ADVANCE DIRECTIVE FOR HEALTH CARE

LIVING WILL

I, ______________________

whose address is


while competent to govern myself and manage my affairs, have the fundamental right to make voluntary, informed choices to accept, reject, or choose among alternative courses of medical and surgical treatment. I make this Advance Directive for Health Care to express my wishes for use in the event that I am no longer able to participate actively in making my own health care decisions. I direct that this document become part of my permanent medical records and it shall be deemed to revoke all Advance Directives executed by me prior to this date.

1. Life Sustaining Treatment. "Life Sustaining Treatment" means the use of any medical devices or procedure, 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, and thereby increase the expected life span of a patient.

2. Fluids and Nutrition. I request that artificially provided fluids and nutrition, such as by feeding tube or intravenous infusion: [initial one]

_____ Shall be withheld or withdrawn as "Life Sustaining Treatment."

_____ Shall be provided to the extent medically appropriate even if other "Life Sustaining Treatment" is withheld or withdrawn.

3. Directives as to Medical Treatment. I request that "Life Sustaining Treatment" be withheld or withdrawn from me in each of the following circumstances: [initial all that apply]

_____ If the "Life Sustaining Treatment" is experimental and not a proven therapy, or is likely to be ineffective or futile in prolonging my life, or is likely merely to prolong an imminent dying process;

_____ If I am permanently unconscious (total and irreversible loss of consciousness and capacity for interaction with the environment);

_____ If I am in a terminal condition (terminal stage of an irreversibly fatal illness, disease, or condition); or

_____ If I have a serious irreversible illness or condition, and the likely risks and burden associated with the medical intervention to be withheld or withdrawn outweigh the likely benefits to me from such intervention.

_____ None of the above. I direct that all medically appropriate measures be provided to sustain my life, regardless of my physical or mental condition.

_____ Other instructions:

4. Cardiac Arrest. In the circumstances initialed above, my attending physician may issue an order not to attempt cardiopulmonary resuscitation in the event I suffer a cardiac or respiratory arrest.

5. Pain Control. I request that medical treatment to alleviate pain, provide comfort, or mitigate suffering be provided so that I may be as free of pain and suffering as possible.

6. Pregnancy. If I have been diagnosed as pregnant, I direct that all "Life Sustaining Treatment" be continued during the course of the pregnancy.

7. Appointment of Health Care Representative. (N.J.S. 26:2H-58) I hereby appoint the following individuals to serve, in order of priority, as my Health Care Representative. If my first choice is unavailable, unable, disqualified or unwilling to serve, then the next designated person shall serve. If a prior choice as agent subsequently becomes available and able to serve, then such person may, insofar as then practicable, serve as my Health Care Representative. I hereby appoint (listed in order)

1. __________________________________________

2. __________________________________________

If I have designated any successor Health Care Representative, then my Health Care Representative shall consult with the successor Representative[s] appointed hereunder during the course of his/her decision-making prior to exercising any of the powers granted under this Appointment of Health Care Representative; provided, however, that the final decision shall be solely within the discretion of my then-acting Health Care Representative.

If I lack decision-making capacity as defined in the New Jersey Advance Directive for Health Care Act (N.J.S. 26:2H-53 et seq.), or under a corresponding statute in any other jurisdiction, my Health Care Representative shall have authority to make health care decisions on my behalf, in good faith and within the bounds of the authority granted herein and by law. My Health Care Representative shall exercise my right to be informed of my medical condition, prognosis and treatment options, and to give informed consent to, or refusal of, health care and to make any and all health care decisions for me and to plan and arrange for all medical care and related care and treatment on my behalf and at my expense.

For purposes of determining my decision-making capacity, as defined in the New Jersey Advance Directives for Health Care Act, or under a corresponding statute in any jurisdiction, I authorize all health care providers (including physicians, nurses and all other persons [including entities]) who may have provided, or be providing, me with any type of health care, to disclose to my Health Care Representative, or if none, to my family, protected health information that relates directly or indirectly to my capacity to act rationally and prudently in my own best interests, and to make rational and reasonable decisions regarding my health care. I understand that information disclosed pursuant to this authorization is subject to re-disclosure and may no longer be protected by the privacy rules of 45 CFR § 164.

My Health Care Representative shall give priority to this Directive and may also consider, as appropriate and necessary as evidence of my wishes:

1. My verbal and nonverbal expressions; other reliable resources of information as to my values, preferences and goals; and reliable oral or written statements made by me.

2. My Health Care Representative shall exercise reasonable discretion, in good faith, to effectuate the terms, intent and spirit of this Directive and of my wishes. If my wishes cannot be adequately determined, then my Health Care Representative shall make health care decisions in my best interest.

8. Lack of Health Care Representative. This Advance Directive shall be legally operative even if I have not designated a Health Care Representative or if neither my Representative nor any alternative designee is able or available to serve. This Directive shall be honored in accordance with its terms by all who act on my behalf. If this Directive is not specific to my medical condition and treatment alternatives, then my physician, in consultation with my Health Care Representative, or if none, then my family, shall exercise reasonable judgment to effectuate my wishes, giving full weight to the terms, intent and spirit of the Directive.

9. Organ Donation. [initial one]

_____ I wish, if feasible, to donate for transplant any part or all of any organ, tissue, eye, bone, arteries or other body parts or portions of my body which may be useful to another person. My Health Care Representative may take any action in furtherance of this gift (which I intend to be an anatomical gift in accordance with N.J.S. 26:6-57 et seq. or similar law). Consistent with this gift, "Life Sustaining Treatment" may be temporarily continued or modified if I am brain dead so as to preserve and protect for transplant the useful portions of my body.

_____ I do not wish to make an anatomical gift.

10. Signature. By signing below, I indicate that I understand the contents of this Advance Directive for Health Care.

Dated: __________________________ Name: _________________________________

Witness Statement. We attest to the fact that the person who signed this directive did so in our presence, is personally known to us and to the best of our knowledge, is of sound mind and free of duress and undue influence. Each of us is eighteen [18] years or older and we also state that we have not been designated herein as Health Care Representatives.

Name: ________________________ Signature: __________________________________

Address: ____________________________________________________________________

Name: ________________________ Signature: __________________________________

Address: ____________________________________________________________________

ACKNOWLEDGMENT (optional)

STATE OF NEW JERSEY, COUNTY OF _________________

I CERTIFY that on ______________, ______________________ personally came before me and acknowledged under oath to my satisfaction that this person:

(a) is named in and personally signed the foregoing instrument; and

(b) executed this instrument as his/her own voluntary act and deed for the uses and purposes herein expressed.

______________________________