signed __________________ City & State _____________
Witness _____________________ Witness _________________

This Is A Legal Document Under the Uniform Anatomical Gift Act.


Advance Directives for Health Care
Organizations and Institutions
Letter from - Mr. Paul W. Armstrong, Chairman
NJ Commission and Task Force
Planning Ahead For Your Health Care: Making Your Wishes Known
1. Introduction: Why this booklet?
2. Questions and Answers
3. Terms You Should Understand

Proxy Directive - (Durable Power of Attorney for Health Care)
A) Choosing a Health Care Representative
B) Alternate Representatives
C) Specific Directions
D) Copies
E) Signature
F) Witnesses

Combined Advance Directive for Health Care
Part One: Designation of a Health Care Representative
A) Choosing a Health Care Representative
B) Alternate Representatives

Part Two: Instruction Directive
C) General Instructions
D) Specific Instructions
E) Additional Instructions
F) Brain Death
G) After Death - Anatomical Gifts

Part Three: Signature and Witnesses
H) Copies
I) Signature
J) Witnesses


Instruction Directive
A) Statement
Part One: Statement of My Wishes Concerning My Future Health Care
B) General Instructions
C) Specific Instructions
D) Additional Instructions
E) Brain Death
F) After Death - Anatomical Gifts

Part Two: Signature and Witnesses
G) Copies
H) Signature
I) Witnesses


Notes
Checklist: Questions to Ask Yourself