WITH RESPECT TO HEALTH CARE DECISIONS
AND POST-MORTEM DECISIONS
FOR USE IN THE STATE OF LOUISIANA
(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.
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.
(e) Two witnesses should sign their names and insert their addresses beneath your signature. These two witnesses must be competent adults. Neither of them may be your relative by blood or marriage or a person who would be entitled to any portion of your estate upon your death.
In addition, you should acknowledge the form before a notary public (see notary statement at the end of the form).
(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.
Note: It is your responsibility to notify your attending physician of the existence of this document.
(g) If at any time you wish to revoke this Declaration/Durable Power of Attorney, you may do so by destroying or defacing the document; by a written revocation which you sign and date; or, if you are unable to write, by an oral or nonverbal expression of such intent. Your attending physician should record the time and date of the revocation in your medical records.
If you do not revoke the Declaration/Durable Power of Attorney, it will remain in effect indefinitely. Obviously, if any of the persons whose names you have inserted in the Declaration/ Durable Power of Attorney dies or becomes otherwise incapable of serving in the role you have assigned, it would be wise to execute a new Declaration/Durable Power of Attorney.
(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.
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Copyright © 1997-2008 by Ira Kasdan. All rights reserved.