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

Appendices

Expression of Intent

See Instructions paragraph (i)

•

The issues surrounding end-of-life medical decisions are

If I am in a coma or have little conscious

critical and most complex. We, therefore, strongly

understanding, with no hope of recovery, then I

recommend that you discuss your wishes and concerns

want to be treated.....

•

openly with your Health Care proxy (as well as the alternate)

If I have brain damage or a brain disease that

and your designated Rabbi. In order to give them guidance,

makes me unable to recognize people or speak and

in the event that you are unable to make your own decisions,

there is no hope that my condition will improve, I

we ask you to review the following scenarios and discuss

wish to be treated.....

with them whether you wish to be treated aggressively with

all

appropriate

life-support

interventions,

Medical technology is constantly advancing, so that new

palliative/comfort

care,

which

may

include

pain

treatment options may become available in the future.

medications, symptom relief, antibiotics and feeding tubes.

Additionally, your advance directives at this time of your

life may not necessarily apply if or when conditions change.

•

If I become terminally ill, I want to be treated.....

We, therefore, urge you to periodically update this HCP,

Health Care Proxy form, along with your DBA, Durable

Power-of-Attorney, and Will.

________________________________________________________

Emergency Instructions Card

See Instructions paragraph (h)

Health Care Proxy

Agent:_________________________________________

Emergency Instructions

I ___________________________________________________

Phone: Office:____________ Home: _________________

have executed a “Halachic Health Care Proxy” (HCP) with

respect to medical and post-mortem decisions, dated

Cell: _________________ E-Mail:__________________

_________________. Pursuant to the Halachic HCP, the persons

listed on the reverse of this card are to serve as my agent and

Alternate Agent: ________________________________

alternate agent, respectively, in making health care decisions for

me if I become unable to do so.

Phone: Office: _____________ Home: _______________

I desire that all such health care decisions, as well as all

Cell: _________________ Email: ___________________

decisions relating to the handling and disposition of my body

after I die, should be made pursuant to Jewish law and custom as

Rabbi: _________________________________________

determined in accordance with Orthodox interpretation and

tradition. If there is any question regarding Jewish law and

Phone: Office______________ Home:_______________

custom, my agent (or any other person making decisions for me)

should consult with and follow the guidance of the rabbi or

Cell:__________________ E-mail___________________

alternate rabbi identified on the reverse of this card. Pending

contact with my agent I desire that health care providers should

Alternate Rabbi ________________________________

undertake all essential emergency measures on my behalf; and I

desire that no autopsy, organ removal, or other post-mortem

Phone: Office:______________ Home:_______________

procedure be performed on my body without authorization from

my agent.

Cell__________________ E-Mail ___________________

The Rabbinical Council Of America - Halachic Health Care Proxy Page 6

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