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ADVANCE DIRECTIVE FOR HEALTH CARE
| 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: |
| 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. |
____________ (initial here) 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 and or discontinued. I also direct that I be given all medically appropriate care necessary to make me comfortable and to relieve pain.
____________ (initial here) 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.
____________ (initial here) 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.
____________ (initial here) My specific instructions are as follows:
TO RECEIVE artificially administered nutrition and hydration (food and fluids).NOT TO RECEIVE artificially administered nutrition and hydration (food and fluids) procedures, except as deemed necessary to provide me with comfort care.However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining treatment, it is my preference that this document be given effect at that point. If life-sustaining treatment will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
| Birthdate: |
II. ADVANCE DIRECTIVE FOR HEALTH CARE -
| DURABLE POWER OF ATTORNEY FOR HEALTH CARE |
My Agent has the authority to direct the withdrawal and withholding of artificially provided food and fluids.My Agent does not have the authority to direct the withdrawal and withholding of artificially provided food and fluids.authorize my Agent, to the extent permitted by law, do not authorize my Agent
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Birthdate: |
A notary public
two witnesses who then sign the document in your presence and in each other's presence.a notary who then notarizes the document.| _____ | (your Agent) |
You should discuss the document and your wishes with any person you want to designate as an Agent before doing so to assure they agree to act on your behalf.
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It's simple and easy to outline your medical preferences with a free New Jersey Living Will template from Rocket Lawyer:
This route is often much less expensive than hiring a traditional law firm. If needed, you may fill out a Living Will on behalf of an elderly parent, a spouse, or another relative, and then help that person sign it after you've drafted it. Keep in mind that for a Living Will to be valid, the principal must be an adult who is mentally competent at the time of signing. If the principal is already unable to make their own decisions, a conservatorship might be required. In this scenario, it's a good idea to speak with an attorney .
Anyone who is over 18 should have a Living Will. Though it's painful to acknowledge, a day could come when you cannot make medical decisions on your own. Here are some typical circumstances in which you may find it helpful to make or update your Living Will:
Whether your New Jersey Living Will has been made as a result of a recent change in your health or as part of a long-term plan, notarization and/or witnesses often help to protect your agent if their power and authority are doubted.
Making a Living Will is usually simple; however, you or your agent might still need legal advice. Finding an attorney to comment on your New Jersey Living Will might be fairly time-consuming. An easier route would be via attorney services at Rocket Lawyer. With a Premium membership, you can get your document looked at by an experienced attorney. As always, Rocket Lawyer is here for you.
The fees associated with hiring and working with a law firm to write a Living Will could add up to between $200 and $1,000, depending on where you are located. When using Rocket Lawyer, you aren't just filling out a Living Will template. If you ever need support from a lawyer, your Rocket Lawyer membership offers up to a 40% discount when you hire an attorney from our network.
With a Premium membership, you will be able to make edits, save it as a Word or PDF document, and/or print it out. In order to complete your New Jersey Living Will form, it should be signed. You should give a final copy of your signed document to your agent(s), care providers, and other impacted parties.
The specific rules and restrictions governing Living Wills are different by state; however, in New Jersey, your Living Will needs the signatures of two witnesses or a notary public. As a general rule, witnesses must be 18 years old or older, and no witness should also be named as your healthcare agent.
