New Jersey - Sample Living Will/Healthcare Proxy Form

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Sample Living Will/Healthcare Proxy Form

I, (name of individual) , currently residing at (address) , being of sound mind and health, hereby make known my directions to my family, friends, all physicians, hospitals, and other health-care providers and any Court or Judge:

After thoughtful consideration, I have decided to forgo all life-sustaining treatment if I shall sustain substantial and irreversible loss of mental capacity and my attending physician is of the opinion that I am unable to eat and drink without medical assistance and it is highly unlikely that I will regain the ability to eat and drink without medical assistance; or my attending physician is of the opinion that I have an incurable or irreversible condition that is likely to cause my death within a relatively short time.

I shall be conclusively presumed to have sustained an irreversible loss of mental capacity upon a determination to such effect by my attending physician or when a Court determines that I have sustained such loss, whichever shall first occur.

As used herein, the term "an incurable or irreversible condition which is likely to cause my death within a relatively short time" is a condition which, without the administration of medical procedures, would serve only to prolong the process of dying and will, in my attending physician's opinion, result in my death within a relatively short period of time. The determination as to whether my death would occur in a relatively short period of time is to be made by my attending physician without considering the possibilities of extending my life with life-sustaining treatment.

I direct that this decision shall be carried into effect even if I am unable to personally reconfirm or communicate it, without seeking judicial approval or authority. Accordingly, if and when it is so determined that (1) I have sustained substantial and irreversible loss of mental capacity and (2) I am unable to eat and drink without medical assistance and it is highly unlikely that I will regain the capacity to eat and drink without medical assistance or I have an incurable or irreversible condition which is likely to cause my death within a relatively short time, all life- sustaining treatment (including without limitation, administration of nourishment and liquids intravenously or by tubes connected to my digestive tract) shall thereupon be withheld or withdrawn forthwith, whether or not I am conscious, alert, or free from pain, and no cardiopulmonary resuscitation shall thereafter be administered to me if I sustain cardiac or pulmonary arrest. In such circumstances I consent to an order not to resuscitate and direct that such an order thereupon be placed in my medical record. I recognize that when life-sustaining treatment is withheld or withdrawn from me, I will surely die of dehydration and malnutrition within days or weeks. All available medication for the relief of pain and for my comfort shall be administered to me after life-sustaining treatment is withheld or withdrawn, even if I am rendered unconscious and my life is shortened thereby.

I wish to die at home and not in a hospital, and I do not want to be transferred to a hospital unless my condition makes it impractical for me to be treated at home, as may be the case during severe hemorrhage, or extreme restlessness, convulsions, or unmanageable pain; in which case, then as soon as possible, I want to be sent back home.

I recognize that there my be many instances besides those described above in which the compassionate practice of good medicine dictates that life-sustaining treatment be withheld or withdrawn, and I do not intend that this instrument be construed as an exclusive enumeration of the circumstances in which I have decided to forgo life-sustaining treatment. To the contrary, it is my express direction that whenever the compassionate practice of good medicine dictates that life-sustaining treatment should not be administered, such treatment shall be withheld or withdrawn from me. I similarly direct that in the event I am able to personally communicate a decision to forgo life-sustaining treatment in other circumstances than those described herein, such instructions shall be followed to the same extent as if originally included in this declaration.

This instrument and the instructions herein contained may be revoked by me at any time and in any manner. However, no physician, hospital, or other health-care provider who withholds or withdraws life-sustaining treatment in reliance upon this Living Will or upon my personally communicated instructions without actual knowledge that I have countermanded these instructions shall have any liability or responsibility to me, my estate, or any other person for having withheld such treatment.

I am in full command of my faculties. I make this Living Will declaration in order to furnish clear and convincing proof of the strength and durability of my determination to forgo life-sustaining treatment in the circumstances described above. I emphasize my firm and settled conviction that I am entitled to forgo such treatment in the exercise of my right to determine the course of my medical treatment. My right to forgo such treatment is paramount to any responsibility of any health-care provider or the authority of any Court or Judge to attempt to force unwanted medical care upon me.

I direct that my family, friends, all physicians, hospitals, and other health-care providers and any Court or Judge honor my decision that my life not be artificially extended by mechanical means and that if there is any doubt as to whether or not life-sustaining treatment is to be administered to me after I have sustained substantial and irreversible loss of mental capacity, such doubt is to be resolved in favor of withholding or withdrawing such treatment.

I have discussed this document with (names of witnesses) , and I appoint said (name of surrogate) as my Surrogate and Health Proxy to act for me in any and all of the within premises, and if any interpretation of this document is ever necessary, my said Surrogate and Health Proxy is authorized to interpret it.

_______________________
Name

Date and place of execution: ____________________________________

WITNESS: __________________________________________________
ADDRESS: __________________________________________________

STATE OF New Jersey

COUNTY OF _______________

On this (date) , before me personally appeared (individual's name) , to me known to be the individual described in and who executed the foregoing instrument, and she acknowledged to me that he/she executed the same.

_______________________
Notary Public

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