"Durable Power of Attorney for Health Care - Will to Live Form" - New Jersey

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Download "Durable Power of Attorney for Health Care - Will to Live Form" - New Jersey

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New Jersey Durable Power of Attorney for Health Care
Will to Live Form
I, (your name)__________________________________________________________________
(your address)__________________________________________________________________
_____________________________________________________________________________
(your phone number)____________________________________________________________
designate_____________________________________________________________________
(Name of health care representative)________________________________________________
(address)______________________________________________________________________
(phone number(s))_______________________________________________________________
as my health care representative to make any health care decisions for me as authorized in this
declaration consistent with the instructions below.
If the person I designate above refuses or is not able to act for me, I designate the following
persons (each to act alone and successively, in the order named):
A. First Successor Health Care Representative
(successor’s name)______________________________________________________________
(successor’s address)_____________________________________________________________
______________________________________________________________________________
(successor’s phone number)_______________________________________________________
B. Second Successor Health Care Representative
(second successor’s name)________________________________________________________
(second successor’s address)______________________________________________________
______________________________________________________________________________
(second successor agent’s phone number)____________________________________________
as my health care representative to make any health care decisions for me as authorized in this
document consistent with the instructions below.
This designation shall become effective only when I become incapable of making my own health
care decisions.
Any prior designation or other advance directive for health care is revoked.
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New Jersey Durable Power of Attorney for Health Care
Will to Live Form
I, (your name)__________________________________________________________________
(your address)__________________________________________________________________
_____________________________________________________________________________
(your phone number)____________________________________________________________
designate_____________________________________________________________________
(Name of health care representative)________________________________________________
(address)______________________________________________________________________
(phone number(s))_______________________________________________________________
as my health care representative to make any health care decisions for me as authorized in this
declaration consistent with the instructions below.
If the person I designate above refuses or is not able to act for me, I designate the following
persons (each to act alone and successively, in the order named):
A. First Successor Health Care Representative
(successor’s name)______________________________________________________________
(successor’s address)_____________________________________________________________
______________________________________________________________________________
(successor’s phone number)_______________________________________________________
B. Second Successor Health Care Representative
(second successor’s name)________________________________________________________
(second successor’s address)______________________________________________________
______________________________________________________________________________
(second successor agent’s phone number)____________________________________________
as my health care representative to make any health care decisions for me as authorized in this
document consistent with the instructions below.
This designation shall become effective only when I become incapable of making my own health
care decisions.
Any prior designation or other advance directive for health care is revoked.
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GENERAL PRESUMPTION FOR LIFE
I direct my health care provider(s) and health care representative(s) to make health care
decisions consistent with my general desire for the use of medical treatment that would preserve
my life, as well as for the use of medical treatment that can cure, improve, reduce or prevent
deterioration in, any physical or mental condition.
Food and water are not medical treatment, but basic necessities. I direct my health care
provider(s) and health care representative to provide me with food and fluids, orally,
intravenously, by tube, or by other means to the full extent necessary both to preserve my life
and to assure me the optimal health possible.
I direct that medication to alleviate my pain be provided, as long as the medication is not used in
order to cause my death.
I direct that the following be provided:
the administration of medication;
cardiopulmonary resuscitation (CPR); and
the performance of all other medical procedures, techniques, and
technologies, including surgery,
–all to the full extent necessary to correct, reverse, or alleviate life-threatening or health
impairing conditions or complications arising from those conditions.
I also direct that I be provided basic nursing care and procedures to provide comfort care.
I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of
an unborn or newborn child, who has been subject to an induced abortion. This rejection does
not apply to the use of tissues or organs obtained in the course of the removal of an ectopic
pregnancy.
I also reject any treatments that use an organ or tissue of another person obtained in a manner
that causes, contributes to, or hastens that person’s death.
I request and direct that medical treatment and care be provided to me to preserve my life
without discrimination based on my age or physical or mental disability or the “quality” of my
life. I reject any action or omission that is intended to cause or hasten my death.
I direct my health care provider(s) and health care representative to follow the policy above,
even if I am judged to be incompetent.
During the time I am incompetent, my health care representative, as named below, is authorized
to make medical decisions on my behalf, consistent with the above policy, after consultation
with my health care provider(s), utilizing the most current diagnoses and/or prognosis of my
medical condition, in the following situations with the written special instructions.
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WHEN MY DEATH IS IMMINENT
A. If I have an incurable terminal illness or injury, and I will die imminently -- meaning that a
reasonably prudent physician, knowledgeable about the case and the treatment possibilities with
respect to the medical conditions involved, would judge that I will live only a week or less even
if lifesaving treatment or care is provided to me -- the following my be withheld or withdrawn:
(Be as specific as possible; SEE SUGGESTIONS.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________________________________
(Cross off any remaining blank lines.)
WHEN I AM TERMINALLY ILL
B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and
even though death is not imminent I am in the final stage of that terminal condition – meaning
that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities
with respect to the medical conditions involved, would judge that I will live only three months or
less, even if lifesaving treatment or care is provided to me – the following may be withheld or
withdrawn:
(Be as specific as possible; SEE SUGGESTIONS.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Cross off any remaining blank lines.)
C. OTHER SPECIAL CONDITIONS:
(Be as specific as possible; SEE SUGGESTIONS.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Cross off any remaining blank lines.)
IF I AM PREGNANT
D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s)
and health care attorney in fact(s) to use all lifesaving procedures for myself with none of the
above special conditions applying if there is a chance that prolonging my life might allow my
child to be born alive. I also direct that lifesaving procedures be used even I am legally
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determined to be brain dead if there is a chance that doing so might allow my child to be born
alive. Except as I specify by writing my signature in the box below, no one is authorized to
consent to any procedure for me that would result in the death of my unborn child.
If I am pregnant, and I am not in the final stage of a terminal condition as defined above,
medical procedures required to prevent my death are authorized even if they may result in the
death of my unborn child provided every possible effort is made to preserve both my life and the
life of my unborn child.
____________________________________
Signature
I understand the full import of this declaration and I am emotionally and mentally
competent to make this decision.
Signed this_____________day of______________________, _________________.
Signature____________________________________________________________
Address
_____________________________________________________________________
Complete only if principal is physically unable to sign:
I have signed the principal’s name above at his/her direction in the presence of the principal and
two witnesses.
Name
___________________________________________
Address
___________________________________________
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–– 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 is of sound mind and free of duress or undue influence. I am 18 years of age or older, and
am not named by this document as the person’s health car representative nor as a successor
health care representative.
First Witness Signature:__________________________________________________________
Residence Address:______________________________________________________________
Date:_________________________________________________________________________
Second Witness Signature:________________________________________________________
Residence Address:______________________________________________________________
Date:_________________________________________________________________________
-ALTERNATIVE TO WITNESSES-
ACKNOWLEDGMENT BY NOTARY PUBLIC, ATTORNEY AT LAW, OR OTHER
PERSON AUTHORIZED TO ADMINISTER OATHS.
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 to before me this ________________ day of __________________, _______.
_________________________________
Notary Public, Attorney at Law
Other Person Authorized to Administer Oaths
Form Prepared 2005
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