NEW JERSEY ADVANCE DIRECTIVE FOR HEALTH CARE
(Living Will & Durable Power of Attorney for Health Care)
[Effective Date: [DATE]]
[// GUIDANCE: This template is drafted to comply with the New Jersey Advance Directives for Health Care Act, N.J. Stat. Ann. §§ 26:2H-53 to -78. Customize bracketed items, delete inapplicable options, and review local hospital policies before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Designation of Health Care Representative
3.2 Instruction (Living Will) Directive
3.3 Statement of Intent & Scope
3.4 Anatomical Gifts (Optional)
3.5 Nomination of Guardian/Conservator (Optional)
3.6 Reliance & Provider Protection
3.7 Revocation Procedures - Representations & Warranties
- Covenants & Restrictions
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution & Witness / Notary Acknowledgment
- Revocation Record (Optional)
1. DOCUMENT HEADER
THIS NEW JERSEY ADVANCE DIRECTIVE FOR HEALTH CARE (the “Directive”) is executed on [DATE] (the “Effective Date”) by [NAME OF PRINCIPAL] (the “Principal”), residing at [ADDRESS], pursuant to the New Jersey Advance Directives for Health Care Act, N.J. Stat. Ann. §§ 26:2H-53 to -78, and is intended to be recognized and given effect in accordance with said Act and any other applicable law.
2. DEFINITIONS
For purposes of this Directive, the following capitalized terms have the meanings set forth below:
“Act” means the New Jersey Advance Directives for Health Care Act, N.J. Stat. Ann. §§ 26:2H-53 to -78, as amended.
“Artificial Nutrition and Hydration” means medically supplied food or fluids provided intravenously or via feeding tube.
“Attending Physician” means the physician or advanced practice nurse who has primary responsibility for the care of the Principal.
“Directive” means this New Jersey Advance Directive for Health Care, including any attachments, schedules, or amendments.
“Health Care Institution” includes any hospital, nursing home, assisted-living facility, hospice, or other entity licensed to provide health-related services.
“Health Care Representative” or “Representative” means the individual appointed in Section 3.1 with authority to make health care decisions on behalf of the Principal.
“Instruction Directive” means the living-will portion of this Directive containing written instructions regarding the Principal’s health care preferences.
“Life-Sustaining Treatment” means any medical procedure, treatment, or intervention that uses mechanical or other artificial means to sustain, restore, or replace a vital bodily function and thereby serves to prolong life.
“Principal” means the individual executing this Directive.
[Add additional defined terms as needed.]
3. OPERATIVE PROVISIONS
3.1 Designation of Health Care Representative
a. Appointment. The Principal hereby designates [NAME OF REPRESENTATIVE], whose address is [ADDRESS] and telephone [PHONE], as Health Care Representative with full authority to make all health care decisions on the Principal’s behalf when the Principal lacks decision-making capacity.
b. Alternate Representative(s). If the person named above is unavailable, unwilling, or unable to act, the Principal appoints the following in successive order:
1. [NAME OF 1ST ALTERNATE] [ADDRESS] [PHONE]
2. [NAME OF 2ND ALTERNATE] [ADDRESS] [PHONE]
c. Scope of Authority. The Representative’s authority includes, without limitation, the powers to:
i. Consent to, refuse, or withdraw any form of health care, including Life-Sustaining Treatment and Artificial Nutrition and Hydration;
ii. Hire and discharge medical personnel;
iii. Request and review medical records;
iv. Authorize admission to or discharge from any Health Care Institution;
v. Take any other action necessary to carry out the Principal’s wishes or best interests.
[// GUIDANCE: Delete or limit specific powers if desired.]
3.2 Instruction (Living Will) Directive
Subject to Section 3.3, the Principal issues the following instructions:
a. End-Stage, Terminal, or Permanently Unconscious Condition
If I am diagnosed, in writing, by my Attending Physician and one additional qualified physician as having either (1) a terminal condition, (2) an end-stage condition, or (3) a permanent loss of consciousness from which, to a reasonable degree of medical certainty, there is no realistic hope of recovery, then:
☐ I direct that Life-Sustaining Treatment be withheld or withdrawn, and that I be permitted to die naturally.
☐ I direct that Life-Sustaining Treatment be continued.
☐ Other (describe): [_]
b. Artificial Nutrition and Hydration
☐ I want Artificial Nutrition and Hydration.
☐ I do NOT want Artificial Nutrition and Hydration.
☐ I leave this decision to my Health Care Representative.
c. Pain Relief & Palliative Care
Regardless of the above, I request that I be given medication or other measures necessary to alleviate pain or discomfort, even if such measures may hasten death.
d. Mental Health Treatment (Optional)
[Insert mental health treatment preferences or “Not Applicable.”]
e. Pregnancy (Optional)
[State any directives that apply if the Principal is pregnant at the time decisions must be made.]
3.3 Statement of Intent & Scope
The instructions in Section 3.2 are intended to be honored to the fullest extent permitted by law. Where the Principal’s intent is unclear, the Health Care Representative shall decide consistent with the Principal’s known wishes or, if unknown, the Principal’s best interests.
3.4 Anatomical Gifts (Optional)
Upon death, I hereby:
☐ Donate any needed organs or tissues.
☐ Donate only the following organs/tissues: [_]
☐ Do not make anatomical gifts.
[// GUIDANCE: Consider completing a separate organ-donor card in addition.]
3.5 Nomination of Guardian/Conservator (Optional)
If a court determines that a guardian or conservator should be appointed, I nominate [NAME] as first choice and [NAME] as second choice.
3.6 Reliance & Provider Protection
Health Care Providers, Health Care Institutions, and insurers may rely on the most current, duly executed copy of this Directive and are entitled to immunity for good-faith compliance pursuant to N.J. Stat. Ann. § 26:2H-61.
3.7 Revocation Procedures
a. Revocation by Principal. This Directive may be revoked at any time by:
i. A signed, dated writing;
ii. An oral statement or other act indicating intent to revoke; or
iii. Execution of a subsequent advance directive.
b. Notice of Revocation. The Principal or any person with knowledge of the revocation should immediately notify the Attending Physician and any Health Care Representative.
[// GUIDANCE: Attach a “Revocation Record” at the end to document any revocation.]
4. REPRESENTATIONS & WARRANTIES
4.1 Capacity. The Principal represents that, as of the Effective Date, the Principal is at least eighteen (18) years old, of sound mind, and under no duress, fraud, or undue influence.
4.2 Compliance. The Principal intends this Directive to be valid in New Jersey and in any jurisdiction that honors out-of-state advance directives.
4.3 No Conflicting Instruments. The Principal warrants that any prior advance directive is either revoked or attached hereto as a supplement and is not inconsistent with this Directive.
5. COVENANTS & RESTRICTIONS
5.1 Health Care Representative Covenants
a. Act in Good Faith. The Representative shall act in good faith and in the Principal’s best interests.
b. Consultation. The Representative shall consult with health care professionals and, when feasible, with family members or significant others.
c. Record-Keeping. The Representative shall maintain, to the extent practicable, a record of major decisions made under this Directive.
5.2 Limitations
The Representative SHALL NOT:
a. Authorize involuntary commitment except as permitted by law;
b. Consent to psychosurgery or experimental treatments without explicit instruction;
c. Override the specific preferences expressed in Section 3.2 unless legally permitted and ethically required.
6. RISK ALLOCATION
6.1 Indemnification of Provider
The Principal agrees that, to the fullest extent permitted by law, no Health Care Provider or Health Care Institution acting in good-faith reliance on this Directive shall incur civil or criminal liability.
6.2 Limitation of Liability
All parties entitled to act hereunder shall be held to a “good-faith” standard. No party shall be liable for monetary damages so long as actions or omissions are taken in reasonable reliance on this Directive.
[// GUIDANCE: New Jersey law already grants statutory immunity; this clause reinforces that protection.]
7. DISPUTE RESOLUTION
7.1 Governing Law
This Directive shall be governed by and construed in accordance with the laws of the State of New Jersey without giving effect to its conflict-of-laws principles.
7.2 Injunctive Relief
Nothing herein shall limit any party’s right to seek declaratory or injunctive relief from a court of competent jurisdiction to enforce or clarify this Directive.
[Arbitration, jury waiver, and forum-selection clauses are intentionally omitted as generally inapplicable to advance directives.]
8. GENERAL PROVISIONS
8.1 Amendment & Waiver
This Directive may be amended only by the Principal through a duly executed writing that satisfies the Act’s requirements. No waiver of any provision shall be effective unless in writing and signed by the Principal.
8.2 Severability
If any provision of this Directive is held invalid, the remaining provisions shall remain in full force and effect.
8.3 Copies & Electronic Signatures
Photocopies, facsimiles, and electronically transmitted copies of this executed Directive shall be as valid as the original.
8.4 Integration
This Directive contains the entire expression of the Principal’s wishes concerning future health care decisions and supersedes all prior inconsistent directives.
8.5 HIPAA Authorization
The Representative is hereby designated as the Principal’s personal representative for purposes of 45 C.F.R. § 164.502(g), and is authorized to obtain and disclose protected health information as necessary to carry out the Principal’s wishes.
9. EXECUTION & WITNESS / NOTARY ACKNOWLEDGMENT
I, [NAME OF PRINCIPAL], the undersigned, subscribe my name to this Directive on the date first written above and do hereby declare that I sign and execute this instrument as my free and voluntary act.
9.1 Principal’s Signature
______ Date: ______
[NAME OF PRINCIPAL]
9.2 OPTION A – TWO (2) WITNESSES
We declare that the Principal is personally known to us, appears to be of sound mind, and signed or acknowledged the foregoing Directive in our presence. At least one of us is not the Principal’s spouse, heir at law, or the Health Care Representative.
Witness #1:
____ Date: __
Name: [_] Address: [_]
Witness #2:
____ Date: __
Name: [_] Address: [_]
9.3 OPTION B – NOTARIZATION (Use instead of Witnesses)
State of New Jersey )
County of ____ ) ss.:
On this _ day of _, 20__, before me, the undersigned notary public, personally appeared [NAME OF PRINCIPAL], personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to this instrument, and acknowledged executing the same for the purposes therein contained.
Notary Public
My Commission Expires: ____
[// GUIDANCE: Either obtain TWO witnesses OR one notary acknowledgment—NOT both—to satisfy N.J. Stat. Ann. § 26:2H-56.]
10. REVOCATION RECORD (Optional)
Date of Revocation: __
Method of Revocation (oral, written, new directive, other): _
Received By (name/title): ___
Health Care Provider Notified: __
Date Provider Notified: ____
[Attach additional pages as needed.]
[END OF DOCUMENT]
[// GUIDANCE:
1. Store executed originals in easily accessible locations and provide copies to family, Health Care Representative(s), and primary care providers.
2. Upload a digital copy to any statewide advance directive registry, hospital portals, or electronic health record systems, if available.
3. Review this Directive periodically—recommend annually or upon major life events—to ensure continued accuracy.]