Advance Directives

Reproduction and distribution by an organization or organized group without the written permission of the National

Hospice and Palliative Care Organization is expressly forbidden.

NEW JERSEY

Advance Directive

Planning for Important Healthcare Decisions

Courtesy of CaringInfo

www.caringinfo.org

800-658-8898

CaringInfo, a program of the National Hospice and Palliative Care Organization (NHPCO), is a

national consumer engagement initiative to improve care and the experience of caregiving

during serious illness and at the end of life. As part of that effort, CaringInfo provides detailed

guidance for completing advance directive forms in all 50 states, the District of Columbia, and

Puerto Rico.

This package includes:

• Instructions for preparing your advance directive. Please read all the instructions.

• Your state-specific advance directive forms, which are the pages with the gray

instruction bar on the left side.

BEFORE YOU BEGIN

Check to be sure that you have the materials for each state in which you may receive

healthcare. Because documents are state-specific, having a state-specific document for each

state where you may spend significant time can be beneficial. A new advance directive is not

necessary for ordinary travel into other states. The advance directives in this package will be

legally binding only if the person completing them is a competent adult who is 18 years of age

or older, or an emancipated minor.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so you will

have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide you

through the process.

3. Talk with your family, friends, and physicians about your advance directive. Be sure the

person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy, scan, or take a photo of the form and

give it to the person you have appointed to make decisions on your behalf, your family,

friends, healthcare providers, and/or faith leaders so that the form is available in the event

of an emergency.

5. You may also want to save a copy of your form in your electronic healthcare record, or an

online personal health records application, program, or service that allows you to share your

medical documents with your physicians, family, and others who you want to take an active

role in your advance care planning.

INTRODUCTION TO YOUR NEW JERSEY ADVANCE HEALTH CARE DIRECTIVE

This packet contains a legal document, a New Jersey Advance Directive, that protects your

right to refuse medical treatment you do not want, or to request treatment you do want, in the

event you lose the ability to make decisions yourself.

Part I is the New Jersey Proxy Declaration. This part lets you name an adult, called your

health care representative, or representative, to make decisions about your health care—

including decisions about life-sustaining treatments—if you can no longer speak for yourself.

Part II is a New Jersey Instruction Declaration, which is your state’s living will. Part II lets

you state your wishes regarding health care decisions in the event that you can no longer make

your own.

Part III contains the signature and witnessing provisions so that your document will be

effective.

You may fill out Part I, Part II, or both, depending on your advance planning needs. You must

complete Part III.

How do I make my New Jersey Advance Health Care Directive legal?

You must sign and date your document, or direct another to sign and date it:

1. in the presence of two witnesses who must be at least 18 years of age. These witnesses

must also sign the document to show that they believe you to be of sound mind, that you

voluntarily signed the document, and that they are not your appointed health care

representative or alternate health care representative;

2. before a notary public, an attorney at law, or another person authorized to administer oaths.

Whom should I appoint as my agent?

Your agent is the person you appoint to make decisions about your healthcare if you become

unable to make those decisions yourself. Your agent may be a family member or a close friend

whom you trust to make serious decisions. The person you name as your agent should clearly

understand your wishes and be willing to accept the responsibility of making healthcare

decisions for you.

You cannot appoint an operator, administrator, or employee of your treating healthcare

institution, unless he or she is related to you by blood, marriage, domestic partnership, or

adoption. However, you can appoint a physician so long as he or she is not serving as your

attending physician at the same time.

You can appoint a second person as your alternate agent. An alternate agent will step in if the

person you name as agent is unable, unwilling, or unavailable to act for you.

Should I add personal instructions to my advance directive?

Yes! One of the most important reasons to execute an advance directive is to have your voice

heard. When you name an agent and clearly communicate to them what you want and don’t

want, they are in the strongest position to advocate for you. Because the future is

unpredictable, be careful that you do not unintentionally restrict your agent’s power to act in

your best interest. Be especially careful with the words “always” and “never.” In any event, be

sure to talk with your agent and others about your future healthcare and describe what you

consider to be an acceptable “quality of life.”

When does my agent’s authority become effective?

Your advance directive goes into effect when your doctor and one other doctor determine in

writing that you are no longer able to understand and appreciate the nature and consequences

of your healthcare decisions and you are no longer able to reach an informed healthcare

decision.

Agent Limitations

If you are female, you may include instructions specific to your pregnancy in the event that you are

pregnant when your Advance Directive goes into effect; however, your agent will be bound by

the current laws of

New Jersey

as they regard pregnancy and termination of pregnancies.

What if I change my mind?

You may revoke your Advance Directive, or any part of it, at any time by:

• Announcing your revocation either orally or in writing to your healthcare representative,

your doctor or other healthcare provider, or a reliable witness,

• Performing any other act that demonstrates your intent to revoke the document, or

• Executing a subsequent Advance Directive.

If you designate your spouse as your representative, his or her authority is automatically

revoked upon divorce or legal separation, unless you specify otherwise in the “further

instructions” section of the Advance Directive. If you designate your domestic partner, his or her

authority is automatically revoked upon termination of your domestic partnership, unless

otherwise specified in the “further instructions” section of the Advance Directive.

Mental Health Issues

These forms do not

expressly

address mental illness, although you can state your wishes and

grant authority to your agent regarding mental health issues. The National Resource Center on

Psychiatric Advance Directives maintains a website (https://nrc-pad.org/) with links to each

state’s psychiatric advance directive forms. If you would like to make more detailed advance

care plans regarding mental illness, you could talk to your physician and an attorney about a

durable power of attorney tailored to your needs.

What other important facts should I know?

Be aware that your advance directive will not be effective in the event of a medical emergency,

except to identify your agent. Ambulance and hospital emergency department personnel are

required to provide cardiopulmonary resuscitation (CPR) unless you have a separate physician’s

order, which are typically called “prehospital medical care directives” or “do not resuscitate

orders.” DNR forms may be obtained from your state health department or department of aging

(https://www.hhs.gov/aging/state-resources/index.html). Another form of orders regarding CPR

and other treatments are state-specific POLST (portable orders for life sustaining treatment)

(https://polst.org/form-patients/). Both a POLST and a DNR form MUST be signed by a

healthcare provider and MUST be presented to the emergency responders when they arrive.

These directives instruct ambulance and hospital emergency personnel not to attempt CPR (or

to stop it if it has begun) if your heart or breathing should stop.

NEW JERSEY ADVANCE DIRECTIVE – PAGE 1 OF 10

PART I: PROXY DIRECTIVE

I, , hereby appoint:

(your name)

(name of health care representative)

(address of health care representative)

(home phone number)

(work phone number)

to be 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

treatment. I direct my health care 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 or if

a situation arises that I did not anticipate, my health care representative

is authorized to make decisions in my best interests.

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 following order

of priority:

1. Name

Address

City State

Telephone

PART I

PRINT YOUR NAME

PRINT THE NAME,

ADDRESS AND

HOME AND WORK

TELEPHONE

NUMBERS OF YOUR

HEALTH CARE

REPRESENTATIVE

PRINT THE NAME,

ADDRESS, AND

TELEPHONE

NUMBER OF YOUR

FIRST ALTERNATE

HEALTH CARE

REPRESENTATIVE

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NEW JERSEY ADVANCE DIRECTIVE - PAGE 2 OF 10

2. Name

Address

City State

Telephone

I direct that my health care representative comply with the following

instructions and/or limitations (optional):

(use additional pages if necessary)

I direct that my health care representative comply with the following

instructions in the event that I am pregnant when this Directive

becomes effective (optional):

(use additional pages if necessary)

PRINT THE NAME,

ADDRESS AND

TELEPHONE

NUMBER OF

YOUR SECOND

ALTERNATE

HEALTH CARE

REPRESENTATIVE

ADD ADDITIONAL

INSTRUCTIONS,

IF ANY

ADD

INSTRUCTIONS, IF

ANY, TO BE

FOLLOWED IN THE

EVENT YOU

ARE PREGNANT

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NEW JERSEY ADVANCE DIRECTIVE – PAGE 3 OF 10

PART II. INSTRUCTION DIRECTIVE

In Part II, 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 health care representative, doctor and family

members or others who may become responsible for your care.

In the sections below, 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 the “Further

Instructions” section below, 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 II before completing your directive.

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:

1. _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 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 the following page please

initial each of the statements (a, b, c) with which you agree:

PART II

INITIAL ONLY ONE

IF YOU INITIAL

STATEMENT 2, YOU

MUST SPECIFY

WHEN YOU WOULD

LIKE TO FOREGO

LIFE-SUSTAINING

MEASURES ON THE

FOLLOWING PAGES

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NEW JERSEY ADVANCE DIRECTIVE - PAGE 4 OF 10

a. I realize that there may come a time when I am diagnosed as

having an incurable and irreversible illness, disease, or condition. If this

occurs, and my attending physician and at least one additional physician

who has personally examined me determine that my condition is terminal,

I direct that life-sustaining measures which would serve only to artificially

prolong my dying be withheld or discontinued. I also direct that I be given

all medically appropriate care necessary to make me comfortable and

relieve pain. To me, terminal condition means that my physicians have

determined that:

I will die within a few days, or

I will die within a few weeks, or

I have a life expectancy of approximately or

less (enter 6 months or 1 year)

b. If there should come a time when I become permanently

unconscious, and it is determined by my attending physician and at least

one additional physician with appropriate expertise who has personally

examined me, that I have totally and irreversibly lost consciousness and

my capacity for interaction with other people and my surroundings, I

direct that life-sustaining measures be withheld or discontinued. I

understand that I will not experience pain or discomfort in this condition,

and I direct that I be given all medically appropriate care necessary to

provide for my personal hygiene and dignity.

c. I realize that there may come a time when I am diagnosed as

having an incurable and irreversible illness, disease, or condition which

may not be terminal. My condition may cause me to experience severe

and progressive physical or mental deterioration and/or a permanent loss

of capacities and faculties I value highly. If, in the course of my medical

care, the burdens of continued life with treatment become greater that

the benefits I experience, I direct that life-sustaining measures be

withheld or discontinued. I also direct that I be given all medically

appropriate care necessary to make me comfortable and to relieve pain.

(Paragraph c. covers a wide range of possible situations in which you may

have experienced partial or complete loss of certain mental or physical

capacities you value highly. If you wish, in the space provided below you

may specify in more detail the conditions in which you would choose to

forego life-sustaining measures. You might include a description of the

faculties or capacities, which, if irretrievably lost would lead you to accept

death rather than continue living. You may want to express any special

concerns you have about particular medical conditions or treatments, or

any other considerations, which would provide further guidance to those

INITIAL EACH

LETTERED

STATEMENT (A, B,

AND/OR C) THAT

REPRESENTS WHEN

YOU WOULD LIKE

TO FOREGO LIFE-

SUSTAINING

MEASURES

IF YOU INITIALED

STATEMENT A,

INDICATE WHAT

YOU CONSIDER TO

BE A TERMINAL

CONDITION THAT

WILL JUSTIFY THE

WITHHOLDING OR

DISCONTINUING OF

LIFE-SUSTAINING

MEASURES

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NEW JERSEY ADVANCE DIRECTIVE - PAGE 5 OF 10

who may become responsible for your care. If necessary, you may attach

a separate statement to this document or provide your wishes in the

“Further Instructions” section, below.)

Examples of conditions that I find unacceptable are:

Specific Instructions: Artificially Provided Fluids and Nutrition;

Cardiopulmonary Resuscitation (CPR).

On page 4, above, you provided general instructions regarding life-

sustaining measures. Here you are asked to give specific instructions

regarding two types of life-sustaining measures—artificially provided fluids

and nutrition and cardiopulmonary resuscitation.

In the space provided, initial the phrase with which you agree:

1. In the circumstances I initialed on page 4, I also direct that artificially

provided fluids and nutrition, such as feeding tube or intravenous infusion,

be withheld or withdrawn and that I be

allowed to die, or

be provided to the extent medically

appropriate.

2. In the circumstances I initialed on page 4, if I should suffer a cardiac

arrest, I also direct that cardiopulmonary resuscitation (CPR)

not be provided and that I be allowed to die,

be provided to preserve my life, unless

medically inappropriate or futile.

3. If neither of the above statements adequately expresses your wishes

concerning artificially provided fluids and nutrition or CPR, please explain

your wishes below.

IF YOU INITIALED

STATEMENT C,

ABOVE, YOU MAY

LIST CONDITIONS

THAT YOU FIND

UNNACCEPTABLE

AND WOULD

JUSTIFY THE

WITHHOLDING OR

DISCONTINUING OF

LIFE-SUSTAINING

MEASURES

INITIAL YOUR

PREFERENCE

REGARDING

ARTIFICIALLY

PROVIDED FLUIDS

AND NUTRITION

(FOOD AND DRINK)

INITIAL YOUR

PREFERENCE

REGARDING CPR

YOU MAY ADD

FURTHER

INSTRUCTIONS

REGARDING

ARTIFICIALLY

PROVIDED FLUIDS

AND NUTRITION OR

CPR HERE

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Palliative Care

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NEW JERSEY ADVANCE DIRECTIVE - PAGE 6 OF 10

BRAIN DEATH:

The State of New Jersey has determined that an individual may be

declared legally dead when there has been an irreversible cessation of

all functions of the entire brain, including the brain stem (also known as

whole brain death). However, individuals who do not accept this

definition of brain death because of their personal religious beliefs may

request that it not be applied in determining their death.

Initial the following statement only if it applies to you:

To declare my death on the basis of the whole brain death

standard would violate my personal religious beliefs. I therefore wish my

death to be declared only when my heartbeat and breathing have

irreversibly stopped.

ORGAN DONATION (OPTIONAL)

(It is now possible to transplant human organs and tissue in order to

save and improve the lives of others. Organs, tissues, and other body

parts are also used for therapy, medical research and education. This

section allows you to indicate your desire to make an anatomical gift

and if so, to provide instructions for any limitations or special uses.)

I do not want to make an organ or tissue donation and I do not

want my representative or family to do so.

Upon my death, I wish to donate:

My body for anatomical study if needed.

Any needed organs, tissues, or eyes.

Only the following organs, tissues, or eyes:

I authorize the use of my organs, tissues, or eyes:

For transplantation

For therapy

For research

For medical education

For any purpose authorized by law.

INITIAL HERE IF

YOU HAVE AN

OBJECTION TO

NEW JERSEY’S

BRAIN DEATH

DEFINITION

ORGAN DONATION

(OPTIONAL)

INITIAL THE

STATEMENT THAT

BEST REFLECTS

YOUR WISHES

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NEW JERSEY ADVANCE DIRECTIVE - PAGE 7 OF 10

FURTHER INSTRUCTIONS:

ADD OTHER

INSTRUCTIONS, IF

ANY, REGARDING

YOUR ADVANCE

CARE PLANS

THESE

INSTRUCTIONS CAN

FURTHER ADDRESS

YOUR HEALTH CARE

PLANS, SUCH AS

YOUR WISHES

REGARDING

HOSPICE

TREATMENT, BUT

CAN ALSO ADDRESS

OTHER ADVANCE

PLANNING ISSUES,

SUCH AS YOUR

BURIAL WISHES

ATTACH

ADDITIONAL PAGES

IF NEEDED

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NEW JERSEY ADVANCE DIRECTIVE - PAGE 8 OF 10

PART III: EXECUTION

This advance directive will not be valid unless it is EITHER:

Signed in the presence of two witnesses who must be at least 18 years

of age. These witnesses must also sign the document to show that they

believe you to be of sound mind, that you voluntarily signed the

document, and that they are not your appointed health care

representative or alternate health care representative (use Alternative

No. 1 if you plan to sign before witnesses);

Signed before a notary public, an attorney at law, or another person

authorized to administer oaths (use Alternative No. 2 if you plan to have

your signature notarized).

PART III

USE ALTERNATIVE

NO. 1 IF YOU PLAN

TO SIGN BEFORE

WITNESSES (P. 9)

USE ALTERNATIVE

NO. 2 IF YOU PLAN

TO HAVE YOUR

SIGNATURE

NOTARIZED (P. 10)

Hospice and

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NEW JERSEY ADVANCE DIRECTIVE - PAGE 9 OF 10

Alternative No. 1.

By writing this advance directive, I inform those who may become

responsible for my health care of my 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(s) and my representative(s) has/have willingly agreed to

accept the responsibility for acting on my behalf in accordance with this

directive and my wishes. 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

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 and 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 or alternate

health care representative.

1. Witness

Address

City State

Signature Date

2. Witness

Address

City State

Signature Date

SIGN AND DATE

YOUR

DOCUMENT AND

PRINT YOUR

ADDRESS

YOUR WITNESSES

MUST PRINT THEIR

NAMES AND

ADDRESSES AND

SIGN AND DATE

HERE

Hospice and

Palliative Care

Organization 2023

Revised.

NEW JERSEY ADVANCE DIRECTIVE - PAGE 10 OF 10

Alternative No. 2.

By writing this advance directive, I inform those who may become

responsible for my health care of my 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(s) and my representative(s) has/have willingly agreed to

accept the responsibility for acting on my behalf in accordance with this

directive and my wishes. 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

Notary, Attorney at Law, or other person authorized to administer oaths

On , before me came

(date)

(name of declarant)

whom I know to be such person, and the declarant did then and there

execute this declaration.

Sworn before me this day of , 20 .

Signature of: (check one)

Notary Public

Attorney at Law

Courtesy of CaringInfo

www.carginfo.org

SIGN AND DATE

YOUR

DOCUMENT AND

PRINT YOUR

ADDRESS

A NOTARY

PUBLIC OR

ATTORNEY AT

LAW SHOULD

COMPLETE THIS

SECTION

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Palliative Care

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