PROXY AND DIRECTIVE WITH RESPECT TO
FOR USE IN NEW HAMPSHIRE
(a) Please print your name on the first line of the form.
(b) In section 1, print the name, address, and day and evening telephone numbers of the person you wish to designate as your agent to make medical decisions on your behalf if, G-d forbid, you ever become incapable of making them on your own.
You may also insert the name, address, and telephone numbers of an alternate agent to make such decisions if your main agent is unable, unwilling, or unavailable to make such decisions.
Under New Hampshire law, you may not designate your health care or residential care provider (or an employee of the provider) as your agent or alternate agent.
It is recommended that before appointing anyone to serve as your agent or alternate agent you should ascertain that person's willingness to serve in such capacity. In addition, if you have made arrangements with a burial society (Chevra Kadisha) for the handling and disposition of your body after death, you may wish to advise your agents of such arrangements.
Note: this form is effective only if you and your agent(s) are competent adults (an adult is a person 18 years of age or older).
(c) In section 3, please print the name, address, and telephone numbers of the Orthodox rabbi whose guidance you want your agent to follow, should any questions arise as to the requirements of halacha.
You should then print the name, address, and telephone numbers of the Orthodox Jewish institution or organization you want your agent to contact for a referral to another Orthodox Rabbi if the rabbi you have identified is unable, unwilling or unavailable to provide the appropriate consultation and guidance.
You are of course free to insert the name of any Orthodox rabbi or institution/organization you would like, but before doing so it is advisable to discuss the matter with the rabbi or institution/organization to ascertain their competency and willingness to serve in such capacity.
(d) At the conclusion of the form, print the date, sign your name, and print your address. If you are not physically able to do these things, New Hampshire law allows another person to sign the form on your behalf at your direction and in your presence.
(e) Two witnesses should sign their names and insert their addresses beneath your signature. These two witnesses must be competent adults. Neither of them should be your agent or alternate agent, your spouse, heir, or a person entitled to any part of your estate. At least one of them may not be your health or residential care provider (or an employee of the provider).
(f) It is recommended that you keep the original of this form among your valuable papers; and that you distribute copies to the health care agent (and alternate agent) you have designated in section 1, to the rabbi and institution/organization you have designated in section 3, as well as to your doctors, your lawyer, and anyone else who is likely to be contacted in times of emergency.
(g) If at any time you wish to revoke this Proxy and Directive, you may do so by executing a new one; or by notifying your agent or health care provider, orally or in writing, of your intent to revoke it.
If you do not revoke the Proxy and Directive, it will remain in effect indefinitely. Obviously, if any of the persons whose names you have inserted in the Proxy and Directive dies or becomes otherwise incapable of serving in the role you have assigned, it would be wise to execute a new Proxy and Directive.
This document may not be changed or modified. If you want to make changes in the form you must make an entirely new one.
If your spouse is your designated agent, the Proxy and Directive will be automatically revoked if you file an action for divorce (unless you appoint an alternate agent).
(h) It is recommended that you also complete the second component of the Halachic Living Will, the "Emergency Instructions Card," and carry it with you in your wallet or billfold.
(i) If, upon consultation with your rabbi, you would like to add to this standardized Proxy and Directive any additional expression of your wishes with respect to medical and/or post-mortem decisions, you may do so by attaching a "rider" to the standardized form. If you choose to do so, or if you have any other questions concerning this form, please consult an attorney.
(j) New Hampshire law requires that before executing this document you read and sign a "disclosure statement" which contains information about the legal effects of the form and explains relevant New Hampshire law. (This statement appears immediately after these instructions.)
POWER OF ATTORNEY FOR HEALTH CARE
Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you when you are no longer capable of making them yourself. "Health care" means any treatment, service or procedure to maintain, diagnose or treat your physical or mental condition. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment. Your agent cannot consent or direct any of the following: commitment to a state institution, sterilization, or termination of treatment if you are pregnant and if the withdrawal of that treatment is deemed likely to terminate the pregnancy unless the failure to withhold the treatment will be physically harmful to you or prolong severe pain which cannot be alleviated by medication.
You may state in this document any treatment you do not desire, except as stated above, or treatment you want to be sure you receive. Your agent's authority will begin when your doctor certifies that you lack the capacity to make health care decisions. If for moral or religious reasons you do not wish to be treated by a doctor or examined by a doctor for the certification that you lack capacity, you must say so in the document and name a person to be able to certify your lack of capacity. That person may not be your agent or alternate agent or any person ineligible to be your agent. You may attach additional pages if you need more space to complete your statement.
If you want to give your agent authority to withhold or withdraw the artificial providing of nutrition and fluids, your document must say so. Otherwise, your agent will not be able to direct that. Under no conditions will our agent be able to direct the withholding of food and drink for you to eat and drink normally.
Your agent will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent will have the same authority to make decisions about your health care as you would have had if made consistent with state law.
It is important that you discuss this document with your physician or other health care providers before you sign it to make sure that you understand the nature and range of decisions which may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgeable about these issues and can answer your questions. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.
The person you appoint as agent should be someone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your physician, or an employee of a home health agency, hospital, nursing home, or residential care home, other than a relative), that person will have to choose between acting as your agent or as your health or residential care provider; the law does not permit a person to do both at the same time.
You should inform the person you appoint that you want him or her to be your health care agent. You should discuss this document with your agent and your physician and give each a signed copy . You should indicate on the document itself the people and institutions who will have signed copies. Your agent will not be liable for health care decisions made in good faith on your behalf.
Even after you have signed this document, you have the right to make health care decisions for yourself so long as you are able to do so, and treatment cannot be give to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing him or her or your health care provider orally or in writing.
This document may not be changed or modified. If you want to make changes in the document you must make an entirely new one.
You should consider designating an alternate agent in the event that your agent is unwilling, unavailable, or ineligible to act as your agent. Any alternate agent you designate will have the same authority to make health care decisions for you as your main agent.
POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO (2) OR MORE QUALIFIED WITNESSES WHO MUST BOTH BE PRESENT WHEN YOU SIGN AND ACKNOWLEDGE YOUR SIGNATURE. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:
- the person you have designated as your agent;
ONLY ONE OF THE TWO WITNESSES MAY BE YOUR HEALTH OR RESIDENTIAL CARE PROVIDER OR ONE OF THEIR EMPLOYEES.
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Copyright © 1997-2008 by Ira Kasdan. All rights reserved.