Jewish Law
Halachic Forms
    -- Halachic Living Will (North Carolina)

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 Agent: _________________________


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 determination that I lack sufficient understanding or capacity to make or communicate such decisions shall be made by the following physician(s) or other competent adult:

Name: ____________________________________________


Address: _________________________________________

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 agent to consult with and follow the guidance of an Orthodox Rabbi whose guidance on issues of Jewish law and custom my agent 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 health care proxy, 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. Signature: By signing here, I indicate that I am mentally alert and competent, fully informed as to the contents of this document, and understand the full import of this grant of powers to my health care agent.

Date: ____________________________________________



Signature: _______________________________________


Residing at ______________________________________
[address]

I hereby state that the principal (the person who executed this document) __________________, being of sound mind, signed the foregoing health care power of attorney in my presence, and that I am not related to the principal by blood or marriage, and I would not be entitled to any portion of the estate of the principal under any existing will or codicil of the principal or as an heir under the Intestate Succession Act, if the principal died on this date without a will. I also state that I am not the principal's attending physician, nor an employee of the principal's attending physician, nor an employee of a nursing home or any group care home where the principal resides. I further state that I do not have any claim against the principal.

__________________ Residing at ___________________
witness
                               ___________________
                               [address]


__________________ Residing at ___________________
witness
                               ___________________
                               [address]

STATE OF NORTH CAROLINA

COUNTY OF __________________

I, ___________________________, a Notary Public for _________________ County, North Carolina, hereby certify that _____________________________ appeared before me and affirmed to me and to the witnesses in my presence that this instrument is a health care power of attorney, and that he/she willingly and voluntarily made and executed it as his/her free act and deed for the purposes expressed in it.

I further certify that _________________________ and ____________________, witnesses, appeared before me and affirmed that they witnessed _________________________ (principal) sign the attached health care power of attorney, believing him/her to be of sound mind; and also affirmed that at the time they witnessed the signing (i) they were not related to the principal or his spouse, and (ii) they did not know nor have a reasonable expectation that they would be entitled to any portion of his/her estate upon his/her death, and (iii) they were not a physician attending him/her, nor an employee of and attending physician, nor an employee of a health facility in which he/she was a patient, nor an employee of a nursing home or any group-care home in which he/she resided, and (iv) they did not have a claim against him/her. I further certify that I am satisfied as to the genuineness and due execution of the instrument.

This the _____________ day of ______________________, 19____.

__________________________________
Notary Public

SEAL

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.