The Rabbinical Council Of America - Halachic Health Care Proxy (Page 3 of 6) in pdf

Proxy and Directive With Respect To

Health Care Decisions and Post-Mortem Decisions

I, _______________________________________________________________________, hereby declare as follows:

1. Appointment of Agent: In recognition of the fact that

my own health care decisions because of illness, injury or

there may come a time when I will become unable to make

other circumstances, I hereby appoint

Agent

Name _______________________________________________________________________

Address _____________________________________________________________________

Telephone/Email:

Office___________________________

Home __________________________________

Cell ____________________________

E-mail: _________________________________

as my health care agent to make any and all health care decisions for me, consistent with my wishes as set forth in this directive.

If the person named above is unable, unwilling or unavailable to act as my agent, I hereby appoint

Alternate Agent

Name _______________________________________________________________________

Address______________________________________________________________________

Telephone/Email:

Office___________________________

Home __________________________________

Cell ____________________________

E-mail: _________________________________

to serve in such capacity.

This appointment shall take effect in the event I become

cardiac or respiratory arrest; the performance of life-

unable, because of illness, injury or other circumstances, to

sustaining surgical procedures and the initiation or

make my own health care decisions.

maintenance of any particular course of life-sustaining

medical treatment or other form of life-support maintenance,

2. Jewish Law to Govern Health Care Decisions: I am

including the provision of nutrition and hydration; and the

Jewish. It is my desire, and I hereby direct, that all health

criteria by which death shall be determined, including the

care decisions made for me (whether made by my agent, a

method by which such criteria shall be medically ascertained

guardian appointed for me, or any other person) be made

or confirmed.

pursuant to Jewish law and custom as determined in

3. Ascertaining the Requirements of Jewish Law: In

accordance with Orthodox interpretation and tradition.

determining the requirements of Jewish law and custom in

Without limiting in any way the generality of the foregoing,

connection with this declaration, I direct my agent to consult

it is my wish that Jewish Law and custom should dictate the

with the following Orthodox Rabbi and I ask my agent to

course of my health care with respect to such matters as the

comply with his halachic decisions:

performance of cardio-pulmonary resuscitation if I suffer

Rabbi

Name______________________________________________________________________

Address____________________________________________________________________

The Rabbinical Council Of America - Halachic Health Care Proxy Page 3

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