New Jersey Instruction Directive Template printable pdf download

NEW JERSEY INSTRUCTION DIRECTIVE

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 decisions. In these

circumstances, those caring for me will need direction concerning my care and they will require information about

my values and health care wishes. In order to provide the guidance and authority needed to make decisions on

my behalf:

A) I, _________________________________, hereby declare and make known to my family, physician, and

others, my instructions and wishes for my future health care.

I direct that all health care decisions, including

decisions to accept or refuse any treatment, service or procedure used to diagnose, treat or care for my physical or

mental condition and decisions to provide, withhold or withdraw life-sustaining measures, be made in accordance

with my wishes as expressed in this document. This instruction directive 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. I direct that this document become part of my permanent

medical records.

Part One: Statement of My Wishes Concerning My Future Health Care

In Part One, you are asked to provide instructions concerning your future health care. This will require making

important and perhaps difficult choices. Before completing your directive, you should discuss these matters with

your doctor, family members or others who may become responsible for your care.

In Section B and C, you may state the circumstances in which various forms of medical treatment, including life-

sustaining measures, should be provided, withheld or discontinued. If the options and choices below do not fully

express your wishes, you should use Section D, and/or attach a statement to this document which would provide

those responsible for your care with additional information you think would help them in making decisions about

your medical treatment.

Please familiarize yourself with all sections of Part One before completing your

directive.

B) GENERAL INSTRUCTIONS: To inform those responsible for my care of my specific wishes, I make the

following statement of personal views regarding my health care:

Initial ONE of the following two statements with which you agree:

_____ I direct that all medically appropriate measures be provided to sustain my life, regardless

of my physical or mental condition

2. _

____ There are circumstances in which I would not want my life to be prolonged by further

medical treatment. In these circumstances, life-sustaining measures should not be initiated and if

they have been, they should be discontinued. I recognize that this is likely to hasten my death.

In the following, I specify the circumstances in which I would choose to forego life-sustaining

measures.

If you have initialed statement 2 on page 1, please initial each of the statements (a, b, c) with which you

agree:

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New Jersey Instruction Directive Template