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New Jersey Living Will Form (Advance Directive) |
The New Jersey Living Will document is also sometimes refereed to as a living health care directive. This document is created with the US statutes 26:2H-53 to 26:2H-91 in mind and requires at least two witnesses or a notary, becoming invalid should the patient be found to be pregnant. It is a formal declaration to legally choose the medical treatment they will receive should they become incapacitated seriously so they are no longer able to do so. The document includes all type of personal wishes for the patient and extends as far as end of life decisions.
How to Write
Instruction Directive
A) The principal must enter their name.
Part 1: Statement Of Wishes Regarding Future Health Care
B) General Instructions
1) The principal must initial to denote their wish to receive all medical treatment.
2) The principal must initial to denote their wish not to receive any medical treatment.
2a) The principal must initial so that in the event of a terminal condition they will receive treatment for relief from pain but not to prolong life. They must also choose and enter their definition of `Terminal Condition` from the bracketed phrases.
2b) The principal must initial so that in the event of permanent unconsciousness they will receive treatment for relief from pain but not to prolong life. They must also choose and enter their definition of `Terminal Condition` from the bracketed phrases.
2c) The principal must initial so that in the event of an incurable illness, which may or may not be terminal, they will receive treatment for relief from pain and to prolong life only if the benefits outweigh the burdens.
The principal may also identify specific conditions which would cause them to feel they would not wish to receive life sustaining treatment.
C. Specific Instructions
The principal must denote the specific type of medical health care they wish to receive by entering the relevant bracketed phrase in the appropriate fields.
1) Artificial hydration and nutrition.
2) Cardiopulmonary resuscitation (CPR) during cardiac arrest.
3) Where the previous two fields do not express the wishes of the principal sufficiently then they must enter details of their specific wishes in the appropriate field.
D. Additional Instructions
The principal is able to provide details of any other health care preferences they have.
E. Brain Death
The principal may choose to initial to denote that they wish their death to be declared solely on a basis of cardiopulmonary cessation and not through being wholly brain dead.
F. Anatomical Gifts
The patient must initial to denote their wishes regarding offering an anatomical gift after their death.
- Initial to show intention to offer an anatomical gift.
- A. Initial to offer any required body parts for the purposes of transplant, therapy, medical research or education .
- B. Initial and enter the specific body parts offered for the purposes of transplant, therapy, medical research or education.
- C. Initial to offer an anatomical gift solely for the purposes of anatomical study.
- D. Initial and enter any specific requirements or limitations regarding an anatomical gift.
2) Initial NOT to make an anatomical gift.
Part 2: Signatures And Witnesses
G. Copies
The details of those in possession of either the original or a copy of this document must be entered.
- Name.
- Address.
- City.
- State.
- Telephone number.
H. Signature
The principal must enter their details.
- Date.
- Signature.
- Address.
- City.
- State.
I. Witnesses
The witnesses must enter their details.
- Signature.
- Address.
- City.
- State.
- Date.
