New Jersey Living Will Template
This Living Will is designed to be in compliance with the New Jersey Advance Directives for Health Care Act. It serves as a legal document to outline your healthcare preferences in case you become unable to make decisions for yourself.
Part 1: Information of the Declarant
Full Name: ___________________________________________________
Date of Birth: ________________________________________________
Address: _____________________________________________________
City: _________________________ State: NJ Zip Code: ____________
Phone Number: _________________________________________________
Part 2: Healthcare Directives
In the event that I become incapable of making my own healthcare decisions, I direct the following:
- Life-Sustaining Treatment: In situations where my recovery is unlikely, I choose the following option concerning life-sustaining treatment:
- To have all treatments that could extend my life, including medical and surgical procedures, despite my physical condition.
- To refuse life-sustaining treatments, allowing natural death to occur if I am in a permanent vegetative state or terminal condition.
- Pain Relief and Comfort Care: I request that pain relief and comfort care be provided to me to manage pain or discomfort, even if such treatments hasten my death.
- Artificial Nutrition and Hydration: I wish to receive/do not wish to receive artificial nutrition and hydration if the likelihood of recovery is low:
- Receive artificial nutrition and hydration.
- Do not receive artificial nutrition and hydration.
- Other Instructions: _____________________________________________ _____________________________________________________________
Part 3: Appointment of a Healthcare Proxy
I hereby designate the following individual as my Health Care Representative to make medical decisions for me if I am unable to communicate my wishes:
Name: ___________________________________________________________
Relationship: ____________________________________________________
Address: ________________________________________________________
City: _________________________ State: NJ Zip Code: _______________
losing the capacity to make healthcare decisions.
Part 4: Optional Organ Donation
I wish to donate only the following organs/tissues for transplant or research (specify): ______________________________________________
OR
I wish to donate any needed organs/tissues for transplant or research.
Part 5: Execution
This declaration reflects my firm and settled commitment to refuse medical treatment aimed at prolonging my life in the circumstances described above. I understand that my healthcare provider and appointed Health Care Representative are legally bound to act in accordance with my wishes as stated in this Living Will.
Date: ___________________________
Declarant's Signature: __________________________________________
Witness 1 Signature: ____________________________________________
Witness 1 Name (Printed): ________________________________________
Witness 2 Signature: ____________________________________________
Witness 2 Name (Printed): _______________________________________
This document must be signed in the presence of two adult witnesses, neither of whom is designated as the Health Care Representative. The witnesses confirm that the declarant appears of sound mind and not under duress at the time of signing.