SAMPLE ADVANCE DIRECTIVE WITH RESPECT TO HEALTH-CARE AND POST-MORTEM DECISIONS
1. Designation of Health Care Surrogate
Your Name: (Last) ______________ (First) ___________ (Middle Initial) ___
In the event that I have been determined to be incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care decisions:
Name of Surrogate: (Last) _______________ (First) _____________________
I fully understand that this designation will permit my designee to make health care decisions, except for anatomical gifts, unless I have executed an anatomical gift declaration pursuant to law, and to provide, withhold, or withdraw consent on my behalf; to apply for public benefits to defray the cost of health care; and to authorize my admission to or transfer from a health care facility. I further affirm that this designation is not being made as a condition of treatment or admission to a health care facility.
2. Jewish Law to Govern Health Care Decisions:
I am Jewish. It is my desire, and I hereby direct, that all health care decisions made for me (whether made by my surrogate, a guardian appointed for me, or any other person) be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition. Without limiting in any way the generality of the foregoing, it is my wish that Jewish law and custom should dictate the course of my health care with respect to such matters as the performance of cardiopulmonary resuscitation if I suffer cardiac or respiratory arrest; the performance of life-sustaining surgical procedures and the initiation or maintenance of any particular course of life-sustaining medical treatment or other form of life-support maintenance, including the provision of nutrition and hydration; and the criteria by which death shall be determined, including the method by which such criteria shall be medically ascertained or confirmed.
3. Ascertaining the Requirements of Jewish Law:
In determining the requirements of Jewish law and custom in connection with this declaration, I direct my surrogate to consult with the following Orthodox Rabbi and I ask my surrogate to follow his guidance:
Name of Rabbi: (Last) _________________ (First) _______________________
If such Rabbi is unable, unwilling or unavailable to provide such consultation and guidance, then I direct my surrogate to consult with, and I ask my surrogate to follow the guidance of, an Orthodox Rabbi referred by the following Orthodox Jewish institution or organization:
Name of Institution/Organization: ___________________________________
If such institution or organization is unable, unwilling or unavailable to make such a reference, or if the Orthodox Rabbi referred by such institution or organization is unable, unwilling or unavailable to provide such guidance, then I direct my surrogate to consult with, and I ask my surrogate to follow the guidance of, an Orthodox Rabbi whose guidance on issues of Jewish law and custom my surrogate in good faith believes I would respect and follow.
4. Direction to Health Care Providers:
Any health care provider shall rely upon and carry out the decisions of my surrogate, and may assume that such decisions reflect my wishes and were arrived at in accordance with the procedures set forth in this directive, unless such health care provider shall have good cause to believe that my surrogate has not acted in good faith in accordance with my wishes as expressed in this directive. If the persons designated above as my surrogate and alternate surrogate are unable, unwilling or unavailable to serve in such capacity, it is my desire, and I hereby direct, that any health care provider or other person who will be making health care decisions on my behalf follow the procedures outlined in section three (3) above in determining the requirements of Jewish law and custom. Pending contact with the surrogate and/or Orthodox Rabbi described above, it is my desire, and I hereby direct, that all health care providers undertake all essential emergency and/or life sustaining measures on my behalf.
5. Access to Medical Records and Information; HIPAA:
I direct that all of my protected health information (as such term is defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA" )) and other medical records shall be made available to my surrogate upon request in the same manner as such information and records would be released and disclosed to me, and my surrogate shall have and may exercise all of the rights I would have regarding the use and disclosure of such information and records. In the event that the authority of my surrogate has not yet been established, I authorize each of my health care providers to release and disclose all my protected health information and other medical records to the individual nominated hereunder as my surrogate for the purpose of determining my capacity to make my own health care decisions, including, without limitation, the issuance and release of any written opinion relating to my capacity that such person may have requested. The foregoing direction and authorization shall supersede any prior agreement that I may have made with any of my health care providers to restrict access to or disclosure of my protected health information or other medical records, and shall expire with respect to any health care provider upon being revoked by me in a writing delivered to such health care provider.
6. Post-Mortem Decisions:
It is also my desire, and I hereby direct, that after my death, all decisions concerning the handling and disposition of my body be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition. For example, Jewish law generally requires expeditious burial and imposes special requirements with regard to the preparation of the body for burial. It is my wish that Jewish law and custom be followed with respect to these matters. Further, subject to certain limited exceptions, Jewish law prohibits the performance of any autopsy or dissection. It is my wish that Jewish law and custom be followed with respect to such procedures, and with respect to all other post -mortem matters including the removal and usage of any of my body organs or tissue for transplantation or any other purposes. I direct that any health care provider in attendance at my death notify the surrogate and/or Orthodox Rabbi described above immediately upon my death, in addition to any other person whose consent by law must be solicited and obtained, prior to the use of any part of my body as an anatomical gift, so that appropriate decisions and arrangements can be made in accordance with my wishes. Pending such notification, and unless there is specific authorization by the Orthodox Rabbi consulted in accordance with the procedures outlined in section three (3) above, it is my desire, and I hereby direct, that no post-mortem procedure be performed on my body. I further affirm that this designation is not being made as a condition of treatment or admission to a health care facility.
7. Incontrovertible Evidence of My Wishes:
If, for any reason, this document is deemed not legally effective as a health care proxy, or if the persons designated in section one (1) above as my surrogate and alternate surrogate are unable, unwilling or unavailable to serve in such capacity, I declare to my family, my doctor and anyone else whom it may concern that the wishes I have expressed herein with regard to compliance with Jewish law and custom should be treated as incontrovertible evidence of my intent and desire with respect to all health care measures and post-mortem procedures; and that it is my wish that the procedure outlined in section three (3) above should be followed in determining the requirements of Jewish law and custom.
8. Duration and Revocation:
It is my understanding and intention that unless I revoke this proxy and directive, it will remain in effect indefinitely. My signature on this document shall be deemed to constitute a revocation of any prior health care proxy, directive or other similar document I may have executed prior to today's date.
My Signature: ________________ Print Name: ______________ Date: ______