Healthcare Power of Attorney

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

AND ADVANCE DIRECTIVE

(New Jersey)

This template is drafted to satisfy the requirements of N.J. Stat. Ann. §§ 26:2H-53 et seq. (Advance Directives for Health Care Act) and the HIPAA Privacy Rule, 45 C.F.R. § 164.508. Customize all bracketed fields before execution.

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

1.1 Parties.
(a) “Principal”: [PRINCIPAL LEGAL NAME], residing at [ADDRESS].
(b) “Agent”: [PRIMARY AGENT LEGAL NAME], residing at [ADDRESS].
(c) “1st Alternate Agent”: [ALT AGENT #1 NAME] (optional).
(d) “2nd Alternate Agent”: [ALT AGENT #2 NAME] (optional).

1.2 Recitals.
A. Principal desires to designate a health care representative pursuant to N.J. Stat. Ann. §§ 26:2H-53 et seq.
B. Principal is of sound mind and under no duress or undue influence.
C. Consideration is acknowledged by the mutual promises herein.

1.3 Effective Date; Durability.
This instrument becomes effective upon the Principal’s incapacity, as determined in good-faith medical judgment, and shall remain durable notwithstanding future incapacity unless revoked pursuant to Section 6.1.

1.4 Governing Law.
This document shall be governed by the health-care decision laws of the State of New Jersey.

2. DEFINITIONS

“Advance Directive” – This Durable Power of Attorney for Health Care and any properly executed amendments.
“Agent” – The person authorized under Section 3.1.
“Alternate Agent” – A successor Agent designated in Section 3.1(c)–(d).
“End-Of-Life Decisions” – Choices regarding life-sustaining treatment, artificial nutrition/hydration, resuscitation, and similar interventions.
“Good Faith” – Honesty in fact and in accordance with reasonable medical standards.
“Health Care Decision” – Any consent, refusal, or withdrawal of treatment, service, diagnostic procedure, placement, or other matter affecting the Principal’s physical or mental condition.
“HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and regulations promulgated thereunder.
“Incapacity” – A physician’s written determination that the Principal lacks decision-making capacity.
“Living Will Provision(s)” – The Principal’s written instructions in Section 3.3.

3. OPERATIVE PROVISIONS

3.1 Appointment & Succession.
(a) Primary Agent. Principal appoints the Agent to make Health Care Decisions on Principal’s behalf.
(b) Scope. Authority includes all Health Care Decisions the Principal could make personally, subject to Sections 3.2 and 3.3.
(c) Successors. If the Agent is unwilling, unavailable, or disqualified, authority passes in the order listed in Sections 1.1(c)–(d).

3.2 Scope of Authority.
The Agent is specifically authorized to:
(i) consent to, refuse, or withdraw medical or surgical procedures;
(ii) access, review, and disclose medical records (HIPAA release, Section 3.4);
(iii) admit or discharge the Principal from facilities;
(iv) employ and discharge health-care providers;
(v) authorize autopsy and organ donation per N.J. law;
(vi) take all other lawful actions necessary to implement this Advance Directive.

3.3 End-Of-Life Directions.
(a) Life-Sustaining Treatment. It is the Principal’s intention that [CHOOSE: “life-sustaining treatment be withheld/withdrawn if it would only prolong the dying process” OR “all available life-sustaining treatment be provided unless medically futile”].
(b) Artificial Nutrition/Hydration: [SELECT PREFERENCE].
(c) Pain Management. Palliative care is authorized even if it may hasten death.
(d) Pregnancy Exception (optional under NJ law): [INCLUDE/OMIT].

3.4 HIPAA Authorization.
The Agent (and any Alternate Agent when acting) is a “personal representative” under HIPAA and may obtain, use, and disclose protected health information to the same extent the Principal could. This authorization is effective immediately and survives the Principal’s death to resolve matters relating to health-care treatment or payment.

3.5 Nomination of Guardian.
If a court deems a guardian necessary, Principal nominates the acting Agent.

3.6 Reliance & Certification.
Third parties may rely on copies of this document and on the Agent’s certification of continuing authority.

4. REPRESENTATIONS & WARRANTIES

4.1 Principal represents:
(a) capacity to execute;
(b) thorough review and understanding of this document.

4.2 Agent represents (by signing in Section 10.2):
(a) willingness to serve;
(b) commitment to act in Good Faith and in accordance with the Principal’s known wishes.

Survival. These representations and warranties survive revocation or replacement of an Agent.

5. COVENANTS & RESTRICTIONS

5.1 Agent Covenants.
(a) Use substituted judgment consistent with Principal’s known wishes; if unknown, act in Principal’s best interests.
(b) Consult available medical professionals and family.
(c) Maintain contemporaneous records of major decisions upon request of authorized family or the court.

5.2 Restrictions.
The Agent shall not:
(i) authorize euthanasia or assisted suicide;
(ii) act for personal financial gain;
(iii) override the explicit Living Will Provisions in Section 3.3.

Notice. Agent shall promptly inform Alternate Agents of inability to serve.

6. DEFAULT & REMEDIES

6.1 Revocation by Principal.
Principal may revoke this Advance Directive in whole or in part by:
(a) written revocation delivered to Agent and primary health-care provider;
(b) oral statement witnessed by two adults; or
(c) execution of a subsequent Advance Directive.

6.2 Removal of Agent.
A court of competent jurisdiction may remove an Agent for breach of fiduciary duty, bad faith, or incapacity.

6.3 Graduated Remedies.
Before court action, disputing parties shall confer in good faith. Failing resolution, injunctive relief may be sought pursuant to Section 8.3.

Attorney Fees. A prevailing party in litigation to enforce or interpret this document shall recover reasonable attorneys’ fees and costs.

7. RISK ALLOCATION

7.1 Indemnification of Agent.
The Principal’s estate shall indemnify and hold harmless the Agent and any Alternate Agent from all liability, costs, and expenses, except for acts or omissions constituting bad faith, willful misconduct, or gross negligence (“Excluded Conduct”).

7.2 Limitation of Liability.
No Agent shall be liable to the Principal, the estate, or any third party for any decision made in Good Faith and without Excluded Conduct.

7.3 Insurance.
Nothing herein requires the Agent to obtain liability insurance, but the estate may procure coverage at its expense.

7.4 Force Majeure.
The Agent is not liable for non-performance caused by events reasonably beyond the Agent’s control, including natural disasters or systemic health-care disruptions.

8. DISPUTE RESOLUTION

8.1 Governing Law.
This Advance Directive is governed by the substantive law of New Jersey.

8.2 Forum Selection.
Exclusive venue lies in the Superior Court of New Jersey, Chancery Division – Probate Part, for the county in which the Principal resides at the time of filing.

8.3 Injunctive Relief.
Because Health Care Decisions are time-sensitive, any court of competent jurisdiction may issue temporary or permanent injunctive relief to enforce or enjoin actions under this document.

8.4 Arbitration & Jury Trial.
Arbitration is not mandated, and no jury-trial waiver is granted.

9. GENERAL PROVISIONS

9.1 Amendment & Waiver.
Only the Principal may amend this document by written instrument executed with the same formalities. No waiver is effective unless in writing.

9.2 Assignment.
Authority granted herein is personal to the Agent and may not be assigned.

9.3 Successors & Assigns.
Subject to Section 9.2, this instrument binds and benefits the Principal’s heirs, executors, administrators, and legal representatives.

9.4 Severability.
Invalidity of any provision shall not affect remaining provisions; courts may reform invalid language to fulfill the principal intent.

9.5 Integration; Merger.
This document constitutes the entire agreement regarding health-care decision-making authority and supersedes all prior inconsistent directives.

9.6 Counterparts; Electronic Signatures.
This document may be executed in counterparts and by electronic signature, each deemed an original.

10. EXECUTION BLOCK

10.1 Principal’s Signature

I, [PRINCIPAL NAME], the undersigned Principal, sign my name to this Durable Power of Attorney for Health Care and Advance Directive on [DATE], at [CITY, STATE].

______________________________
[PRINCIPAL NAME], Principal

10.2 Agent’s Acceptance

I, [AGENT NAME], accept the appointment as Agent and agree to act in Good Faith pursuant to this instrument.

______________________________
[AGENT NAME], Agent  Date: ______

(Optional)
______________________________
[ALT AGENT #1 NAME], 1st Alternate Date: ______

______________________________
[ALT AGENT #2 NAME], 2nd Alternate Date: ______

10.3 Witnesses (Use EITHER Section 10.3 or 10.4)

We declare that the Principal appears to be of sound mind and under no duress, fraud, or undue influence.

Witness #1:
______________________________
Name: [PRINT] Address: [ADDRESS] Date: ______

Witness #2:
______________________________
Name: [PRINT] Address: [ADDRESS] Date: ______

10.4 Notary Acknowledgment (Alternative to witnesses)

State of New Jersey )
County of ________ ) ss.:

On [DATE], before me, [NOTARY NAME], a Notary Public in and for said State, personally appeared [PRINCIPAL NAME], proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person executed it.

______________________________
[NOTARY NAME]
Notary Public, State of New Jersey
My commission expires: ________