NEW JERSEY 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, _____________________________________________________ [declarant’s full legal name], hereby designate ______________________________________________________ [health care representative’s full legal name]

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:

 

__________________________________________           __________________________________________

Name of 1^st Alternate Representative                                Name of 2^nd Alternate Representative

 

__________________________________________           __________________________________________

Street Address                                                              Street Address

 

__________________________________________           __________________________________________

City                              State                   Zip Code        City                              State                   Zip Code

 

__________________________________________           __________________________________________

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.

             

(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:

 

__________________________________________           __________________________________________

Name of 1^st Recipient                                                     Name of 2^nd Recipient

 

__________________________________________           __________________________________________

Street Address                                                              Street Address

 

__________________________________________           __________________________________________

City                              State                  Zip Code          City                              State                  Zip Code

 

__________________________________________           __________________________________________

Telephone                                                                      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 of Person Making Declaration (Declarant)

 

__________________________________________

(Type or Print Name of Declarant)

 

__________________________________________

Street Address

 

__________________________________________

City                              State                  Zip Code

 

(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.

 

 

__________________________________________           __________________________________________

Signature of 1^st Witness                                Date           Signature of 2^nd Witness                               Date

 

__________________________________________           __________________________________________

(Type or Print Name of Witness)                                      (Type or Print Name of Witness)

 

__________________________________________           __________________________________________

Street Address                                                              Street Address

 

__________________________________________           __________________________________________

City                              State                  Zip Code          City                              State                  Zip Code

 

__________________________________________           __________________________________________

Telephone                                                                      Telephone

Other Forms You May Need

• New Jersey General Durable Power of Attorney for Property & Finances (Immediate)
• HIPAA Authorization and Waiver