Advance Directives - Living Wills

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Advance Directive – Living Wills
On January 11, 1992, a New Jersey law took effect, which mandates that all health care facilities ask
patients whether they have an advance directive or living will. At the Essex Specialized Surgical Institute,
we have made this part of the admitting process. If you have an advance directive or living will, please
bring a copy of it with you to the Essex Specialized Surgical Institute on the day of your scheduled
procedure.
If you do not have an advance directive or living will, please read the following information. An advance
directive or living will is a document which allows you to give written instruction to those caring for you
indicating the type of health care you would wish to receive or reject in the event you become unable to
express these decisions for yourself. There are three different types of advance directives:
A PROXY DIRECTIVE
In a proxy directive, a competent adult names a trusted relative or friend to make health care
decisions on his or her behalf when he or she is unable to make these decisions.
AN INSTRUCTION DIRECTIVE
In an instruction directive, a competent adult provides specific written instructions concerning the
type of medical treatment he or she would want performed, or would not want performed, and
under what circumstances.
A COMBINED DIRECTIVE
In this directive, competent adult states his or her general wishes regarding the kind of health care
he or she wishes to receive but appoints a trusted relative or friend to carry them out.
A brochure containing living will forms and instructions is available from the NJ Bioethics Commission. If
you wish to receive the brochure, please send a 9inch by 12 inch self addressed envelope with $1 in postage
attached to:
The NJ Bioethics Commision
CN 807
Trenton, NJ 08625
Do you have an Advance Directive or Living Will…………………. Yes ____ No ____
If yes, please bring a copy of it with you to Essex Specialized Surgical Institute.
___________________________________________________
Signature of Patient (Indicating awareness of above)
Receipt of Notice of Privacy Practices Written Acknowledgement Form
I, _________________________________________________, have received a copy of Essex Specialized
Surgical Institute Notice of Privacy Practices.
____________________________________________________
___________________
Signature of Patient
Date

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