New Jersey Advance Directive Form

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A New Jersey advance directive is a document that lets a person create their end-of-life treatment options and select an agent to speak for them if they cannot do so for themselves. A directive is a combination of a power of attorney and a living will that outlines a person’s health care goals in the chance if they become incapacitated. Once the form is completed and signed, it may be used when the patient is no longer capable of making their own decisions.

Advance Directive Includes

Table of Contents

Laws

Statutes§ 26:2H-53 to § 26:2H-78 (New Jersey Advance Directives for Health Care Act)

Signing Requirements (§ 26:2H-56) – Two (2) witnesses

State Definition (§ 26:2H-55) – “Advance directive for health care” or “advance directive” means a writing executed in accordance with the requirements of this act. An “advance directive” may include a proxy directive or an instruction directive, or both.

Versions (7)


AARP

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Atlantic Health System

Download: Adobe PDF

 

 

 


Catholic Church

Download: Adobe PDF

 

 

 


Hackensack UMC

Download: Adobe PDF

 

 

 


Psychiatric Advance Directive

Download: Adobe PDF

 

 

 


Spanish (Español) Version

Download: Adobe PDF

 

 

 


Virtua Health System

Download: Adobe PDF

 

 

 

How to Write

Download: Adobe PDF

Step 1 – Download The New Jersey Advance Directive For Health Care From This Site

The New Jersey Advance Directive For Health Care package is available as a “PDF” or “Adobe PDF” file. The link above as well as the button near captioning the sample picture can both be used to initiate a direct download to a preferred folder in your system.

Step 2 – Begin The Living Will With The New Jersey Declarant’s Identity

The first two pages of this package dispense several definitions and instructions to the contents of this paperwork. The New Jersey Principal issuing this paperwork should read through this area making sure to comprehend the information it presents. 

 

Step 3 – Supply The New Jersey Declarant’s Directive When Terminal

After reviewing the beginning of this package, locate the “New Jersey Advance Directive For Health Care (Living Will)” section making up the first part of this directive. This directive will seek a presentation of the New Jersey Principal’s treatment preferences when faced with a life-threatening or severely debilitating medical condition. The first paragraph, noticeable by the two asterisks at its start, should have the full name of the New Jersey Declarant (or Principal) recorded on the blank line that follows.

 

Step 4 – Document The New Jersey Declarant’s Instructions When Permanently Unconscious

Several sections have been developed to obtain the New Jersey Declarant’s medical decisions in severe medical scenarios where the question of life support or life-sustaining treatment must be dealt with. Section “A – Terminal Condition” discusses a scenario where the New Jersey Declarant is “…Diagnosed As Having An incurable And Irreversible” medical condition. Review the conditions of this scenario then prepare to initial one of the two statements that follow to apply it as his or her desired response.  Statement 1 should be initialed by the New Jersey Declarant if he or she wishes that New Jersey Medical Personnel to cease life-sustaining treatment (or refuse its application) when he or she has no hope of recovery. This does not apply to life support systems that manage the New Jersey Principal’s pain and comfort. Statement 2 in “A – Terminal Condition” if the New Jersey Principal approves all life-sustaining treatment to be applied or continued whenever it is “Medically Appropriate”

 

Step 5 – Present The New Jersey Declarant Preferences When Faced With Steady Deterioration

Section “B – Permanently Unconscious” the discussion shall turn to the possibility of the New Jersey Principal being rendered permanently unconscious. When this happens, it will be unlikely that his or her body will be able to maintain its vital functions independently causing the natural death of the New Jersey Principal. If he or she has no hope of recovering consciousness, cognizance, memory, or the ability to comprehend and communicate with people then, his or her stance on receiving life-support care will be requested. This will be discussed in the first paragraph of the “B – Permanently Unconscious.”  If the New Jersey Principal does not approve of life support care when permanently unconscious under the conditions of the paragraph above and wishes that New Jersey Medical Personnel attending to his or her care remove or refrain from applying life support care, then he or she should initial the blank line corresponding to Statement 1 in “B -Permanently Unconscious”The New Jersey Principal can direct that all “…Life-Sustaining Treatment be Continued” when needed to prolong his or her life even when “Permanently Unconscious” by initialing Statement 2. The subject of deterioration is not limited to the body in this directive. Notice that “Section C – Incurable And Irreversible Conditions That Are Not Terminal” enables you to take the precaution of informing New Jersey Medical Personnel of your preferences when you suffer a severe mental deterioration that is permanent and untreatable. While not necessarily fatal, the results of mental deterioration can prevent someone from having the quality of life they believe is acceptable. Review the scenario presented before continuing to choose the directive that New Jersey Medical Providers should institute when you are in this condition and unable to communicate
If the New Jersey Principal experiences a medical condition where death is not necessarily oncoming but has lost his or her mental acuity then he or she may declare that medical life support techniques be denied or withdrawn then Statement 1, following the words “…I Will Never Regain The Ability To Make Decision And Express My Wishes”  The New Jersey Principal may have determined that life support care can be administered even when mental deterioration is imminent as a result of his or her medical condition. If so, then Statement 2 must be initialed.  

 

Step 6 – Deliver Declarant Preferences For Experimental And/Or Futile Treatment

There may be times when New Jersey Physicians tending to the Patient believe that a relatively new or experimental life-sustaining treatment may provide a reasonable chance of recovery. If the New Jersey Principal does not wish to receive the treatment falling under the criteria in Section “D – Experimental And/Or Futile Treatment” then he or she must formally refuse it by initialing Statement 1 in this section. No additional options are available, thus, if the New Jersey Principal does not initial this choice it will be assumed that authorization to the extent the other parts of this document allow has been given to apply “Experiment And/Or Futile Treatment” of life-supporting procedures.

 

Step 7 – Indicate The New Jersey Declarant’s Directives When Experiencing Brain Death

If brain death occurs or is imminent then the New Jersey Principal has the option to declare that his or her death has occurred “…On The Basis Of The Whole Brain Death Standard Would Violate…” his or her personal beliefs. To make this declaration the New Jersey Principal must initial Statement 1 in “E – Brain Death.” 

 

Step 8 – Establish The New Jersey Declarant’s Authorization Or Refusal Of Medical Responses

The next portion of the directive expects either the New Jersey Principal’s authorization or his or her refusal for every treatment option listed. This will be done through a review of some basic statements. Thus, if the New Jersey Principal will accept CPR administered when needed then he or she should initial the first blank line however if he or she refuses to allow cardiopulmonary resuscitation he or she should initial the blank line after the words “I Do Not Want” but preceding the term “Cardiopulmonary Resuscitation.”  If the New Jersey Principal authorizes the use of “Mechanical Respiration” then he or she must initial the first line of the next treatment option. If not, then the New Jersey Principal can refuse “Mechanical Respiration” by initialing the blank space just before this treatment option. The New Jersey Principal can approve the use of “Tube Feeding” by initialing the words “I Do Want” for the third treatment option. Authorization for “Tube Feeding” can be removed or denied by initialing the sixth space of this area. If the New Jersey Principal does not wish New Jersey Medical Personnel to administer “Antibiotics” the first space in the fourth treatment option must be initialed. The use of “Antibiotics” can be forbidden by the New Jersey Principal when he or she initials the space following the term “I Do Not want” and before the term “Antibiotics.”   Next, the fifth decision to be made will be to have “Maximum Pain Relief” administered when the New Jersey Principal’s suffering requires relief. To allow the use of pain management methods, the New Jersey Principal must initial the space after “I Do Want” of this decision. If he or she intends to refuse “Maximum Pain Relief” then the space displayed preceding this term must be initialed by the New Jersey Principal. The New Jersey Principal can decide to prematurely approve of “Kidney Dialysis” to be administered when needed by initialing the space after the term “I Do Want” or deny it by initialing the blank line immediately before the words “Kidney Dialysis.”   The top of the next page seeks a decision on whether the New Jersey Principal will authorize surgeries or not. If so, then he or she must initial the first space provided on the “Surgery” line. If the Principal will not authorize “Surgery” performed, then he or she must confirm this fact by initialing the blank line labeled “Surgery (Such As Amputation)”   The next topic is “Blood Transfusion.” The Principal can authorize blood transfusions by initialing the first space on this line or deny them by initialing the second available blank line (just before the words “Blood Transfusion”).  The Principal can elect to “Die At Home” buy initialing the second to last blank space however, if the New Jersey Principal does not require or does not want this then he or she should initial the final blank space in this section.

 

Step 9 – Address The New Jersey Principal’s Organ Donation Status

Section “G – Organ Donation” shall seek the New Jersey Principal’s definition to his or her status as an organ donor. If the New Jersey Principal agrees to making anatomical gifts after his or her death, then the first space in this section should be marked. If not, then he or she should initial the space between the wording “I Do Not Want” and preceding the term “To Donate My Organs.” 

 

Step 10 – Include Additional Or Specific Instructions Directly From The New Jersey Declarant

The text box labeled “Specific Instructions” is available for direct instructions from the New Jersey Principal completing this form. He or she can place provisions, conditions, restrictions, or even comments regarding treatments and life-prolonging procedures. If there is not enough room in the text box more space can be inserted, or you can continue on an attached document that is present at the time of the New Jersey Principal’s signing of this directive. 

 

Step 11 – Provide The New Jersey Declarant’s HIPAA Authorization For The Intended Attorney-in-Fact

the next portion of this directive allows the appointment of a Health Care Attorney-in-Fact however before this can be done, the Agent must be approved of having access to the rights of a Personal Representative of the New Jersey Principal as this entity is defined by the Health Insurance Portability And Accountability Act Of 1996. This requires a specific “Signature” of approval to be submitted by the Principal at the end of the section titled “HIPAA Provision In Medical Directives” 

 

Step 12 – Identify The New Jersey Principal Issuing This Appointment

As mentioned earlier, the next section is the “Durable Power Of Attorney For Health Care For The Appointment Of A Health Care Representative.” Since authorization has been delivered to the intended Agent to access the New Jersey Principal’s medical information the first order of business will be to formally name the Agent. This process requires that the first blank line of the first paragraph be populated with the full name of the New Jersey Principal. 

 

Step 13 – Dispense The Identity And Location Of The New Jersey Attorney-in-Fact For Health Care

Continue through this statement to the term “…Hereby Appoint” then input the full “Name” of the intended Attorney-in-Fact for health care on the blank line that follows. Identifying the New Jersey Attorney-in-Fact for health care also requires that his or her “City,” “State,” and “Zip” are displayed where requested across the next three lines.

 

Step 14 – Read Through The Required Wording For This Appointment

The appointment being made shall require that the New Jersey Principal make a declaration with the language in the paragraph that follows. Read the text provided as it will solidify New Jersey Principal’s desire to have the named Attorney-in-Fact handle and determine his or her health care decisions when New Jersey Medical Staff require guidance and authorization to continue. It should be mentioned that it will be assumed by one and all that the New Jersey Principal and his or her Attorney-in-Fact have a clear line of communication so that the Principal’s directives can be accurately dispensed by the Attorney-in-Fact. 

 

Step 15 – Set A Successor To The New Jersey Attorney-in-Fact As A Precaution

The New Jersey Principal behind this directive should be concerned regarding any scenario where his or her Attorney-in-Fact is ineffectual, unavailable, unwilling, or has had his or her powers revoked leaving the concerned Principal with no representation. This result of the Attorney-in-Fact’s failure or inability can be prevented by setting up a specific Party to succeed this Attorney-in-Fact. Known as the Alternate Health Care Representative, this person has no power or authority over the Principal’s health care decisions so long as the original New Jersey Attorney-in-Fact can actively represent the Principal before Health Care Providers. Review the “If The Previously Named…” statement then record the full “Name” and current “Telephone” number of the Alternate Health Care Representative on the first two lines following this statement.

The next line presented is labeled “Address” and expects the building number, street or road name or number, and unit number found in the New Jersey Alternate Health Care Representative’s home address.  Continue to the lines labeled “City,” “State,” and “Zip Code” where the remainder of the Alternate Health Care Representative’s address must be provided. 

 

Step 16 – The New Jersey Principal Must Date His Or Her Signature

The final three lines of this appointment require that a specific date be established as the day the New Jersey Principal formally grants power to his or her Attorney-in-Fact by providing a valid signature. This report requires its first item to be the two-digit calendar day of the month displayed on the space after the words “…After Careful Deliberation This”  The final two lines require the month and the two-digit year for the New Jersey Principal’s signature date furnished as their contents. 

 

Step 17 – A Properly Executed Signature Must Be Used To Issue This Appointment

The line labeled with the word “Signature” that follows should be utilized by the New Jersey Principal to execute this appointment. He or she must sign this line in front of two Witnesses or a New Jersey Notary Public.  The New Jersey Principal must now enter the first “Address” line from his or her residential after signing this document. The lines labeled “City,” “State” and “Zip Code” should be used by the New Jersey Principal to provide a complete address report on his or her residential address.   

 

Step 18 – Obtain Witness Or Notary Verification Of The New Jersey Principal’s Signature

The “Witnesses” section that follows the New Jersey Principal’s signature section should be tended by the two people watching him or her sign this document. When the first Witness signs the first “Witness Signature” line and prints his or her name on the “Witness Name” line, it will be accepted as verification that he or she has watched the Principal’s signing.  The First Signature Witness should also supply his or her “Address,” “City,” “State,” and “Zip Code” to the lines that follow. This will aid as a confirmation of the Witness’s identity. The Second Witness is expected to prove that he or she has seen the New Jersey Principal sign this document by signing the next line designated with the words “Witness Signature.” After this signing, the Second Witness should use the “Witness Name” line to provide his or her printed name then, continue by providing documentation of his or her “Address,” “City,” State,” and “Zip Code.”If the New Jersey Principal has decided to verify this document’s execution by signing it before a Notary Public instead of two Witnesses, then the above Witness signature areas may be left unattended but the statement beginning with the words “Sworn And Subscribed…” must be completed by the Notary Public and his or her signature and/or seal should be delivered below this. 

 

Step 19 – Discuss The New Jersey Practitioner Orders For Life-Sustaining Treatment

The “New Jersey Practitioner Orders For Life-Sustaining Treatment (POLST)” form requires that a New Jersey Licensed Physician, APN, or PA complete and sign it. This can only be done with the cooperation of the New Jersey Declarant or Patient. 

 

Step 20 – Identify The New Jersey Declarant

The first line presents two labeled areas where the New Jersey Principal must have his or her name and “Date Of Birth” furnished where requested.

 

Step 21 – Deliver The New Jersey Declarant’s Home Address

Continue to the second blank line at the top of the page where the New Jersey Declarant’s complete address should be furnished for display on the blank line labeled “Print Person’s Address.”

 

Step 22 – Establish The Patient’s Goals Of Care

The New Jersey Declarant or Patient’s purpose for issuing this document should be explained in the text box labeled “Goals Of Care” in Section A. The New Jersey Declarant or Patient’s address must be presented on the “Print Person’s Address” line. Here, a report defining whether the New Jersey Declarant or Patient values comfort, longevity, cognizance, being pain-free, and/or what his or her definitions and priorities regarding a preferred quality of life should be displayed. 

Step 23 – Display The New Jersey Declarant’s Approval For Medical Interventions

Section B, titled “Medical Interventions,” supplies several statements defining the level of care the New Jersey Declarant approves as a response when seeking to treat his or her condition or prolong the Declarant’s life. If the New Jersey Declarant authorizes “Full Treatment” to be provided by New Jersey Medical Staff to revive the Declarant, then the first checkbox should be marked.    The New Jersey Declarant may only authorize non-invasive measures to prolong life or treat the debilitating medical condition that has incapacitated him or her. If so, then the second checkbox “Limited Treatment” should be selected. This will require an additional discussion. A crucial question that must be answered when the New Jersey Declarant is found incapacitated is whether Medical Responders should transfer him or her to a hospital for treatment and interventions. If the New Jersey Declarant has determined this is acceptable then select the box labeled “Transfer To Hospital For Medical Interventions” 

If the New Jersey Declarant has indicated that only “Limited Treatment” will be considered an appropriate response to his or her incapacitation and that a transfer to a hospital is only justifiable when comfort needs or pain management cannot be properly addressed in his or her current location, then the “Transfer To Hospital Only If Comfort…” checkbox should be selected. 

If the New Jersey Declarant only authorizes treatment for the symptoms causing his or her incapacitation to be administered. This means that “Aggressive Comfort Treatment To Relieve Pain And Suffering” will be administered such as administering oxygen through the manual treatment of airway obstruction.  “Additional Orders” concerning what the New Jersey Declarant authorizes can be provided on the blank line provided in Section B.

 

Step 24 – Furnish The New Jersey Declarant’s Preferences Regarding Artificial Nutrition

In cases where the New Jersey Declarant requires “Artificially Administered Fluids And Nutrition” to survive, his or her preferences will be sought by responding to Medical Staff. In Section D, the first checkbox should be marked if the New Jersey Declarant refuses the administration of artificial nutrition entirely.    If the Patient will accept “Long-Term Artificial Nutrition” administered to maintain his or her life, then select the second checkbox The third checkbox should be selected if the Patient only approves of a “Defined Trial Period Of Artificial Nutrition” being administered.  

 

Step 25 – Display The New Jersey Declarant’s Cardiopulmonary And Airway Management Directives

The first area of Section D, titled “Cardiopulmonary Resuscitation (CPR)” requests any personal beliefs regarding a CPR response be documented. If the New Jersey Declarant will authorize CPR administered as a response to being discovered in cardiac arrest, then select the “Attempt Resuscitation/CPR” box If the New Jersey Declarant intends to deny Medical Staff of the authorization needed to attempt resuscitation through CPR methods when his or her heart has stopped beating and his or her lungs have ceased functioning, then select the checkbox labeled “Do Not Attempt Resuscitation/DBAR Allow Natural Death. 

 

Step 26 – Present The Declarant Directives For Airway Management

Section D also requests that a record of the New Jersey Declarant’s instructions for “Airway Management” is presented. In this case, the New Jersey Declarant will have been found unable to breathe. If he or she approves of being treated through any means necessary, then select the checkbox labeled “Intubate/Use Artificial Ventilation As Needed” If the New Jersey Declarant has indicated that he or she does not approve of intubation, then select the checkbox labeled “Do Not Intubate…” This still allows Responders to administer O2 (oxygen from a tank) and apply manual treatment as needed.  The third checkbox should be elected under “Airway Management” if the New Jersey Declarant has an “Additional Order” that should be recorded on the blank line provided. 

Step 27 – Report The Level Of Authority Over The POLST Carried By A Concerned Health Care Agent/Surrogate

Section E requests clarification as to the New Jersey Declarant’s Attorney-in-Fact. If he or she approves of this entity or a Court Surrogate’s ability to fill this form out with a doctor in his or her name, then mark the “Yes” box in this area. 

If the New Jersey Declarant will not authorize his or her Health Care Attorney-in-Fact execution of this form in his or her name, then select the “No” box in Section E.

 

Step 28 – Record The Organ Donor Status Of The New Jersey Principal

Before proceeding to the “Signatures” area in Section F, locate the question “Has The Person Named Above Made An Anatomical Gift.” If so, then select the box labeled “Yes.” If not or if this is not known, then select either the “No” checkbox or the “Unknown” checkbox as required.  Notice, in the example provided that the New Jersey Declarant has marked “Yes” because he or she is a registered Organ Donor.

Step 29 – Obtain The Authorizing Signature To Execute The New Jersey Declarant’s POLST Directives

The New Jersey Declarant must sign this document after it has been discussed with the attending New Jersey Physician, APN, or PA. The “Signatures” section on the left side of Section F, requires that the New Jersey Declarant print his or her name on the “Name” line., while the attending New Jersey Medical Professional must print his or her name on the “Print – Physician/APN/PA Name” line as well as supply his or her office number.   Next, the New Jersey Declarant must sign the “Signature” line on the left below his or her printed name leaving the line labeled “Physician/APN/PA Signature (Mandatory) line on the right must be signed by the attending New Jersey Medical Professional. This Party must also supply the date and time when he or she signed this document on the “Date/Time” area of this line. The attending New Jersey Medical Professional must print his or her name on the “Print – Physician/APN/PA Name” line (located near the bottom right), as well as supply his or her office number since this form, may require that he or she contacted in the future regarding its content. Once the Physician, Advance Practice Nurse or Registered Nurse has printed his or her name and supplied the Practice or Facility phone number where he or she can be reached, the next line, divided by the labels “Physician/APRN/PA Signature (Mandatory)” and “Date/Time,” seeks the New Jersey Medical Professional’s signature produced above the first label and his or her signature date and time above the latter. Only the New Jersey Medical Professional who has discussed, completed, and intends to approve the content of this form may perform this action.

 

Step 30 – Document Who The Signature Party Is To The New Jersey Patient

Lastly, one of the five checkboxes on the left must be selected to indicate if the New Jersey Declarant Signature was supplied by the “Person Named Above,” his or her “Health Care Representative/Legal Guardian, his or her “Spouse/Civil Union Partner,” the “Parent of Minor” with the Minor being the Declarant, or the some “Other Surrogate.” The final blank line on the right must display the New Jersey Medical “Professional License Number” of the approving Health Care Provider.   

 

Step 31 – Discuss The New Jersey Declarant’s Health Care Surrogate

The final topic is the New Jersey Health Care Surrogate that may have been identified earlier in the POLST. If this Party has been named in the New Jersey Power Of Attorney then select the “Yes” box in the “Surrogate Information” section or select the “No” box to indicate this is a different person from that named earlier or on an earlier power appointment. The third checkbox (“Unknown”) may be selected if this information is not available. In the example below, the New Jersey Decalarant’s Surrogate is the same person as his or her previously identified New Jersey Health Care Agent (or Attorney-in-Fact) so the “Yes” box has been selected, his or her name has been presented on the “Print Name Of Surrogate” line exactly as it appears on the concerned power document, and his or her contact “Phone Number” has been documented.
The full address of the New Jersey Declarant’s Surrogate should be placed on display directly below his or her reported name as requested by the label displayed.

 

 

 

 

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