COMBINED ADVANCE DIRECTIVE FOR HEALTH CARE
(Combined Proxy and Instruction Directive)
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 will turn to someone who knows my values and health care wishes. I understand that those responsible for my care will seek to make health care decisions in my best interests, based upon what they know of my wishes. In order to provide the guidance and authority needed to make decisions on my behalf:
I, ___________________________________ hereby declare and make known my instructions and wishes for my future health care. This advance directive 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. I direct that this document become part of my permanent medical records.
In completing Part One of this directive, you will designate an individual you trust to act as your legally recognized health care representative to make health care decisions for you in the event you are unable to make decisions for yourself.
In completing Part Two of this directive, you will provide instructions concerning your health care preferences and wishes to your health care representative and others who will be entrusted with responsibility for your care, such as your physician, family members and friends.
Part One: Designation of a Health Care Representative
A) CHOOSING A HEALTH CARE REPRESENTATIVE:
I hereby designate:
name _________________________________________ address _______________________________________ city ___________________________ state __________ telephone ______________________
as my health care representative to make any and all health 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, or a situation arises I did not anticipate, my health care representative is authorized to make decisions in my best interests, based upon what is known of my wishes.
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.
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 will turn to someone who knows my values and health care wishes. I understand that those responsible for my care will seek to make health care decisions in my best interests, based upon what they know of my wishes. In order to provide the guidance and authority needed to make decisions on my behalf:
I, ___________________________________ hereby declare and make known my instructions and wishes for my future health care. This advance directive 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. I direct that this document become part of my permanent medical records.
In completing Part One of this directive, you will designate an individual you trust to act as your legally recognized health care representative to make health care decisions for you in the event you are unable to make decisions for yourself.
In completing Part Two of this directive, you will provide instructions concerning your health care preferences and wishes to your health care representative and others who will be entrusted with responsibility for your care, such as your physician, family members and friends.
Part One: Designation of a Health Care Representative
A) CHOOSING A HEALTH CARE REPRESENTATIVE:
I hereby designate:
name _________________________________________ address _______________________________________ city ___________________________ state __________ telephone ______________________
as my health care representative to make any and all health 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, or a situation arises I did not anticipate, my health care representative is authorized to make decisions in my best interests, based upon what is known of my wishes.
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.
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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 order of priority stated:
1. name _____________________________________ 2.
address ___________________________________
city __________________________ state _______ telephone _________________________________
city __________________________ state _______ telephone _________________________________
name ________________________________
address ______________________________
city _____________________ state _______
telephone ____________________________
Part Two: Instruction Directive
In Part Two, 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, family members or others who may become responsible for your care.
In Sections C and D, 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 Section E, 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 Two before completing your directive.
C) 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:
In Part Two, 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, family members or others who may become responsible for your care.
In Sections C and D, 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 Section E, 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 Two before completing your directive.
C) 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, unless I have indicated
that I wish to donate my organs or tissues
pursuant to paragraph G , in which case I
understand that certain measures, such as
mechanical ventilation may be maintained to
facilitate the donation. I recognize that this 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:
*This section includes changes made by the New Jersey Organ and Tissue Sharing Network consistent with current organ donation policies in New Jersey.
*This section includes changes made by the New Jersey Organ and Tissue Sharing Network consistent with current organ donation policies in New Jersey.
Page 2 of 6
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 to relieve pain.
In the space provided, write in the bracketed phrase with which you agree:
To me, terminal condition means that my physicians have determined that: ________________________________________________________________________________________
[I will die within a few days] [I will die within a few weeks]
[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 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.
(Paragraph c. covers a wide range of possible situations in which you may have experienced partial or complete loss of certain mental and 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 who may become responsible for your care. If necessary, you may attach a separate statement to this document or use Section E to provide additional instructions.)
Examples of conditions which I find unacceptable are:
________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
In the space provided, write in the bracketed phrase with which you agree:
To me, terminal condition means that my physicians have determined that: ________________________________________________________________________________________
[I will die within a few days] [I will die within a few weeks]
[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 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.
(Paragraph c. covers a wide range of possible situations in which you may have experienced partial or complete loss of certain mental and 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 who may become responsible for your care. If necessary, you may attach a separate statement to this document or use Section E to provide additional instructions.)
Examples of conditions which I find unacceptable are:
________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
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D) SPECIFIC INSTRUCTIONS: Artificially Provided Fluids and Nutrition; Cardiopulmonary
Resuscitation (CPR). On page 3 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, write in the bracketed phrase with which you agree:
1. In the circumstances I initialed on page 3, I also direct that artificially provided fluids and nutrition, such as by feeding tube or intravenous infusion,
________________________________________________________________________________________
[be withheld or withdrawn and that I be allowed to die] [be provided to the extent medically appropriate]
2. In the circumstances I initialed on page 3, 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.
________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
E) ADDITIONAL INSTRUCTIONS: (You should provide any additional information about your health care preferences which is important to you and which may help those concerned with your care to implement your wishes. You may wish to direct your health care representative, family members, or your health care providers to consult with others, or you may wish to direct that your care be provided by a particular physician, hospital, nursing home, or at home. If you are or believe you may become pregnant, you may wish to state specific instructions. If you need more space than is provided here you may attach an additional statement to this directive.)
________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
F) BRAIN DEATH: (The State of New Jersey recognizes the irreversible cessation of all functions of the entire brain, including the brain stem (also known as whole brain death), as a legal standard for the declaration of death. However, individuals who cannot accept this standard 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:
_____ To declare my death on the basis of the whole brain death standard would violate my personal religious beliefs. I therefore wish my death to be declared solely on the basis of the traditional criteria of irreversible cessation of cardiopulmonary (heartbeat and breathing) function.
In the space provided, write in the bracketed phrase with which you agree:
1. In the circumstances I initialed on page 3, I also direct that artificially provided fluids and nutrition, such as by feeding tube or intravenous infusion,
________________________________________________________________________________________
[be withheld or withdrawn and that I be allowed to die] [be provided to the extent medically appropriate]
2. In the circumstances I initialed on page 3, 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.
________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
E) ADDITIONAL INSTRUCTIONS: (You should provide any additional information about your health care preferences which is important to you and which may help those concerned with your care to implement your wishes. You may wish to direct your health care representative, family members, or your health care providers to consult with others, or you may wish to direct that your care be provided by a particular physician, hospital, nursing home, or at home. If you are or believe you may become pregnant, you may wish to state specific instructions. If you need more space than is provided here you may attach an additional statement to this directive.)
________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
F) BRAIN DEATH: (The State of New Jersey recognizes the irreversible cessation of all functions of the entire brain, including the brain stem (also known as whole brain death), as a legal standard for the declaration of death. However, individuals who cannot accept this standard 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:
_____ To declare my death on the basis of the whole brain death standard would violate my personal religious beliefs. I therefore wish my death to be declared solely on the basis of the traditional criteria of irreversible cessation of cardiopulmonary (heartbeat and breathing) function.
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G) AFTER DEATH - ANATOMICAL GIFTS: (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.)
Initial the statements which express your wishes:
*1. ______ I hereby make the following anatomical gift to take effect upon my death:
______ any needed organs ______ any needed tissues ______ eyes
_____________________________________________________________________________________
______ for the following purpose(s):
______ transplantation and therapy
______ research
______ education, including whole body for anatomical study
_____________________________________________________________________________________
If you wish to provide additional instructions, such as indicating your preference that your organs be given to a specific person or institution, or be used for a specific purpose, please do so in the space provided below.
___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
*2. ______ Notwithstanding any directive contained in any other section of this document, I consent to the commencement and maintenance of any medical procedure necessary to evaluate, maintain or preserve my organs or tissues for purposes of donation for the purposes indicated above, including, but not limited to, medical respiration and artificial nutrition and hydration.
Part Three: Signature and Witnesses
H) COPIES: The original or a copy of this document has been given to the following people (NOTE: If you have chosen to designate a health care representative, it is important that you provide him or her with a copy of your directive.)
Initial the statements which express your wishes:
*1. ______ I hereby make the following anatomical gift to take effect upon my death:
______ any needed organs ______ any needed tissues ______ eyes
_____________________________________________________________________________________
______ for the following purpose(s):
______ transplantation and therapy
______ research
______ education, including whole body for anatomical study
_____________________________________________________________________________________
If you wish to provide additional instructions, such as indicating your preference that your organs be given to a specific person or institution, or be used for a specific purpose, please do so in the space provided below.
___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
*2. ______ Notwithstanding any directive contained in any other section of this document, I consent to the commencement and maintenance of any medical procedure necessary to evaluate, maintain or preserve my organs or tissues for purposes of donation for the purposes indicated above, including, but not limited to, medical respiration and artificial nutrition and hydration.
Part Three: Signature and Witnesses
H) COPIES: The original or a copy of this document has been given to the following people (NOTE: If you have chosen to designate a health care representative, it is important that you provide him or her with a copy of your directive.)
1. name _____________________________________ 2.
address ___________________________________
city __________________________ state _______ telephone _________________________________
city __________________________ state _______ telephone _________________________________
name ________________________________
address ______________________________
city _____________________ state _______
telephone ____________________________
*This section includes changes made by the New Jersey Organ and Tissue Sharing Network consistent with current organ donation policies
in New Jersey.
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I) SIGNATURE: By writing this advance directive, I inform those who may become entrusted with
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 and he or
she has willingly agreed to accept the responsibility for acting on my behalf in accordance with this
directive. 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_________
J) 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.
Signed this _____________ day of ______________, 20______. signature ____________________________________________ address _____________________________________________ city ___________________________________ state_________
J) 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.
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witness ____________________________________________
address ____________________________________________
city _________________________________ state _________
signature __________________________________________
date _______________________
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witness ____________________________________________
address ____________________________________________
city _________________________________ state _________
signature __________________________________________
date _______________________
source http://www.njsharingnetwork.org/document.doc?id=199
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