The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care
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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 ______________________________ 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.
The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care
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(If you have any additional specific instructions concerning your care you may use the space below or attach an
additional statement.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
D) COPIES: The original or a copy of this document has been given to my health care representative and to the
following:
1. name ___________________________________
address _________________________________
city ________________________ state _______ telephone __________________________
2. name ___________________________________
address _________________________________
city ________________________ state _______ telephone __________________________
E) SIGNATURE: By writing this durable power of attorney for health care, I inform those who may become
entrusted with my care of my health care wishes and intend to ease the burdens of decision making which this
responsibility may impose. I have discussed the terms of this designation with my health care representative and
he or she has willingly agreed to accept the responsibility for acting on my behalf in accordance with my wishes
as expressed in this document. I understand the purpose and effect of this document and sign it knowingly,
voluntarily and after careful deliberation.
Signed this _____________ day of ______________, 20______.
signature _____________________________________________
address ______________________________________________
city ____________________________________ state_________
F) WITNESSES: I declare that the person who signed this document, or asked another to sign this document on
his or her behalf, did so in my presence, that he or she is personally known to me, and that he or she appears to be
of sound mind and free of duress or undue influence. I am 18 years of age or older, and am not designated by this
or any other document as the person’s health care representative, nor as an alternate health care representative.
1. witness____________________________________ 2. witness _______________________________
address ___________________________________ address ______________________________
city _______________________ state __________ city ____________________ state _________
signature _________________________________ signature _____________________________
date ______________________________________ date _________________________________
