(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 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.

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 that 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.

I hereby designate:

Name __________________________

Address __________________________

__________________________

Telephone __________________________

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 interests, 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.

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:

1. Name: __________________________

Address: __________________________

__________________________

Telephone: __________________________

2. Name: __________________________

Address: __________________________

__________________________

Telephone: __________________________

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, physician, family members, or others who may become responsible for your care.

In Sections C and D 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 Section E and/or attach a statement to this document that 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.

To inform those responsible for my care of my specific wishes, I make the following statement of personal views regarding my health care.

In Section C 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, write in the bracketed phrase with which you agree:

____________________________________________________________

____________________________________________________________

____________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

The State of New Jersey recognizes the irreversible condition 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.

______ 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.

It is now possible to transplant human organs and tissues 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.

for the purposes of transplantation, therapy, medical research, or education, or

The original or a copy of this document has been given to the following people:

1. Name _________________________ Address _________________________

City/State/Zip ___________________ Telephone _______________________

2.. Name _________________________ Address _________________________

City/State/Zip ___________________ Telephone _______________________

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 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/Zip _______________________________________________

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, or as an alternate health care representative.

1. Witness 2. Witness

_________________________ _________________________

(print name) (print name)

_________________________ _________________________

(signature) (signature)

_________________________ _________________________

(address) (address)

_________________________ _________________________

(city, state, zip) (city, state, zip)

_________________________ _________________________

(date) (date)

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