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New Jersey Durable Power of Attorney for Health Care Form


New Jersey Durable Power of Attorney for Health Care Form
New Jersey Durable Power of Attorney for Health Care Form
The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care
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PROXY DIRECTIVE--(Durable Power of Attorney for Health Care)
Designation of Health Care Representative
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 decision. 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.
A) CHOOSING A HEALTH CARE REPRESENTATIVE:
I, ______________________________, hereby designate _________________________________________,
of _________________________________________________________________________________________
___________________________________________________________________________________________,
(home address and telephone number of health care representative)
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 interest, 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.
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 the order of priority stated:
1. name ________________________________ 2. name ________________________________
address ______________________________ address ______________________________
city _____________________ state _______ city ______________________ state _______
telephone ____________________________ telephone _____________________________
C) SPECIFIC DIRECTIONS: Please initial the statement below which best expresses your wishes.
_____ My health care representative is authorized to direct that artificially provided fluids and nutrition,
such as by feeding tube or intravenous infusion, be withheld or withdrawn.
_____ My health care representative does not have this authority, and I direct that artificially provided
fluids and nutrition be provided to preserve my life, to the extent medically appropriate.
New Jersey Durable Power of Attorney for Health Care Form
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