Making an Anatomical Gift
in New Jersey
This Document does not
constitute legal advice, and should not be relied upon as such. It is for
educational purposes only. Your attorney can prepare a Living Will and Medical Advance Directive
MEDICAL ADVANCE DIRECTIVE
OF
____________________________________
1. This document is prepared in accordance with the
New Jersey Directives for Health Care Act.
2. While competent to govern myself and manage my
affairs, I intend to exercise such legal rights as I may have to participate in
decisions relating to my physical care and treatment or to make decisions to
refuse care and treatment.
3. If I become incompetent to govern myself and manage
my affairs or become unable to make or communicate decisions relating to my
medical care and treatment, then this directive shall stand as my final
expression of such legal rights as I may have to refuse medical or surgical
treatment and to accept the consequences of such refusal, subject only to such
limitations as may be imposed upon my exercise of these rights by the
legislature or courts of the jurisdiction in which I am being cared for from
time to time.
4. If I should suffer an incurable injury, disease, or
illness certified by two physicians (one of whom may be my attending physician)
(a) to be such as has resulted in permanent loss of consciousness or (b) to be
such that the application of life-sustaining procedures would serve only to
postpone my death and where my attending physician determines that my death is
fairly predictable within what he or she considers to be a relatively short
time as a consequence of such condition or related complications whether or not
life-sustaining procedures are utilized, I direct that such procedures be
withheld or withdrawn and that I be permitted to die naturally. By way of
example and not by way of limitation, such procedures
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may include repeated cardiac resuscitation and
mechanical respiration, subject to my wishes expressed in Paragraph 6, below.
5. For purposes of my own care and treatment I direct
that the artificial provision of nourishment or water for hydration are among
such life-sustaining procedures which may be withheld or withdrawn, subject to
my wishes expressed in Paragraph 6, below.
6. I hereby consent to the donation of my organs and
tissues, including eyes, upon my death, for purposes of transplantation and
research. 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, including, but not limited to administration of
medication, mechanical respiration and artificial nutrition and hydration.
7. I hereby authorize the administration of pain
relieving drugs even if they may hasten the moment of my death.
8. I do not wish to condition the effectiveness of
this directive upon its conforming to any religious doctrines or beliefs to
which I may be believed to subscribe unless such conditions are set forth in a
writing which makes specific reference to this Advance Directive. I have not
made such a writing in connection with this Advance Directive.
9. I have considered the possibility of limiting the
effectiveness of this Advance Directive to a fixed period of time from the date
hereof and have decided that it shall remain in full force and effect for as
long as I may live.
10. I recognize that a time may come when I cannot
participate in my medical care decisions (even if there are favorable prospects
for my eventual recovery) and also that it is not possible for me to anticipate
the very wide variety of medical decisions which may need to be
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made in the future and to provide specific written
directions. Accordingly, I appoint
________________________________________________________________ currently
residing at ______________________________________________________________, as
my Health Care Representative. Pursuant to 42 CFR Part 164.502(g), (“HIPAA
Privacy Regulations")
____________________________________________________________ is entitled to act
as my personal representative, and shall therefore have full access to my
healthcare information for purposes of making the decisions described herein.
11. I hereby authorize my Health Care Representative
to accept or reject life- supporting care and treatment on my behalf. I further
authorize my Health Care Representative to plan and arrange for all medical
care and related care and treatment on my behalf and at my expense. The
directions of my Health Care Representative shall be binding in all respects
upon all those involved in my care. My Health Care Representative and all those
acting upon his or her directions shall be entitled to indemnification from my
estate in connection with all claims asserted against him or her unless the
directions given and relied on are wholly inconsistent with my intentions as
expressed above.
12. This Advance Directive shall not be affected by my
disability or incapacity or any doubt or uncertainty relating thereto.
Dated: _____________, 20__
____________________________
Signed, published and declared by
_____________________ to be his Medical Advance Directive in
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our presence and, we thereupon at his request and in
his presence, and in the presence of each other, subscribed our names as
attesting witnesses and our respective residence addresses. To the best of our
knowledge ____________________ is of sound mind and free of duress or undue
influence.
____________________________ residing at
____________________________ _____________________________
____________________________ residing at
____________________________ _____________________________
[Health Care Representative not to act as a witness]
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STATE OF NEW JERSEY )
) ss.:
COUNTY OF )
I CERTIFY that on _____________, 20__, _________________________________
personally came before me and he acknowledged under
oath, to my satisfaction, that he (a) is named in and personally signed the
foregoing instrument; and (b) signed, sealed and delivered the same as his
voluntary act and deed for the uses and purposes therein expressed.
_________________________
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