New Jersey Living Will Template
This living will template is intended to provide individuals in the State of New Jersey with a means to express their wishes regarding medical treatment in the event they are unable to communicate their decisions due to illness or incapacity. It has been designed in alignment with the New Jersey Advance Directives for Health Care Act.
Part 1: Personal Information
- Full Name: ___________________________________________________________
- Date of Birth: ________________________________________________________
- Address: _____________________________________________________________
- City: _________________________ State: NJ Zip Code: ____________________
- Phone Number: ________________________________________________________
- Email Address: ________________________________________________________
Part 2: Declaration of Health Care Wishes
I, __________________________________ [insert your name], being of sound mind, hereby direct that my health care providers and family members should follow the instructions below concerning my health care. These instructions are meant to apply if I am unable to make my own health care decisions.
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Life-Sustaining Treatment: I direct that life-sustaining treatment, including CPR, mechanical ventilation, artificial nutrition, and hydration, be:
- Administered in all circumstances.
- Withheld or withdrawn if (specify conditions): ___________________________________
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Pain Relief: Even if it may hasten my death, I wish to receive treatment to relieve pain and suffering.
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Other Wishes: (Here you may include other specific wishes such as refusal of certain treatments in specific circumstances, preferences about organ donation, funeral arrangements, and whom you prefer to make decisions for you if you are unable to do so yourself.)
- ______________________________________________________________________
- ______________________________________________________________________
Part 3: Signature and Witness
To ensure that this living will is recognized and respected, please sign below in the presence of two witnesses. The witnesses should not be individuals who you have appointed as your health care representative or alternative representative, nor should they be your health care providers or employees of your health care providers.
- Your Signature: __________________________________ Date: ________________
- Witness 1 Signature: ______________________________ Date: ________________
- Witness 2 Signature: ______________________________ Date: ________________
By signing this document, you declare that you understand the nature and significance of such a living will and that you are making these decisions freely and voluntarily.
Making decisions about your healthcare wishes in advance and putting them in writing helps ensure those wishes are respected. It also provides a clear guide to your loved ones and healthcare providers, relieving them from making these difficult decisions on your behalf without your input. This document should be reviewed periodically and updated as your preferences and circumstances change.