Proxy Directive (Durable Power Of Attorney For Health Care ) printable pdf download

The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care

PROXY DIRECTIVE--(Durable Power of Attorney for Health Care)

Designation of Health Care Representative

I understand that as a competent adult, I have the right to make decisions about my health care. There may

come a time when I am unable, due to physical or mental incapacity, to make my own health care decision. In

these circumstances, those caring for me will need direction and they will turn to someone who knows my values

and health care wishes. By writing this durable power of attorney for health care I appoint a health care

representative with the legal authority to make health care decisions on my behalf and to consult with my

physician and others. I direct that this document become part of my permanent medical records.

A) CHOOSING A HEALTH CARE REPRESENTATIVE:

I, ______________________________, hereby designate _________________________________________,

of _________________________________________________________________________________________

___________________________________________________________________________________________,

(home address and telephone number of health care representative)

as my health care representative to make any and all health care decisions for me, including decisions to accept or

to refuse any treatment, service or procedure used to diagnose or treat my physical or mental condition and

decisions to provide, withhold or withdraw life-sustaining measures. I direct my representative to make decisions

on my behalf in accordance with my wishes as stated in this document, or as otherwise known to him or her. In

the event my wishes are not clear, my representative is authorized to make decisions in my best interest, based on

what is known of my wishes.

This durable power of attorney for health care shall take effect in the event I become unable to make my own

health care decisions, as determined by the physician who has primary responsibility for my care, and any

necessary confirming determinations.

B) ALTERNATE REPRESENTATIVES: If the person I have designated above is unable, unwilling or

unavailable to act as my health care representative, I hereby designate the following person(s) to act as my health

care representative, in the order of priority stated:

1. name ________________________________

2. name ________________________________

address ______________________________

city _____________________ state _______

city ______________________ state _______

telephone ____________________________

telephone _____________________________

C) SPECIFIC DIRECTIONS: Please initial the statement below which best expresses your wishes.

_____

My health care representative is authorized to direct that artificially provided fluids and nutrition,

such as by feeding tube or intravenous infusion, be withheld or withdrawn.

_____

My health care representative does not have this authority, and I direct that artificially provided

fluids and nutrition be provided to preserve my life, to the extent medically appropriate.

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Proxy Directive (Durable Power Of Attorney For Health Care )