Fill - Free fillable NEW JERSEY Advance Directive Planning for Important Health PDF form

NEW JERSEY

Advance Directive

Planning for Important Health Care Decisions

CaringI

nfo

1731 King St., Suite 100,

Alexandria,

VA 22314

www.caringinfo.org

800/658-8898

CARINGINFO

CaringInfo, a program of the National Hospice and Palliative Care Organization

(NHPCO), is a national consumer engagement initiative to improve care at the end of

life.

It’s About How You LIVE

It’s

About

How You LIVE is a national community engagement campaign encouraging

individuals to make informed decisions about end-of-life care and services. The

campaign encourages people to:

Learn about options for end-of-life services and care

Implement plans to ensure wishes are honored

Voice decisions to family, friends and health care providers

Engage in personal or community efforts to improve end-of-life care

Note: The following is not a substitute for legal advice. While CaringInfo updates the

following information and form to keep them up-to-date, changes in the underlying law

can affect how the form will operate in the event you lose the ability to make decisions

for yourself. If you have any questions about how the form will help ensure your

wishes are carried out, or if your wishes do not seem to fit with the form, you may wish

to talk to your health care provider or an attorney with experience in drafting advance

directives. If you have other questions regarding these documents, we recommend

contacting your state attorney general's office.

Reproduction and distribution by an organization or organized group without the written permission of

the National Hospice and Palliative Care Organization is expressly forbidden.

Using these Materials

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may

receive health care.

2. These materials include:

•

Instructions for preparing your advance directive, please read all the

instructions.

•

Your state-specific advance directive forms, which are the pages with the

gray instruction bar on the left side.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so

you will have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will

guide you through the process.

3. Talk with your family, friends, and physicians about your advance directive. Be sure

the person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy the form and give it to the

person you have appointed to make decisions on your behalf, your family, friends,

health care providers and/or faith leaders so that the form is available in the event

of an emergency.

5. You may also want to save a copy of your form in an online personal health records

application, program, or service that allows you to share your medical documents

with your physicians, family, and others who you want to take an active role in your

advance care planning.

Introduction to Your New Jersey Advance Directive

This packet contains a legal document, a New Jersey Advance Directive, that

protects your right to refuse medical treatment you do not want, or to request

treatment you do want, in the event you lose the ability to make decisions yourself.

You may fill out Part I, Part II, or both, depending on your advance planning needs.

You must complete Part III.

Part I is the New Jersey Proxy Declaration. This part lets you name an adult,

called your health care representative, or representative, to make decisions about your

health care—including decisions about life-sustaining treatments—if you can no longer

speak for yourself.

Part II is a New Jersey Instruction Declaration, which is your state’s living will.

Part II lets you state your wishes regarding health care decisions in the event that you

can no longer make your own.

Part III contains the signature and witnessing provisions so that your document will be

effective.

Your advance directive goes into effect when your doctor and one other doctor

determine in writing that you are no longer able to understand and appreciate the

nature and consequences of your health care decisions and you are no longer able to

reach an informed health care decision.

This form does not expressly address mental illness. If you would like to make advance

care plans regarding mental illness, you should talk to your physician and an attorney

about a durable power of attorney tailored to your needs.

Note: These documents

will be

legally binding

only if the

person completing them

is a

competent

adult who is at least 18 years of age.

Instructions Completing Your Advance Directive for Health care

How do I make my Advance

Direct

ive for

ealt

h Care legal?

You must sign and date your document, or direct another to sign and date it:

1. in the presence of two witnesses who must be at least 18 years of age. These

witnesses must also sign the document to show that they believe you to be of

sound mind, that you voluntarily signed the document, and that they are not

your appointed health care representative or alternate health care

representative;

2. before a notary public, an attorney at law, or another person authorized to

administer oaths.

Can I add personal instructions to my Living Will?

One of the strongest reasons for naming a representative is to have someone who can

respond flexibly as your health care situation changes and deal with situations that you

did not foresee. If you add instructions to this document it may help your

representative carry out your wishes, but be careful that you do not unintentionally

restrict your representative’s power to act in your best interest. In any event, be sure to

talk with your representative about your future medical care and describe what you

consider to be an acceptable “quality of life.”

Whom should I appoint as my representative?

Your representative is the person you appoint to make decisions about your health care

if you become unable to make those decisions yourself. Your representative may be a

family member or a close friend whom you trust to make serious decisions. The person

you name as your representative should clearly understand your wishes and be willing

to accept the responsibility of making health care decisions for you.

You can appoint a second person as your alternate representative. The alternate will

step in if the first person you name as a representative is unable, unwilling, or

unavailable to act for you.

You cannot appoint an operator, administrator, or employee of your treating health

care institution, unless he or she is related to you by blood, marriage, domestic

partnership, or adoption. However, you can appoint a physician so long as he or she is

not serving as your attending physician at the same time.

What if I change my mind?

You may revoke your Advance Directive, or any part of it, at any time by:

•

Announcing your revocation either orally or in writing to your health care

representative, your doctor or other health care provider, or a reliable witness,

•

Performing any other act that demonstrates your intent to revoke the document,

•

Executing a subsequent Advance Directive.

If you designate your spouse as your representative, his or her authority is

automatically revoked upon divorce or legal separation, unless you specify otherwise in

the “further instructions” section of the Advance Directive. If you designate your

domestic partner, his or her authority is automatically revoked upon termination of your

domestic partnership, unless otherwise specified in the “further instructions” section of

the Advance Directive.

What other important facts should I know?

If you are female, you may include instructions specific to your pregnancy in the event that

you are pregnant when your Advance Directive goes into effect.

PART I

PRINT YOUR NAME

PRINT THE NAME,

ADDRESS AND

HOME AND WORK

NEW JERSEY ADVANCE DIRECTIVE – PAGE 1 OF 10

PART I: PROXY DIRECTIVE

I, , hereby appoint:

(your name)

(name of health care representative)

TELEPHONE

NUMBERS OF YOUR

HEALTH CARE

REPRESENTATIVE

(address of health care representative)

(home phone number)

(work phone number)

to be 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

treatment. I direct my health care 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 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

PRINT THE NAME,

ADDRESS, AND

TELEPHONE

NUMBER OF YOUR

FIRST ALTERNATE

HEALTH CARE

REPRESENTATIVE

Hospice and

Palliative Care

Organization 2020

Revised.

Telephone

NEW JERSEY ADVANCE DIRECTIVE - PAGE 2 OF 10

PRINT THE NAME,

ADDRESS AND

TELEPHONE

NUMBER OF

YOUR SECOND

ALTERNATE

HEALTH CARE

REPRESENTATIVE

2. Name

Address

City State

Telephone

ADD ADD

ITIONAL

I direct that my health care representative comply with the following

instructions and/or limitations (optional):

INSTRUCTIONS,

ANY

ADD

NSTRUCTIONS, IF

ANY, TO BE

FOLLOWED IN THE

EVENT YOU

ARE PREGNANT

Hospice and

Palliative Care

Organization

2020 Revised.

(use additional pages if necessary)

I direct that my health care representative comply with the following

instructions in the event that I am pregnant when this Directive

becomes effective (optional):

(use additional pages if necessary)

NEW JERSEY ADVANCE DIRECTIVE – PAGE 3 OF 10

PART II

INITIAL ONLY ONE

IF YOU INITIAL

STATEMENT 2, YOU

MUST SPECIFY

WHEN YOU WOULD

LIKE TO FOREGO

LIFE-SUSTAINING

MEASURES ON THE

FOLLOWING PAGES

Hospice and

Palliative Care

Organization 2020

Revised.

PART II. INSTRUCTION DIRECTIVE

In Part II, 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 and family

members or others who may become responsible for your care.

In the sections below, 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 the “Further

Instructions” section below, 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 II before completing your directive.

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 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:

INITIAL EACH

LETTERED

STATEMENT (A, B,

AND/OR C) THAT

REPRESENTS WHEN

YOU WOULD LIKE

TO FOREGO LIFE-

SUSTAINING

MEASURES

IF YOU INITIALED

STATEM

ENT A,

INDICATE WHAT

YOU CONSIDER TO

BE A TERMINAL

CONDITION THAT

WILL JUSTIFY THE

WITHHOLDING OR

DISCONTINUING OF

LIFE-SUSTAINING

MEASURES

Hospice and

Palliative Care

Organization

2020 Revised.

NEW JERSEY ADVANCE DIRECTIVE - PAGE 4 OF 10

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

relieve pain. To me, terminal condition means that my physicians have

determined that:

I will die within a few days, or

I will die within a few weeks, or

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 that

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 or 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

NEW JERSEY ADVANCE DIRECTIVE - PAGE 5 OF 10

who may become responsible for your care. If necessary, you may attach

a separate statement to this document or provide your wishes in the

“Further Instructions” section, below.)

Examples of conditions that I find unacceptable are:

Specific Instructions: Artificially Provided Fluids and Nutrition;

Cardiopulmonary Resuscitation (CPR).

On page 4, above, 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, initial the phrase with which you agree:

1. In the circumstances I initialed on page 4, I also direct that artificially

provided fluids and nutrition, such as feeding tube or intravenous infusion,

be withheld or withdrawn and that I be

allowed to die, or

be provided to the extent medically

appropriate.

2. In the circumstances I initialed on page 4, 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.

IF YOU INITIALED

STATEMENT C,

ABOVE, YOU MAY

LIST CONDITIONS

THAT YOU

FIND

UNNACCEPTABLE

AND

WOULD

JUSTIFY THE

WITHHOLDING OR

DISCONTINUING OF

LIFE-SUSTAINING

MEASURES

INITIAL YOUR

PREFERENCE

REGARDING

ARTIFICIALLY

PROVIDED FLUIDS

AND NUTRITION

(FOOD AND DRINK)

INITIAL YOUR

PREFERENCE

REGARDING CPR

YOU MAY ADD

FURTHER

INSTRUCTIONS

REGARDING

ARTIFICIALLY

PROVIDED FLUIDS

AND NUTRITION OR

CPR HERE

National

Hospice

and

Palliative

Care

Organization

2020 Revised.

NEW JERSEY ADVANCE DIRECTIVE - PAGE 6 OF 10

INITIAL HERE IF

YOU HAVE AN

OBJECTION TO

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:

NEW JERSEY’S

To declare my death on the basis of the whole brain death

BRAIN DEATH

DEFINITION

ORGA

N DONATION

(OPTIONAL)

NITIAL THE

standard would violate my personal religious beliefs. I therefore wish my

death to be declared only when my heartbeat and breathing have

irreversibly stopped.

ORGAN DONATION (OPTIONAL)

(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.)

I do not want to make an organ or tissue donation and I do not

want my representative or family to do so.

STATEMENT THAT

Upon my death, I wish to donate:

BEST REFLECTS

YOUR WISHES

Hospice and

Palliative Care

Organization

2020 Revised.

My body for anatomical study if needed.

Any needed organs, tissues, or eyes.

Only the following organs, tissues, or eyes:

I authorize the use of my organs, tissues, or eyes:

For transplantation

For therapy

For research

For medical education

For any purpose authorized by law.

NEW JERSEY ADVANCE DIRECTIVE - PAGE 7 OF 10

FURTHER INSTRUCTIONS:

ADD OTHER

INSTRUCTIONS,

ANY,

REGARDING

YOUR ADVANCE

CARE PLANS

THESE

INSTRUCTIONS CAN

FURTHER ADDRESS

YOUR HEALTH CARE

PLANS, SUCH AS

YOUR WISHES

REGARDING

HOSPICE

TREATMENT, BUT

CAN ALSO ADDRESS

OTHER ADVANCE

PLANNING ISSUES,

SUCH AS

YOUR

BURIAL

WISHES

ATTACH

ADDITIONAL PAGES

IF NEEDED

Hospice and

Palliative Care

Organization

2020 Revised.

NEW JERSEY ADVANCE DIRECTIVE - PAGE 8 OF 10

PART III

USE ALTER

NATIVE

NO. 1 IF YOU PLAN

TO SIGN BEFORE

WITNESSES (P. 9)

USE ALTERNATIVE

NO. 2 IF YOU PLAN

TO HAVE YOUR

SIGNATURE

NOTARIZED (P. 10)

Hospice and

Palliative Care

Organization

2020 Revised.

PART III: EXECUTION

This advance directive will not be valid unless it is EITHER:

Signed in the presence of two witnesses who must be at least 18 years

of age. These witnesses must also sign the document to show that they

believe you to be of sound mind, that you voluntarily signed the

document, and that they are not your appointed health care

representative or alternate health care representative (use Alternative

No. 1 if you plan to sign before witnesses);

Signed before a notary public, an attorney at law, or another person

authorized to administer oaths (use Alternative No. 2 if you plan to have

your signature notarized).

NEW JERSEY ADVANCE DIRECTIVE - PAGE 9 OF 10

Alternative No. 1.

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 decision making which this responsibility may impose. I have

discussed the terms of this designation with my health care

representative(s) and my representative(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_ .

Signature

Address

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 and 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 or alternate

health care representative.

1. Witness

Address _________________________

_______________________________

City State ________

Signature ______________________________ Date

2. Witness

SIGN AND DATE

YOUR

DOCUMENT AND

PRINT YOUR

ADDRESS

YOUR WITNESSES

MUST PRINT THEIR

NAMES AND

ADDRESSES AND

SIGN AND DATE

HERE

Hospice and

Palliative Care

Organization 2020

Revised.

Address

City State

Signature Date

NEW JERSEY ADVANCE DIRECTIVE - PAGE 10 OF 10

Alternative No. 2.

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 decision making which this responsibility may impose. I have

discussed the terms of this designation with my health care

representative(s) and my representative(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.

SIGN AND DATE

YOUR

DOCUMENT AND

PRINT YOUR

ADDRESS

Signed this day of 20_ .

Signature

Address

City ______________________________ State

Notary, Attorney at Law, or other person authorized to administer oaths

A NOTARY

PUBLIC OR

ATTORNEY AT

LAW SHOULD

COMPLETE THIS

SECTION

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: (check one)

Notary Public

Attorney at Law

ourtesy

of CaringInfo

Hospice and

Palliative Care

Organization

2020 Revised.

1731 King St., Suite 100,

Alexandria,

VA 22314

www.caringinfo.org,

800/658-8898

You Have Filled Out Your Health Care Directive, Now What?

1. Your New Jersey

Advance Directive

is an important legal document. Keep the original

signed document in a secure but accessible place. Do not put the original document in

a safe deposit box or any other security box that would keep others from having access

to it.

2. Give photocopies of the signed original to your representative and alternate

representative, doctor(s), family, close friends, clergy, and anyone else who might

become involved in your health care. If you enter a nursing home or hospital, have

photocopies of your document placed in your medical records.

3. Be sure to talk to your representative(s), doctor(s), clergy, family, and friends about

your wishes concerning medical treatment. Discuss your wishes with them often,

particularly if your medical condition changes.

4. You may also want to save a copy of your form in an online personal health records

application, program, or service that allows you to share your medical documents with

your physicians, family, and others who you want to take an active role in your advance

care planning.

5. If you want to make changes to your documents after they have been signed and

witnessed, you must complete a new document.

6. Remember, you can always revoke your New Jersey document.

7. Be aware that your New Jersey document will not be effective in the event of a medical

emergency. Ambulance and hospital emergency department personnel are required to

provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive

that states otherwise. These directives called “prehospital medical care directives” or

“do not resuscitate orders” are designed for people whose poor health gives them little

chance of benefiting from CPR. These directives instruct ambulance and hospital

emergency personnel not to attempt CPR if your heart or breathing should stop.

Currently not all states have laws authorizing these orders. We suggest you speak to

your physician if you are interested in obtaining one. CaringInfo does not distribute

these forms.

OR donate online today: www.NationalHospiceFoundation.org/donate

Congratulations!

You’ve downloaded your free, state specific advance directive.

You are taking important steps to make sure your wishes are known. Please consider helping us

keep this resource free.

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resources, tools, and information to educate and empower individuals to access advance care

planning, caregiving, hospice and grief services.

Please show your support for our mission and consider making a tax-deductible gift

to the National Hospice Foundation today.

Since 1992, the National Hospice Foundation has been dedicated to creating FREE resources for

individuals and families facing a life-limiting illness, raising awareness for the need for hospice

and palliative care, and providing ongoing professional education and skills development to

hospice and palliative care professionals across the nation. To learn more, please visit

www.NationalHospiceFoundation.org

You may wonder if a gift of $35, $50 or $100 to the National Hospice Foundation would make a

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Return to:

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