AND WRITTEN DIRECTIVE
PROXY AND DIRECTIVE WITH RESPECT TO
FOR USE IN TEXAS
1. Appointment of Agent: In recognition of the fact that there may come a time when I will become unable to make my own health care decisions because of illness, injury or other circumstances, I hereby appoint
Name of Agent: ___________________________________ Address: _________________________________________ _________________________________________ Telephone: Day _________________ Evening _________
as my health care agent to make any and all health care decisions for me, consistent with my wishes as set forth in this directive, and subject to any specific requirements and limitations of applicable law.
If the person named above is unable, unwilling or unavailable to act as my agent, I hereby appoint
Name of Alternate Attorney-in-fact: ______________ Address: _________________________________________ _________________________________________ Telephone: Day _________________ Evening _________
to serve in such capacity.
This appointment shall take effect in the event I become unable, because of illness, injury or other circumstances, to make my own health care decisions. The authority of my agent shall begin when my attending physician certifies in writing, and files the certification in my medical record, that, based in my physician's medical judgement, I lack the capacity to make such decisions.
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 be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition. By way of example, and 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 or non-performance of cardio-pulmonary resuscitation if I suffer cardiac or respiratory arrest; the initiation or discontinuance of any particular course of medical treatment or other form of life-support maintenance, including tube-delivered nutrition and hydration; and the method and timing of determination of death.
3. Ascertaining the Requirements of Jewish Law: In order to effectuate my wishes, if any question arises as to the requirements of Jewish law and custom in connection with this declaration, I direct my agent to consult with and follow the guidance of the following Orthodox Rabbi:
Name of Rabbi: ___________________________________ Address: _________________________________________ _________________________________________ Telephone: Day _________________ Evening _________
If such rabbi is unable, unwilling or unavailable to provide such consultation and guidance, then I direct my agent to consult with and follow the guidance of an Orthodox Rabbi referred by the following Orthodox Jewish institution or organization:
Name of Institution/Organization: ________________ Address: _________________________________________ _________________________________________ Telephone: Day _________________ Evening _________
If such institution or organization is unable, unwilling or unavailable to make such a reference, or if the rabbi referred by such institution or organization is unable, unwilling or unavailable to provide such guidance, then I direct my health care decision-maker to consult with and follow the guidance of an Orthodox Rabbi whose guidance on issues of Jewish law and custom my health care decision-maker 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 agent, 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 agent has not acted in good faith in accordance with my wishes as expressed in this directive.
If the persons designated in paragraph 1 above as my agent and alternate agent 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 paragraph 3 above if any questions of Jewish law and custom should arise.
Pending contact with the agent and/or 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. 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. By way of example, and without limiting in any way the generality of the foregoing, it is my wish that there be conformance with Jewish law and custom with respect to such matters and questions as whether there exist exceptional circumstances that would permit an exception to the general prohibition under Jewish law against the performance of an autopsy or dissection of my body; the permissibility or non-permissibility of the removal and usage of any of my body organs or tissue for transplantation purposes; and the expeditious burial of my body and all preparations leading to burial.
Time is of the essence with regard to these questions. I therefore direct that any health care provider in attendance at my death notify the agent and/or 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, it is my desire, and I hereby direct, that no autopsy, dissection or other post-mortem procedure be performed on my body.
6. Incontrovertible Evidence of My Wishes: If, for any reason, this document is deemed not legally effective as a durable power of attorney for health care or a written directive with respect to health care decisions, or if the persons designated in paragraph 1 above as my agent and alternate agent 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 paragraph 3 above should be followed if any questions of Jewish law and custom should arise.
7. Severability: In the event that any provision of this directive shall be held invalid or unenforceable, it shall not in any way invalidate, affect, or impair the remaining provisions of this directive, it being my intention that this directive shall be enforced to the extent permitted by law.
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.
9. Acknowledgement of Disclosure Statement: I have been provided with a disclosure statement explaining the effect of this document. I have read and understand the information contained in the disclosure statement (see "Appendix A")
Date: ________________________ Signature: _______________________________________ Residing at ______________________________________ [address]
(Note: This document will not be valid under Tennessee law unless it is signed and acknowledged before a notary public by the principal (the person who executes the document) and two witnesses.
I declare under penalty of perjury that the person who signed this document has identified himself (or herself) to me, and that he (or she) signed or acknowledged this document in my presence. He (or she) appears to be of sound mind, and has requested that I serve as a witness to the execution of this document. He (or she) stated in my presence that he (or she) is aware of the nature of this document and signed it voluntarily and free from any duress.
I declare that I am not the agent appointed by this document, and that I am not a provider of health or residential care, an employee of a provider of health or residential care, the operator of a community care facility, or an employee of an operator of a health care facility. I am not a patient in the health care facility where the person who signed this document is a patient. I am not related to the person who signed this document by blood, marriage, or adoption and, to the best of my knowledge, I am not entitled to any part of his (or her) estate on his (or her) death under a will or by operation of law.
________________ Residing at _____________________ witness ____________________________ [address] ________________ Residing at _____________________ witness ____________________________ [address]
INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY FOR HEALTH CARE
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
Your agent's authority begins when your doctor certifies that you lack the capacity to make health care decisions.
Your agent is obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent has the same authority to make decisions about your health care as you would have had.
It is important that you discuss this document with your physician or other health care provider before you sign it to make sure that you understand the nature and range of decisions that 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. The person must be 18 years of age or older or a person under 18 years of age who has had the disabilities of minority removed. 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 has 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 the person 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 have signed copies. Your agent is not 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 as long as you are able to do so and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing your agent or your health or residential care provider orally or in writing, or by your execution of a subsequent durable power of attorney for health care. Unless you state otherwise, your appointment of a spouse dissolves on divorce.
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 may wish to designate an alternate agent in the event that your agent is unwilling, unable, or ineligible to act as your agent. Any alternate agent you designate has the same authority to make health care decisions for you.
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO OR MORE QUALIFIED WITNESSES. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:
(1) the person you have designated as your agent;
Note: The text of this document was prepared more than ten years ago. We therefore recommend you consult with a local estates and trusts attorney before executing this document to ensure that it conforms to current state law. Agudath Israel is in the process of updating the Halachic Living Wills for most states.
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Copyright © 1997-2008 by Ira Kasdan. All rights reserved.