Jewish Law
Halachic Forms
    -- Halachic Living Will (Instructions for Texas)

(a) Please print your name on the first line of the form.

Note: This form is effective only if you are a competent adult (an adult is a person 18 years of age or older).

(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: Texas law allows virtually any competent adult to serve as a health care agent. Thus, you may appoint as your agent (or alternate agent) your spouse, adult child, parent or other adult relative.

You may also appoint a non-relative to serve as your agent (or alternate agent), unless that individual is your health care or residential care provider, or an employee of these people or institutions.

(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 should be:

1- the person you have appointed as your health care agent or alternate agent);
2- related to you by blood, marriage, or adoption;
3- a person entitled to any part of your estate upon your death;
4- your health or residential care provider or the provider's employee;
5- your attending physician or an employee of your attending physician; or
6- a patient in a health care facility in which you are a patient.

(f) It is recommended that you keep the original of this form among your valuable papers; and that you distribute signed 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 notifying your agent or health care provider, orally or in writing, of your intent to revoke it; by destroying it; by signing and dating a written revocation; or by orally stating your intent to revoke it. You should notify your attending physician of a revocation.

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.

In addition, if your spouse is your designated health care agent, a subsequent divorce will revoke the Proxy.

Note: If you want to make any changes in the form you must complete an entirely new form.

(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) Texas 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 describes relevant Texas law. This statement is attached to the form as "Appendix A".

(The disclosure statement applies to a durable power of attorney for health care. This Halachic Living Will form was designed to qualify as both a durable power of attorney for health care and as a directive under the Natural Death Act.)