New Jersey Living Will
This Living Will serves as a legal document expressing your healthcare preferences in accordance with New Jersey state laws. It outlines your wishes regarding medical treatment in the event that you become unable to communicate your decisions.
Instructions: Please fill out the following information as indicated.
- Full Name: ______________________________
- Address: ______________________________
- City: ______________________________
- State: ______________________________
- Zip Code: ______________________________
- Date of Birth: ______________________________
Statement of Wishes: This is my Living Will. I direct my healthcare providers to follow my wishes as detailed below:
If I become unable to make my own healthcare decisions, I wish to state the following:
- 1. I do not wish to receive life-sustaining treatment if my condition is terminal and I cannot communicate effectively.
- 2. I prefer to receive comfort care and palliative treatment to alleviate pain.
- 3. If I am in a persistent vegetative state, I do not wish to receive any life-prolonging measures.
- 4. I authorize my healthcare agent to make decisions on my behalf concerning my medical treatment.
Signature: ______________________________
Date: ______________________________
Witnesses: This section must be completed by two adult witnesses who are not related to you and who will not inherit from you.
- Witness 1 Name: ______________________________
- Witness 1 Signature: ______________________________
- Date: ______________________________
- Witness 2 Name: ______________________________
- Witness 2 Signature: ______________________________
- Date: ______________________________
This Living Will takes effect when I am unable to communicate my wishes regarding medical treatment. I understand that I can revoke this document at any time, as long as I am competent to do so.